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Hyaluronic acid injections remain a common nonsurgical alternative for the treatment of knee osteoarthritis despite limited clinical evidence and varying global recommendations regarding its use. We used the Google Trends tool to provide a quantitative analysis of public interest in hyaluronic acid injections for knee osteoarthritis in the United States and Europe.We customized Google Trends parameters to obtain search data from January 2009 to December 2019 in both the United States and Europe. Combinations of "arthritis", "osteoarthritis", "hyaluronic acid", "knee arthritis", "knee osteoarthritis", and "knee injection" were entered into the Google Trends tool, and trend analyses were performed.The models generated to describe public interest in hyaluronic acid for knee injections in both the United States and Europe showed increased Google queries as time progressed (Our results indicate a significant increase in Google queries related to hyaluronic acid injections for knee osteoarthritis since 2009 in both the United States and Europe. Our models suggest that despite mixed evidence supporting its use, orthopedic surgeons should expect continued public interest in hyaluronic acid for knee osteoarthritis. The results of our study may help to prepare surgeons for patient inquiries, inform the creation of evidence-based shared decision-making tools, and direct future research.

BackgroundQuality measures provide a way to assess health care delivery and to identify areas for improvement that can inform patient care delivery. When operationalized by a hospital or a payer, quality measures can also be tied to physician or hospital reimbursement. Prior work on quality measures in orthopaedic surgery have identified substantial gaps in measurement portfolios and have highlighted areas for future measure development. This study aims to identify the portfolio of quality measures in pediatric orthopaedic surgery.MethodsWe used methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and reviewed PubMed/ MEDLINE and EMBASE, the American Academy of Orthopaedic Surgery (AAOS), National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ), for quality measures and candidate quality measures. Quality measure and candidate quality measures were categorized as structure, process, or outcome. Measures were also classified into 1 of the 6 National Quality Strategy priorities (safety, effective, patient centered, timely, efficient, and equitable).ResultsA review of PubMed/EMBASE returned 1640 potential quality measures and articles. A review of AAOS, NQF, and AHRQ databases found 80 potential quality measures. After screening we found a total of 18 quality measures and candidate quality measures specifically for pediatric orthopaedic surgery. Quality measures addressed conditions such as supracondylar humerus fractures, developmental dysplasia of the hip, and osteochondritis dissecans. There were 10 process measures, 8 outcome measure, and 0 structure measures. When we categorized by National Quality Strategy priorities and found 50% (9/18) were effective clinical care, 44% (8/18) were person and care-giver centered experience and outcomes, 6% (1/18) were efficient use of resources.ConclusionsThere are few quality measures and candidate quality measures to assess pediatric orthopaedic surgery. Of the quality measure available, process measures are relatively over-represented. Pediatric orthopaedic surgeons can lead the development of outcome (eg, patient-reported outcomes after surgery) and structure measures (eg, subspecialty training certification) to assess quality of care in pediatric orthopaedic surgery.Level of evidenceLevel II-systematic review.

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters.A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 ± 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis.Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP.All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury.This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.

Context The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004–2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19. Objective Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period. Design Retrospective cohort study. Setting This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016–June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic. Patients or Other Participants Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified. Main Outcome Measure(s) Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses. Results A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant. Conclusions Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

Anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) surgery are common. Laboratory-based biomechanical assessment can evaluate ACL injury risk and rehabilitation progress after ACLR; however, lab-based measurements are expensive and inaccessible to most people. Portable sensors such as wearables and cameras can be deployed during sporting activities, in clinics, and in patient homes. Although many portable sensing approaches have demonstrated promising results during various assessments related to ACL injury, they have not yet been widely adopted as tools for out-of-lab assessment. The purpose of this review is to summarize research on out-of-lab portable sensing applied to ACL and ACLR and offer our perspectives on new opportunities for future research and development. We identified 49 original research articles on out-of-lab ACL-related assessment; the most common sensing modalities were inertial measurement units, depth cameras, and RGB cameras. The studies combined portable sensors with direct feature extraction, physics-based modeling, or machine learning to estimate a range of biomechanical parameters (e.g., knee kinematics and kinetics) during jump-landing tasks, cutting, squats, and gait. Many of the reviewed studies depict proof-of-concept methods for potential future clinical applications including ACL injury risk screening, injury prevention training, and rehabilitation assessment. By synthesizing these results, we describe important opportunities that exist for clinical validation of existing approaches, using sophisticated modeling techniques, standardization of data collection, and creation of large benchmark datasets. If successful, these advances will enable widespread use of portable-sensing approaches to identify ACL injury risk factors, mitigate high-risk movements prior to injury, and optimize rehabilitation paradigms.

Purpose In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country’s needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India. Methods In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway. Results The Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country’s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging. Discussion/Conclusion In Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways. Level of Evidence Level III.

The purpose of this study was to evaluate the impact of an 8-week remote summer program in supporting underrepresented students interested in orthopaedic surgery.We received 115 applications, and a total of 17 students participated in the program (14.8%). Nine faculty mentors were matched with 1 or 2 students each. The program delivered a curriculum from June-August 2021 consisting of (1) weekly instructional courses on research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic topics, diversity in medicine, leadership, and work-life balance; and (3) a research experience paired with a faculty mentor and peer mentor. We surveyed students to measure skill progression, satisfaction, and overall program evaluation. Preprogram/postprogram evaluation, midprogram check-in, and student feedback surveys were collected.Program participants represented a range of race and ethnic backgrounds, research experience levels, and various geographic locations across the United States. The cohort included a high rate of female (42%) and Black (35%) participants. On average, postprogram survey scores indicated that participants believed that the summer program improved their research skills (9.6 of 10), improved their orthopaedic interest (8.9 of 10), and improved mentorship and networking (9.1 of 10). For feedback surveys, 14 respondents of 15 total responses (93%) felt they were adequately matched to their faculty mentor. Twelve (80%) felt they had realistic deliverables for research projects within the 8-week program. Thirteen (87%) indicated they contributed to an abstract or manuscript as a coauthor.Our findings indicate that students improved their research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. The long-term goal is to improve the accessibility and quality of mentorship for underrepresented students in order to foster an equitable pathway into the field of orthopaedic surgery.

Anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) surgery are common. Many ACL-injured subjects develop osteoarthritis within a decade of injury, a major cause of disability without cure. Laboratory-based biomechanical assessment can evaluate ACL injury risk and rehabilitation progress after ACLR; however, lab-based measurements are expensive and inaccessible to a majority of people. Portable sensors such as wearables and cameras can be deployed during sporting activities, in clinics, and in patient homes for biomechanical assessment. Although many portable sensing approaches have demonstrated promising results during various assessments related to ACL injury, they have not yet been widely adopted as tools for ACL injury prevention training, evaluation of ACL reconstructions, and return-to-sport decision making. The purpose of this review is to summarize research on out-of-lab portable sensing applied to ACL and ACLR and offer our perspectives on new opportunities for future research and development. We identified 49 original research articles on out-of-lab ACL-related assessment; the most common sensing modalities were inertial measurement units (IMUs), depth cameras, and RGB cameras. The studies combined portable sensors with direct feature extraction, physics-based modeling, or machine learning to estimate a range of biomechanical parameters (e.g., knee kinematics and kinetics) during jump-landing tasks, cutting, squats, and gait. Many of the reviewed studies depict proof-of-concept methods for potential future clinical applications including ACL injury risk screening, injury prevention training, and rehabilitation assessment. By synthesizing these results, we describe important opportunities that exist for using sophisticated modeling techniques to enable more accurate assessment along with standardization of data collection and creation of large benchmark datasets. If successful, these advances will enable widespread use of portable-sensing approaches to identify ACL injury risk factors, mitigate high-risk movements prior to injury, and optimize rehabilitation paradigms.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences ( P = .413) or proportion with difference ≥3 mm ( P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

Background: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon–femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients. Purpose: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens. Study Design: Descriptive laboratory study. Methods: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface. Results: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts ( P < .047) and the younger and older cohorts ( P < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively. Conclusion: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens. Clinical Relevance: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon- dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting post-operative infections. Allografts had a higher risk of infection than autografts (odds ratio=6.8; 95% CI: 0.9-54.5; p=0.045). Diabetes (odds ratio=28.6; 95% CI: 5.5-149.9; p=0.004) was a risk factor for infection. Patient age, sex, BMI and smoking status were not associated with risk of infection after rACLR. STATEMENT OF CLINICAL SIGNIFICANCE: While there is a low rate of infection following rACLR, use of allograft and comorbidity with diabetes are associated with a higher risk of infection following this surgery.

Background:Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.Purpose:To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.Study Design:Case-control study; Level of evidence, 3.Methods:This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.Results:A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age Conclusion:Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

BACKGROUND: We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India. METHODS: An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019. RESULTS: 173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12 months, and 49.1% had assessed children with DDH aged > 2 years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays. CONCLUSIONS: In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s43465-020-00233-0) contains supplementary material, which is available to authorized users.

Objective. Quantification of meniscus vascularity has been limited with previous techniques, and minimal data exist describing differential vascular zones in the skeletally immature meniscus. The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in neonatal specimens with adults. We hypothesized that the developing meniscus has greater and more uniform vascularity throughout all zones. Design. Ten fresh-frozen human cadaveric knees (5 neonatal, age 0-6 months; 5 adult, 34-67 years) underwent gadolinium-enhanced MRI using an established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement within the same regions (normalized against background tissue) was compared between pre- and post-contrast images. Results. The medial and lateral menisci had similar distribution of perfusion (45.8% ± 8.1% medial vs. 54.2% ± 8.1% lateral in neonatal knees; 50.6% ± 11.3% medial vs. 49.4% ± 11.3% lateral in adult knees, P = 0.47). Increased perfusion was demonstrated in the periphery compared with the central zone (2.3:1 in neonatal knees and 3.25:1 in adult knees, P = 0.31). Neonatal specimens demonstrated 6.0-fold greater overall post-contrast meniscal signal enhancement compared with adults ( P < 0.0001), with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusions. While blood flow to the periphery is greater than to central zones in all menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including to the central zone, suggesting that the immature meniscus is a more biologically active tissue than its adult counterpart.

Background:An unsalvageable osteochondritis dissecans (OCD) fragment has been defined as one that cannot be saved. Unsalvageable OCD lesions have been treated with various techniques, including fragment excision, microfracture, osteochondral autograft transfer, fresh osteochondral allograft transplantation, and autologous chondrocyte implantation (ACI).Hypothesis:Patients who underwent ACI as treatment for unsalvageable OCD more than 10 years ago would maintain satisfactory patient-oriented outcome measures and have a low need for additional open surgery, especially arthroplasty.Study Design:Case series; Level of evidence, 4.Methods:All Swedish and Norwegian patients (59 patients with 67 OCD lesions) who underwent ACI for OCD under the direction of the senior author between 1990 and 2005 were identified through manual chart review. Features of the patient, OCD lesion, and surgery were extracted from the medical record and intraoperative photographs. Patients were sent questionnaires to assess the Knee injury and Osteoarthritis Outcome Score, Tegner-Wallgren activity score, and Lysholm score. In addition, patients were asked whether they had to undergo further surgery, including knee replacement, of the knee that underwent ACI. They were asked whether they would have the surgery again if in the same situation.Results:A total of 55 patients (93%) with 61 OCD lesions (91%) responded. The median follow-up duration was 19 years (range, 10-26 years) and the median age at follow-up was 43 years (range, 28-69 years). Subsequent arthroscopy was performed in the majority of cases, although many of these were scheduled “second looks” as part of a study. With respect to other subsequent surgery, 12 knees (20%) underwent any additional open surgery, but only 2 knees (3%) underwent arthroplasty. Eight knees (13%) underwent revision ACI. Most patients reached their preinjury activity level (62%) and would undergo ACI again if in the same situation (85%). If failure is defined as revision of the graft or conversion to arthroplasty, then survivorship after ACI for OCD in the current study would be 87% at 10 years, 85% at 15 years, and 82% at 20 years.Conclusion:ACI for OCD provides a durable treatment option. At a median follow-up of 19 years, there was a very low (~3%) conversion to total knee arthroplasty.

Background: The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients. Purposes: To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery. Study Design: Descriptive laboratory study. Methods: Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90° to 100°. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure. Results: The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of ≤8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for ≤8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005). Conclusion: The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances Clinical Relevance: As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.

Limb asymmetry after ACL reconstruction is often cited as a risk factor for ACL reinjury. We assessed ground reaction forces on each limb during a drop vertical jump, and compared kinetic symmetry between limbs in adolescents post-ACL reconstruction versus healthy controls.Forty-four participants who underwent an ACL reconstruction (16 male/28 female, mean age 16.1 ± 1.5, mean 7.3 ± 0.9 months post-ACL reconstruction) and 34 controls (20 male/14 female, mean age 14.9 ± 1.1) completed a drop vertical jump captured on a Vicon system and Bertec force plates. Kinetic variables were calculated individually for each limb. Inter-limb asymmetry was calculated as an index between each limb (involved versus uninvolved for the ACL reconstruction group, and left versus right for controls), and was compared between groups using independent t-tests.Asymmetry was significantly more pronounced in the ACL reconstruction group versus the controls for peak contact ground reaction force (11.6% vs 4.4%, p = 0.009), eccentric impulse (8.8% vs 3.8%, p = 0.009), eccentric mean force (8.0% vs 3.4%, p = 0.006), concentric peak ground reaction force (4.1% vs 0.8%, p = 0.003), concentric impulse (5.1% vs 1.1%, p = 0.001), and peak landing ground reaction force (12.7% vs 1.7%, p 0.001).Limb kinetic asymmetry during a drop vertical jump was more pronounced in adolescents post-ACL reconstruction versus controls for both eccentric- and concentric-phase variables, which may indicate the use of compensatory strategies to offload the post-operative limb. Targeted interventions to produce more symmetric loading and unloading during jumping tasks should be developed, tested, and monitored to determine the impact on rehabilitation programs, return-to-sport evaluations, and injury prevention outcomes.

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) are increasingly common in pediatric patients. Historically, ACL reconstructions were delayed in pediatric patients to avoid physeal damage with potential for possible leg-length discrepancy or angular deformity. Current research shows delaying reconstruction or choosing non-operative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction with techniques to avoid physeal growth disturbance is now widely accepted amongst physicians. The purpose of this review was to first describe the pediatric ACL in terms of relevant anatomy and biomechanics, physical exam, and diagnostic imaging. Secondly, the importance of skeletal age and concern for physeal injury is then discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

In-person sport participation was suspended across the United States in the spring of 2020 to slow the spread of the novel coronavirus (COVID-19). The purpose of this study was to survey the impact of COVID-19 on young athletes during a period of social and organized sports restrictions. An anonymous cross-sectional survey study was conducted of youth athletes in the midst of social distancing mandates and consisted of six components: demographics, sport participation, changes in sport-related goals/aspirations, sleep habits, and measures of anxiety and depression. 711 individuals who accessed the survey link yielded 575 (81%) participants with responses available for analysis. All respondents (aged 13.0 years) played organized sports, 62% were single-sport athletes, and 74% considered high-level. Participants were training ∼3.3 h less per week, spending more time outside, and 86% of participants continued to train while social distancing. Sleep duration increased (∼1.2 h/night) and sleep quality improved in 29% of young athletes. Additionally, 22% and 28% reported PROMIS® anxiety and depression scores characterized as 'mild', 'moderate', or 'severe'. Older single-sport participants reported higher depression scores, while higher anxiety scores were seen in female participants with fewer years played. 10% of young athletes and 20% of teenagers changed their sports-related goals. Training style modifications, decreased training, and increased sleep quantity and quality were positive effects of COVID-19 restrictions, while athletic aspirational changes were undesirable effects. Single-sport athletes may be at greater risk for psychological symptoms when their routine is altered.

A paucity of data exists on the treatment of pediatric lateral meniscus root tears (LMPRTs). This study aims to characterize the biomechanics of the lateral knee joint in pediatric cadavers following LMPRT and root repair. Our hypotheses were: (1) compared with the intact state, LMPRT would be associated with decreased contact area; (2) compared with the intact state, LMPRT would be associated with increased contact pressures; and (3) compared with LMPRT, root repair would restore contact area and pressures toward intact meniscus values.Eight cadaver knees (ages 8-12 years) underwent contact area and pressure testing of the lateral compartment. Tekscan pressure mapping sensors covering the tibial plateau were inserted underneath the lateral meniscus. Appropriate pressure load equivalents were applied by a robot at degrees of flexion: 0, 30, 60. Three meniscus conditions were tested: (1) intact, (2) complete root tear, and (3) repaired root tear. Root repairs were performed with transtibial pullout sutures. Statistical analysis was performed.Root tear significantly decreased mean contact area at 30° (Transosseous pullout repair is a clinically validated treatment for LMPRT. This study provides baseline biomechanics data of transtibial pullout repair of pediatric LMPRTs.

Juvenile osteochondritis dissecans (JOCD) is an orthopedic joint disorder of children and adolescents that can lead to premature osteoarthritis. Thirteen patients (mean age: 12.3 years, 4 females), 15 JOCD-affected and five contralateral healthy knees, that had a baseline and a follow-up magnetic resonance imaging (MRI) (mean interval of 8.9 months) and were treated nonoperatively during this interval were included. Retrospectively, patients were assigned to operative or nonoperative groups based on their electronic medical records. Volumetric mean T

The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004 to 2014. Interestingly, there are limited recent data on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19.Given the impact of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period.Retrospective cohort study.This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016 to June 2021, with March 1, 2020 considered the "start" of the COVID-19 pandemic.Using CPT codes, patients 18 years old and younger who underwent ACLR surgery were identified.None.Patient demographics and overall rates of surgery pre- and intra-pandemic were compared. Data were analyzed using bivariate, mixed model, and time series analyses.A total of 24,843 ACLRs were identified during this time period. In total, 1,853 fewer surgeries were performed after March 2020 than expected given pre-pandemic trends. Examining demographics, intra-pandemic, there was an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. There was also a significant shift in the proportion of ACLRs by region, with increased surgeries performed in the Midwest and decreased in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant.Based on pre-pandemic trends, there were fewer patients than projected who underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States.An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated.We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers.The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

Background:An increased posterior tibial slope (PTS) results in greater force on the anterior cruciate ligament (ACL) and is a risk factor for ACL injuries. Biomechanical studies have suggested that a reduction in the PTS angle may lower the risk of ACL injuries. However, the majority of these investigations have been in the adult population.Purpose:To assess the mean medial and lateral PTS on pediatric cadaveric specimens without known knee injuries.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 39 pediatric knee specimens with computed tomography scans were analyzed. Specimens analyzed were between the ages of 2 and 12 years. The PTS of each specimen was measured on sagittal computed tomography slices at 2 locations for the medial and lateral angles. The measurements were plotted graphically by age to account for the variability in development within age groups. The anterior medial and lateral tibial plateau widths were measured. The distance between the top of the tibial plateau and the physis was measured. The independent-samples t test and analysis of variance were used to analyze the measurements.Results:The mean PTS angle for the medial and lateral tibial plateaus was 5.53° ± 4.17° and 5.95° ± 3.96°, respectively. The difference between the PTS angles of the medial and lateral tibial plateaus was not statistically significant ( P > .05). When plotted graphically by age, no trend between age and PTS was identified.Conclusion:This data set offers values for the PTS in skeletally immature specimens without a history of ACL injury and suggests that age may not be an accurate predictive factor for PTS.

Background:The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) has demonstrated normally distributed scores in children aged 10 to 18 years. It has been used to evaluate knee injuries; however, there is limited information regarding its use in evaluating other injury types.Purpose:To (1) assess the validity and utility of HSS Pedi-FABS in youth athletes with injuries to different parts of the body and (2) evaluate the association between the HSS Pedi-FABS and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health 7 (PGH), as well as PROMIS–Pain Interference (PGH-PI) and PROMIS-Fatigue (PGH-F) components.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:The authors performed a retrospective review of youth athletes aged 10 to 18 years who completed the HSS Pedi-FABS as part of their previsit intake questionnaire between April 2016 and July 2020. HSS Pedi-FABS score distributions were compared and evaluated for ceiling effects in cohorts determined by demographic, injury characteristic, and sports participation variables; a ceiling effect was determined to be present if >15% of respondents received the highest possible score. HSS Pedi-FABS scores were analyzed for a correlation with PGH, PGH-PI, and PGH-F components.Results:Included were 2274 patients (mean age, 14.6 ± 2.1 years; 53.0% female) participating in 21 distinct primary sports for 9.6 ± 7.9 hours per week. The mean HSS Pedi-FABS scores by injury group were as follows: elbow (22.7 ± 6.7), shoulder (21.0 ± 8.7), ankle (20.2 ± 8.8), knee (19.5 ± 9.1), and hip (15.4 ± 10.4) ( P < .001). Broad distribution was seen in each cohort, with no floor or ceiling effects. The HSS Pedi-FABS score correlated with patient-reported hours per week ( r = 0.33), days per week ( r = 0.33), and years of participation ( r = 0.21) ( P < .001 for all). All 3 PROMIS components correlated with HSS Pedi-FABS: PGH ( r = 0.28), PGH-PI ( r = –0.11), and PGH-F ( r = –0.15) ( P < .001).Conclusion:Study findings indicated that the HSS Pedi-FABS is a valid tool for measuring physical activity level in most injured youth athletes, not just those with knee injuries. The correlation of HSS Pedi-FABS with the PGH suggests a positive relationship of childhood physical activity with general health.

Purpose To better define the epidemiology of discoid meniscus by analyzing a large, national database for incidence rates and associations with demographic variables. Methods From Optum’s Clinformatics® Data Mart Database, incidence rates and proportions of reported racial categories - Asian, Black, Hispanic, and Caucasian - of diagnosed discoid meniscus cases (n = 198) in the study population of patients receiving arthroscopic meniscectomy or repair procedures (n = 60,042) were calculated and compared via chi-square tests to the total population. To control for age, sex, and socioeconomic factors such as income, multivariable logistic regression analysis was performed. Results Proportions of discoid meniscus patients who were Asian, Black, Hispanic, or Caucasian were

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Background: A discoid lateral meniscus (DLM) is a congenital anomaly of the knee in which the lateral meniscus has an “O” shape and contains irregular, abnormal collagenous tissue. A DLM can cause mechanical symptoms and pain. Treatment of a symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached at the capsule. Reports in the literature recommend a residual width of 6 to 8 mm. Purpose/Hypothesis: The purpose of this research was to determine the width of the lateral meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6 to 8 mm will be sufficient to approximate normal anatomy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We made direct measurements of the radial width of the lateral meniscus from the outer rim at the popliteal hiatus to the inner edge in 19 specimens (age, 2-120 months.) We measured one 4-year-old specimen with a bilateral complete DLM. We also measured 39 digital images of specimens (age, 1-132 months) using ImageJ. Finally, we made direct arthroscopic measurements of 8 skeletally mature specimens. Results: The average width of specimens Conclusion: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6 to 8 mm is insufficient for children ≥8 years old. A width of at least a full centimeter approximates the normal for 8-year-olds and at least 15 mm for adolescents.

The clinical examination of the child or adolescent with a knee injury or pain can vary based on the age of the patient as well as the acuity of the problem. When pediatric patients present with thigh or vague knee pain, the importance of the hip examination cannot be overemphasized. Evaluating the uninjured extremity first is particularly valuable to building trust and confidence with a scared, nervous patient. Having the patient describe and point to locations of symptoms can assist in prioritizing physical exam maneuvers as creating pain through exam will limit later exam compliance. There are four primary elements of the exam: observation, palpation, static stability examination, and dynamic assessment. This review article will summarize physical exam techniques and pertinent findings for meniscus, ligament, and patellofemoral pathology.

For iliotibial band (ITB) lateral extra-articular tenodesis or anterolateral ligamentous/capsular reconstruction with anterior cruciate ligament reconstruction, a clear understanding of the referenced anterolateral knee anatomy is critical-especially given the risk of injury to the physis or key anterolateral structures in the paediatric population, which is at high-risk for primary and secondary anterior cruciate ligament injury. The purpose of this study was to quantitatively assess the anatomy of the knee physes, paediatric lateral collateral ligament (LCL) origin, popliteus origin and ITB tibial insertion.Nine paediatric cadaveric knee specimens with average age 4.2 years (range 2 months-10 years) underwent dissection to identify the LCL's and popliteus' femoral origins and the ITB's tibial insertion. Metallic marking pins demarcated precise anatomic attachment sites, and subsequent computerised tomography scans enabled quantified measurements among them.LCLPopliteus: On the femur, the popliteus origin lay consistently deep to the LCL and inserted both distally and anteriorly to the LCL, a mean distance of 4.6 mm (range 1.9-7.6; standard deviation 2.0). From the joint line, the LCL lay a mean distance of 12.5 mm proximally while the popliteus measured a mean of 8.2 mm. Both were consistently distal to the physis. The LCL was a mean distance of 4.4 mm (range 1.0-9.5) and the popliteus was a mean distance of 8.2 (range 1.7-12.5) from the physis. ITB insertion: The ITB insertion at Gerdy's tubercle had an average footprint measuring 28.2 mmThis study describes relative and quantitative positions of the femoral LCL and popliteus origins and tibial ITB attachment and their respective physeal relationships. Knowledge of paediatric anterolateral knee anatomy will help guide essential future research and procedures providing extra-articular anterolateral rotatory stabilisation and may help reduce iatrogenic physeal injury risk.N/A (descriptive anatomic study).

This systematic review explores the differences in the intrinsic biomechanical properties of different graft sources used in anterior cruciate ligament (ACL) reconstruction as tested in a laboratory setting.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two authors conducted a systematic review exploring the biomechanical properties of ACL graft sources (querying PubMed, Cochrane, and Embase databases). Using the keywords "anterior cruciate ligament graft," "biomechanics," and "biomechanical testing," relevant articles of any level of evidence were identified as eligible and included if they reported on the biomechanical properties of skeletally immature or mature ACL grafts solely and if the grafts were studied in vitro, in isolation, and under similar testing conditions. Studies were excluded if performed on both skeletally immature and mature or non-human grafts, or if the grafts were tested after fixation in a cadaveric knee. For each graft, failure load, stiffness, Young's modulus, maximum stress, and maximum strain were recorded.Twenty-six articles were included. Most studies reported equal or increased biomechanical failure load and stiffness of their tested bone-patellar tendon-bone, hamstring, quadriceps, peroneus longus, tibialis anterior and posterior, Achilles, tensor fascia lata, and iliotibial band grafts compared to the native ACL. All recorded biomechanical properties had similar values between graft types.Most grafts used for ACL reconstruction are biomechanically superior to the native ACL. Utilizing a proper graft, combined with a standard surgical technique and a rigorous rehabilitation before and after surgery, will improve outcomes of ACL reconstruction.

Objectives: The public health opioid abuse epidemic has led to nationwide interest in judicious use and close monitoring of opioid pain medication. Knee arthroscopy(KA) and anterior cruciate ligament reconstruction(ACLR) are common procedures in adolescent patients for which narcotics have been historically utilized for post-operative pain management. The purpose of this study is to investigate pain management strategies following basic KA or ACLR by pediatric sports surgeons who contribute to a multi-center quality improvement initiative(SCORE). Methods: Surgeon participants in SCORE represent fifteen U.S. institutions from primarily academic teaching hospitals who specialize in pediatric sports medicine. Surgeons contribute all ACLR and other KA-related cases. A RedCap survey was distributed to all SCORE surgeon participants in December 2019. A KA (defined as a knee arthroscopy that does not include a ligament reconstruction or a cartilage procedure other than chondroplasty) represented a less invasive procedure, while the ACLR represented a more invasive procedure. Survey results were collected and analyzed for both practice patterns of regional anesthesia utilization and post-operative narcotic prescribing volumes. Results: Twenty-eight SCORE surgeon participants completed the survey, a 100% response rate. A planned prescription of a mean of 16.4 pain pills (range 0-40 pills) were reported for pain management following a KA, only 32.1% of surgeons reported adjunctive regional anesthesia techniques for this procedure in addition to general anesthesia. Following an ACLR, surgeons reported a planned prescription of a mean 23.8 pain pills (range 0-40 pills) and most (92.3%) reported utilization of regional anesthesia for their peri-operative analgesia strategy. Of those using adjunctive regional anesthesia, significant variability was reported: 30.7% reported indwelling catheter placement for peripheral nerve block following ACLR as opposed to a single shot injection method, and several block locations were reported to be utilized of which adductor canal (67.9%) block was the most common (see Figure 1). For both procedure types, variability in multi-modal pain management was noted, with incomplete adoption of the use of additional non-narcotic medication (acetaminophen, 64.2%; and NSAIDS, 75%). Cryotherapy devices were applied/prescribed in 75.0% of knee arthroscopy procedures and 92.8% of ACLR. Conclusions: Despite evidence for effective adjunctive pain management strategies, incomplete adoption of multi-modal techniques and reliance on narcotic medication remains a significant component of pediatric sports surgical practice; with on average > 15 pills prescribed following these procedures. Opportunities for reducing practice variability, adoption of multi-modal analgesia strategies, and decreasing post-operative narcotic use following common adolescent knee procedures exist for this subset of pediatric sports medicine specialists

Introduction The internet is an important tool for applicants seeking information on pediatric orthopaedic surgery fellowship programs. Previous analysis of pediatric orthopaedic surgery fellowship websites demonstrated they were often inaccessible and incomplete. As such, the purpose of this study was to (1) perform an updated assessment of the accessibility and content of pediatric orthopaedic fellowship program websites and (2) compare the results to the previous study to discern temporal trends in website accessibility and quality. Methods A list of pediatric orthopaedic fellowship programs was compiled from the San Francisco Match (SF Match) and the Pediatric Orthopaedic Society of North America (POSNA) online databases. All identified websites were evaluated for (1) accessibility and (2) the presence of 12 education and 12 recruitment criteria. These criteria were determined by prior fellowship website analyses and the needs of current fellowship applicants. Website accessibility and quality were compared with previously reported metrics. Results Approximately 91% of pediatric orthopaedic surgery fellowship programs had a functioning website. While the SF Match and POSNA databases listed nearly identical programs, there were discrepancies in the information provided by the two databases, and individual program website links provided on both databases were often nonfunctional. Fellowship program websites contained an average of 15.1 ± 3.9 total education and recruitment criteria (range: 3 - 21). The most common education criteria featured on program websites included information about research, affiliated hospital information, and rotations. The most common recruitment criteria featured on program websites included program descriptions, contact information, and social media links. There was an increased frequency in nearly all education and recruitment criteria evaluated when compared with 2014 metrics. Discussion Although website accessibility and content have improved since 2014, information on pediatric orthopaedic fellowship program websites remains incomplete, with many websites failing to provide information on criteria deemed important by fellowship applicants. In addition, many discrepancies exist between the SF Match and POSNA databases, the two primary sources of information for pediatric orthopaedic fellowship applicants. Increased consistency on pediatric orthopaedic fellowship websites and both the SF Match and POSNA databases may help applicants to better assess which programs to apply to and which programs to rank highly on their match list.

Background: Understanding the morphology of cartilage/bony maturation in preadolescents may help explain adult trochlear variation. Purpose: To study trochlear morphology during maturation in children and infants using magnetic resonance imaging (MRI). Study Design: Descriptive laboratory study. Methods: Twenty-four pediatric cadaveric knees (10 male and 14 female knees; age, 1 month to 10 years) were included. High-resolution imaging of the distal femoral secondary ossification center was performed using 7-T or 9.4-T MRI scanners. Three-dimensional MRI scans were produced, and images were reformatted; 3 slices in the axial, sagittal, and coronal planes images were analyzed, with coronal and sagittal imaging used for image orientation. Biometric analysis included lateral and medial trochlear height (TH); cartilaginous sulcus angle (CSA); osseous sulcus angle (OSA); trochlear depth; and trochlear facet (TF) length symmetry. Sex comparisons were considered when ≥1 specimen from both sexes of the same age was available; these included 11 knees spanning 4 age groups (ages 1, 3, 4, and 7 years). Results: The analysis of trochlear morphology showed a lateral TH greater than the medial TH at all ages. The thickest cartilage was found on the lateral TF in the younger specimens. Regarding the development of osseous and cartilaginous trochlear contour, a cartilaginous sulcus was present in the 3-month-old specimen and continued to deepen up to the age of 4 years. The shape of the osseous center evolved from round (1 month) to oval (9 months) to rectangular (2 years); no distinct bony trochlear sulcus was present, although a well-formed cartilaginous sulcus was present. The first evidence of formation of a bony sulcus was at 4 years. By the age of 7 to 8 years, the bony contour of the adult distal femur resembled its cartilaginous contour. Female samples had a shallower CSA and OSA than did the male ones in all samples that had a defined OSA. Conclusion: Female trochlear grooves tended to be shallower (flatter). The lateral trochlea was higher (TH) and wider (TF length) during growth than was the medial trochlea in both sexes; furthermore, the development of the osseous sulcus shape lagged behind the development of the cartilaginous sulcus shape in the authors’ study population. Clinical Relevance: Bony anatomy of the trochlear groove did not match the cartilaginous anatomy in preadolescent children, suggesting that caution should be used when interpreting bony anatomy in this age group.

Introduction The Institute of Medicine has defined multiple domains to improve safety, efficiency, and effectiveness of health care. High-Reliability Organizations (HROs) address these issues and promote safety/reliability at the highest level. Methods HROs create a bottom-up, top-down culture that focuses upon continuous improvement by withholding blame on individuals yet requiring all members to be accountable for continuous improvement. Results Supporting staff to speak up, identify, and engage on the path to perfect care and zero harm are elements of a safety culture. In addition to safety, HROs can also focus on effectiveness and efficiency. This may be accomplished by creating consistent care practices that reduce irrational variation, decrease complexity, and lower risk. Discussion Developing a culture focused upon reliability, safety, and staff resilience is critical for HROs. HROs support and empower all staff to be vigilant and report concerns about any issue related to safety and support the development of a "Safety Culture." HROs focus upon safety will be enhanced by an expanded focus upon effectiveness and efficiency to improve value. A focus on standard clinical practices and clinician integration into the supply chain will help organizations produce better value and be an essential tool to reduce complexity and risk within health care systems.

Background Developmental dysplasia of the hip (DDH) is a common condition, affecting 1% to 2% of full-term infants. The American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Pediatrics have published guidelines detailing best practices for DDH screening and treatment. The purpose of this survey was to determine DDH treatment practices of pediatric orthopaedic surgeons in North America. Methods We queried orthopaedic surgeon members of the Pediatric Orthopaedic Society of North America (POSNA) about referral patterns, treatment practices, and use of DDH guidelines. The survey included demographics, clinical scenarios, referrals patterns, and ultrasound practices. Results Of the 1392 members of POSNA, we received 432 total responses and included 353 in statistical analyses. Results show that 68% (233/342) of surgeons practice in an institution that does not endorse a standard care pathway for DDH. Of surgeons who personally use a DDH care pathway, the AAOS guidelines were most cited (143/353, 41%). The majority (94%, 316/337) of surgeons do not believe that universal ultrasound screening should be adopted in the United States. Responses regarding ultrasound screening for "high risk" infants as outlined by AAOS varied based on risk factor. Many (57%, 200/353) surgeons have performed initial evaluations for patients over 12 months of age. While 80% (260/327) of orthopaedic surgeons believe that primary care providers are referring patients appropriately, only 57% (183/323) believe that primary care providers are ordering imaging studies appropriately. Conclusions Results from this survey of POSNA membership indicate an opportunity to better distribute and implement DDH guidelines. In addition, the implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by: (1) reducing the total cost of care, (2) increasing the use of appropriate imaging, (3) increasing timely referral for DDH care, and (4) reducing the presentation rate of walking age DDH patients. Level of evidence The level of evidence rating for this survey-based study is level IV.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS–Sports and Recreation ( P = .04), and KOOS–Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.