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Cast saw injuries are a significant risk of morbidity for our patients and can result in pain, and scarring and in some cases lead to litigation. In order to prevent injury to patients and to better train residents in cast removal, we developed the Cast Saw Injury Protection System (CSIPS). This manuscript and the associated video demonstrate the ability of this system to decrease injury and to train residents and ancillary medical staff in the safe removal of casts.

Background: Over 130,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) are performed annually in the United States. Previous studies have shown that circumferential preconditioning reduces the diameter of fresh-frozen allografts, but no studies have described the effect in ACL autografts used during ACLR. Purpose: To characterize the changes in the hamstring autograft diameter as a result of preparatory circumferential preconditioning. Study Design: Case series; Level of evidence, 4. Methods: A total of 135 patients with ACLR, with a median age of 15 years (interquartile range, 14-16 years; 50.4% boys), were identified in 2 pediatric hospitals. Three orthopaedic surgeons recorded hamstring autograft diameters at 2 time points during graft preparation. Hamstring tendons were prepared using a standardized procedure, tensioned to 15 to 20 lbs, and measured using cylindrical sizing guides. The graft was left with passive compression in the smallest initial rigid sizing guide for 10 minutes on both the tibial and femoral sides and then measured again immediately before implantation. Tunnels were drilled based on the second measurement of graft size. Comparisons were made between the graft diameter before and after circumferential preconditioning. A random-effects regression model and a linear regression model were performed to capture any unexplained variance on the linear predictor scale and determine correlations between demographics and graft characteristics. Results: The median initial diameter for both femoral and tibial sides was 9.5 mm. After longitudinal tension and circumferential preconditioning, the median autograft diameter of both sides decreased by 1 mm ( P < .001) to 8.5 mm. In the random-effects model, decreased patient height was a significant predictor of greater reduction in graft diameter. Increased height was a significant predictor for greater initial graft diameter (average beta coefficient = 3.08; P < .01). No intraoperative complications were noted with implantation of the preconditioned grafts in smaller diameter tunnels. Conclusion: The median diameter of hamstring ACL autografts decreases by 1 mm after circumferential preconditioning within standard cylindrical sizing guides. This allowed for drilling of tunnels that were an average of 1 mm smaller without any noted intraoperative complications with graft insertion.

Background Flexible intramedullary nailing is performed for femoral fractures in pediatric patients who may be too large for spica cast immobilization but who have substantial growth remaining and who are not a candidate for rigid intramedullary nailing. Flexible nailing allows the surgeon to obtain correct alignment of the femur fracture so as to allow for healing without a lower extremity deformity. Description The patient is positioned on a radiolucent table, flexible nails are chosen according to the diameter of the medullary canal, medial and lateral incisions are made along the distal aspect of the thigh, and access to the canal is obtained with use of a drill-bit of the appropriate size. Flexible nails are contoured to place the apex at the location of the fracture site and then passed 1 at a time up to the fracture through the medial and lateral corticotomies. Fracture reduction is obtained, and the nails are passed across the fracture 1 at a time. Leave a small amount of nail prominent at the entry site; the nails are then cut and advanced with a tamp. Alternatives Spica cast immobilization, rigid intramedullary nailing, external fixation, and submuscular plating. Rationale Flexible nailing provides relative stability of a femoral fracture similar to external fixation, submuscular plating, and rigid nailing; however, external fixators come with pin-track complications and infections, as well as a bulky device external to the thigh. Submuscular plating is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult. In an older child with growth remaining, a rigid femoral nail is an option with similar outcomes to flexible nailing; however, the implant is harder to remove. Flexible nailing provides a cosmetic incision with reliable relative fixation in length-stable fractures, and easy removal of implants with equal or even improved outcomes compared with other surgical techniques. Expected outcomes The outcomes of this procedure are excellent. Most pediatric femoral fractures treated with flexible nailing heal well with few complications. Angulation at the fracture site is the most common complication and is more common in fractures of the proximal or distal third of the femur1. Worse outcomes occur in older children and children who are heavier1. Outcomes are improved when flexible nailing is done in length-stable fractures; however, postoperative immobilization in a single-leg spica cast or knee immobilizer can augment fixation in fractures that are not stable. Implant irritation can occur at the insertion site; however, the implants are easy to remove once the fracture has healed. There is a substantially lower rate of malunion when stainless-steel nails (6%) are utilized compared with titanium nails (23%). Consideration should therefore be given to the use of stainless-steel nails for pediatric femoral fractures2. Important tips Use a radiolucent table with either a post or a sheet for counter-traction aids during reductionUse stainless-steel nailsPass the easier nail firstAdvance into the femoral neck or trochanteric apophysisDo not wrap rods around each otherCut off the machined tip of the nail and custom-contour the nail in patients with poor bone quality.

BACKGROUND Musculoskeletal infection is a major cause of morbidity in the pediatric population. Despite the canonical teaching that an irritable joint and signs of infection likely represent an infected joint space, recent evidence in the pediatric hip has demonstrated that alternative diagnoses are equally or more likely and that combinations of pathologies are common. The knee is the second most commonly infected joint in children, yet there remains a paucity of available data regarding the epidemiology and workup of the infected pediatric knee. The authors hypothesize that there is heterogeneity of pathologies, including combinations of pathologies, that presents as a potentially infected knee in a child. The authors aim to show the utility of magnetic resonance imaging and epidemiologic and laboratory markers in the workup of these patients. METHODS A retrospective review of all consults made to the pediatric orthopaedic surgery team at a single tertiary care center from September 2009 through December 2015 regarding a concern for potential knee infection was performed. Excluded from the study were patients with penetrating trauma, postoperative infection, open fracture, no C-reactive protein (CRP) within 24 hours of admission, sickle cell disease, an immunocompromised state, or chronic osteomyelitis. RESULTS A total of 120 patients were analyzed in this study. There was marked variability in pathologies. Patients with isolated osteomyelitis or osteomyelitis+septic arthritis were older, had an increased admission CRP, were more likely to be infected with Staphylococcus aureus, required an increased duration of antibiotics, and had an increased incidence of musculoskeletal complications than patients with isolated septic arthritis. CONCLUSIONS When considering a child with an irritable knee, a heterogeneity of potential underlying pathologies and combinations of pathologies are possible. Importantly, the age of the patient and CRP can guide a clinician when considering further workup. Older patients with a higher admission CRP value warrant an immediate magnetic resonance imaging, as they are likely to have osteomyelitis, which was associated with worse outcomes when compared with patients with isolated septic arthritis. LEVEL OF EVIDENCE Level III-retrospective research study.

Objective Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. Study design Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. Results 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. Conclusion At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Background:In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI).Purpose:To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship–trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated.Results:The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38).Conclusion:Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

Background: Previous studies have investigated the effect of tension and circumferential compression on the diameter of fresh-frozen anterior cruciate ligament (ACL) allografts, but no study has described the effect on soft tissue ACL autografts harvested for implantation in the operating room for ACL reconstruction. The purpose of this study was to elucidate how hamstring autograft diameter changes during preparation for ACL reconstruction with compression in addition to tensioning. We hypothesized that autograft diameter would decrease as the graft was prepared with both tension and circumferential compression. Operative complications related to graft compression were also investigated. Methods: 100 ACL reconstruction surgeries (Age M = 15.3 ± 2.2 years; 53% male) were identified among two orthopedic surgeons. Hamstring tendon grafts were prepared in a standardized procedure to produce a looped graft for all-inside ACL reconstruction. Autografts were tensioned to 15-20 lbs and then their tibial and femoral diameters were measured using cylindrical sizing blocks. The graft diameters were measured again after placement under a saline soaked gauze for 10 minutes with the sizing blocks in place. A Wilcoxon signed rank test with correction for continuity was performed to detect significant change in autograft diameters after compression. Results: Treatment of hamstring autografts with longitudinal tension and circumferential compression significantly decreased the median tibial and femoral graft diameters by 0.75 mm. The median tibial diameter decreased from 9.50 mm to 8.75 mm (p < 0.0001) and the median femoral diameter decreased from 9.50 mm to 8.50 mm (p < 0.0001). 72% of all autografts had the same tibial and femoral diameters at implant. No intraoperative complications were noted with implantation of compressed grafts in smaller diameter tunnels. Conclusions: Median diameters of ACL hamstring autografts harvested in the OR decreased by 0.75 mm after treatment with circumferential compression using cylindrical sizing blocks. This decreased the socket size by one to two 0.5 mm sizes with no adverse events noted intra-operatively due to the compression of the grafts or the smaller sockets. Clinical Relevance: Graft integration in a bone tunnel is dependent on optimal fit of the graft inside the tunnel. If the tunnel is too small, the graft will not fit and if it is too large, it may allow joint fluid into the tunnel leading to tunnel widening and incomplete integration. Pre-tensioning a graft has been noted for many years to be an important way to properly establish the length-tension relationship of a graft. Here, we show that circumferential compression of the graft prior to implantation significantly changes the size of the graft, and thus the size of the tunnels required for implantation. In addition to providing better graft tunnel match, using smaller tunnels requires less bone removal which is particularly advantageous for pediatric, revision, and double bundle ACL reconstruction techniques where space for tunnel drilling is limited.

The purpose of this study was to determine the frequency of use, perceived effectiveness, and preference for arthroscopic surgical skill training resources. An electronic survey was sent to orthopedics residents, residency program directors, and orthopedic sports medicine attending physicians in the United States. The frequency and perceived effectiveness of 10 types of adjunctive arthroscopic skills training was assessed. Residents and faculty members were asked to rate their confidence in resident ability to perform common arthroscopic procedures. Surveys were completed by 40 of 152 (26.3%) orthopedic residency program directors, 70 of 426 (16.4%) sports medicine faculty, and 235 of 3,170 (7.4%) orthopedic residents. The use of adjunctive methods of training varied from only 9.8% of programs with virtual reality training to 80.5% of programs that used reading of published materials to develop arthroscopic skill. Practice on cadaveric specimens was viewed as the most effective and preferred adjunctive method of training. Residents trained on cadaveric specimens reported increased confidence in their ability to perform arthroscopic procedures. The resources for developing arthroscopic surgical skill vary considerably across orthopedic residency programs in the United States. Adjunctive training methods were perceived to be effective at supplementing traditional training in the operating room.

Background: Surgeries employing arthroscopic techniques are among the most commonly performed in orthopaedic clinical practice; however, valid and reliable methods of assessing the arthroscopic skill of orthopaedic surgeons are lacking. Hypothesis: The Arthroscopic Surgery Skill Evaluation Tool (ASSET) will demonstrate content validity, concurrent criterion-oriented validity, and reliability when used to assess the technical ability of surgeons performing diagnostic knee arthroscopic surgery on cadaveric specimens. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Content validity was determined by a group of 7 experts using the Delphi method. Intra-articular performance of a right and left diagnostic knee arthroscopic procedure was recorded for 28 residents and 2 sports medicine fellowship–trained attending surgeons. Surgeon performance was assessed by 2 blinded raters using the ASSET. Concurrent criterion-oriented validity, interrater reliability, and test-retest reliability were evaluated. Results: Content validity: The content development group identified 8 arthroscopic skill domains to evaluate using the ASSET. Concurrent criterion-oriented validity: Significant differences in the total ASSET score ( P < .05) between novice, intermediate, and advanced experience groups were identified. Interrater reliability: The ASSET scores assigned by each rater were strongly correlated ( r = 0.91, P < .01), and the intraclass correlation coefficient between raters for the total ASSET score was 0.90. Test-retest reliability: There was a significant correlation between ASSET scores for both procedures attempted by each surgeon ( r = 0.79, P < .01). Conclusion: The ASSET appears to be a useful, valid, and reliable method for assessing surgeon performance of diagnostic knee arthroscopic surgery in cadaveric specimens. Studies are ongoing to determine its generalizability to other procedures as well as to the live operating room and other simulated environments.

Background: The use of surgical simulation in orthopaedic education is increasing; however, its ideal place within the training curriculum remains unknown. The purpose of this study was to determine the effectiveness of training novice surgeons on an anatomic dry model of the knee prior to training them to perform diagnostic arthroscopy on cadaveric specimens. Methods: Fourteen medical students were randomly assigned to two groups. The experimental group was trained to perform diagnostic arthroscopy of the knee on anatomic dry models prior to training on cadaveric specimens. The control group was trained only on cadaveric specimens. Proficiency was assessed with use of a modified version of a previously validated objective assessment of arthroscopic skill, the Basic Arthroscopic Knee Skill Scoring System (BAKSSS). The mean number of trials required to attain minimal proficiency when performing diagnostic knee arthroscopy was compared between the groups. The cumulative transfer effectiveness ratio (CTER) was calculated to measure the transfer of skills acquired by the experimental group. Results: The mean number of trials to demonstrate minimum proficiency was significantly lower in the experimental group (2.57) than in the control group (4.57) (p < 0.01). The mean time to demonstrate proficiency was also significantly less in the experimental group (37.51 minutes) than in the control group (60.48 minutes) (p < 0.01). The CTER of dry-model training for the task of performing diagnostic knee arthroscopy on cadaveric specimens was 0.2. Conclusions: Previous training utilizing an anatomic dry knee model resulted in improved proficiency for novice surgeons learning to perform diagnostic knee arthroscopy on cadaveric specimens. A CTER of 0.2 suggests that dry models can serve as a useful adjunct to cadaveric training for diagnostic knee arthroscopy but cannot entirely replace it within the orthopaedic curriculum. Further work is necessary to determine the optimal amount of training on anatomic dry models that will maximize transfer effectiveness and to determine how well skills obtained in the simulated environment transfer to the operating room.

The Basic Arthroscopic Knee Skill Scoring System (BAKSSS) has construct validity as an objective measure of arthroscopic proficiency when used to assess the task of performing arthroscopic meniscectomies on cadaver knees. The reliability of this instrument is unknown.We asked whether (1) a simple modification of the BAKSSS would show construct validity similar to that in the initial BAKSSS study, (2) this assessment would be reliable, and (3) this assessment could be used as a high-stakes pass or fail test.Twenty-three orthopaedic residents performed diagnostic knee arthroscopies on cadaveric knee specimens. Their competency was assessed by three live raters using the modified BAKSSS. Interrater reliability was assessed by comparing the scores given by each rater to each subject.The modified BAKSSS showed construct validity with junior residents achieving lower scores (mean score, 20) than senior residents (mean score, 33). The modified BAKSSS had an interrater reliability of kappa = 0.685-0.852. The modified BAKSSS had a kappa = 0.543 when used as a proficiency test for diagnostic arthroscopy.The modified BAKSSS is useful for assessing diagnostic knee arthroscopy proficiency. Future scoring systems should be designed to be generalizable so they can be applied to multiple procedures without the need for modification, allow for video-based assessment, and must be rigorously tested for reliability and other types of validity (eg, face validity, content validity, and criterion-related validity).Having a valid and reliable assessment of basic arthroscopic procedures may allow educators to more adequately evaluate individual residents and the effectiveness of various training modalities.

Background: Examination of arthroscopic skill requires evaluation tools that are valid and reliable with clear criteria for passing. The Arthroscopic Surgery Skill Evaluation Tool was developed as a video-based assessment of technical skill with criteria for passing established by a panel of experts. The purpose of this study was to test the validity and reliability of the Arthroscopic Surgery Skill Evaluation Tool as a pass-fail examination of arthroscopic skill. Methods: Twenty-eight residents and two sports medicine faculty members were recorded performing diagnostic knee arthroscopy on a left and right cadaveric specimen in our arthroscopic skills laboratory. Procedure videos were evaluated with use of the Arthroscopic Surgery Skill Evaluation Tool by two raters blind to subject identity. Subjects were considered to pass the Arthroscopic Surgery Skill Evaluation Tool when they attained scores of ≥3 on all eight assessment domains. Results: The raters agreed on a pass-fail rating for fifty-five of sixty videos rated with an interclass correlation coefficient value of 0.83. Ten of thirty participants were assigned passing scores by both raters for both diagnostic arthroscopies performed in the laboratory. Receiver operating characteristic analysis demonstrated that logging more than eighty arthroscopic cases or performing more than thirty-five arthroscopic knee cases was predictive of attaining a passing Arthroscopic Surgery Skill Evaluation Tool score on both procedures performed in the laboratory. Conclusions: The Arthroscopic Surgery Skill Evaluation Tool is valid and reliable as a pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Clinical Relevance: This study demonstrates that the Arthroscopic Surgery Skill Evaluation Tool may be a useful tool for pass-fail examination of diagnostic arthroscopy of the knee in the simulation laboratory. Further study is necessary to determine whether the Arthroscopic Surgery Skill Evaluation Tool can be used for the assessment of multiple arthroscopic procedures and whether it can be used to evaluate arthroscopic procedures performed in the operating room.

Koehler RJ, Amsdell S, Arendt EA, Bisson LJ, Braman JP, Butler A, Cosgarea AJ, Harner CD, Garrett WE, Olson T, Warme WJ, Nicandri GT. The Arthroscopic Surgical Skill Evaluation Tool (ASSET). Am J Sports Med. 2013;41(6):1229-1237. (Original DOI: 10.1177/0363546513483535 ) Author Jonathan P. Braman’s name appeared incorrectly in this article. The correct author information appears above.