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Past research suggests listeners treat disfluencies as informative cues during spoken language processing. For example, studies have shown that child and younger adult listeners use filled pauses to rapidly anticipate discourse-new objects. The present study explores whether older adults show a similar pattern, or if this ability is reduced in light of age-related declines in language and cognitive abilities. The study also examines whether the processing of disfluencies differs depending on the talker's age. Stereotyped ideas about older adults' speech could lead listeners to treat disfluencies as uninformative, similar to the way in which listeners react to disfluencies produced by non-native speakers or individuals with a cognitive disorder. Experiment 1 used eye tracking to capture younger and older listeners' real-time reactions to filled pauses produced by younger and older talkers. On critical trials, participants followed fluent or disfluent instructions referring to either discourse-given or discourse-new objects. Younger and older listeners treated filled pauses produced by both younger and older talkers as cues for reference to discourse-new objects despite holding stereotypes regarding older adults' speech. Experiment 2 further explored listeners' biased judgments of talkers' fluency, using auditory materials from Experiment 1. Speech produced by an older talker was rated as more disfluent and slower than a younger talker even though these features were matched across recordings. Together, the findings demonstrate (a) older listeners' effective use of disfluency cues in real-time processing and (b) that listeners treat both older and younger talkers' disfluencies as informative despite biased perceptions regarding older talkers' speech. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

PURPOSE: Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity. METHODS: Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System – Expanded and Revised I–V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ? 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh. Endpoints: Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator’s, patient’s, and parent’s/caregiver’s GICS, Gross Motor Function Measure-66 (GMFM-66). RESULTS: Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development. CONCLUSION: Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.

Purpose The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. Methods The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. Conclusion This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. Level of evidence V

Purpose Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. Methods A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. Results Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). Conclusions The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. Level of Evidence V

INTRODUCTION Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011). METHODS A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey. RESULTS Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001). DISCUSSION Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011. LEVEL OF EVIDENCE Level IV. Type of evidence: therapeutic.

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 Resident involvement in patient care in the general surgery setting is most often encountered in an academic setting. Many community hospitals have residents involved in patient care as well. There are no studies that gauge patients’ perceptions in the involvement of residents in their general surgery care in the community setting. Methods Patients were given a Northeast Georgia Health System Graduate Medical Education Department Institutional review Board approved 26-question questionnaire during their office visit gauging their wiliness to allow a resident be involved in their care, and their understanding of what a resident is. Results A total of 196 patients completed the survey with answers that could be analyzed. Overall, 67.3% would allow residents be involved in their care. The main reasons for this were to educate future surgeons, they enjoy a teaching environment, and that they have had residents involved in their care and it was a good experience. Of the 27 % that did not want a resident involved in their care, the main reason was they only wanted their doctor involved in their care. Of the respondents, 58 % were comfortable having a resident involved in their surgery or procedure. Only 14% noted that they would prefer not to have a resident involved in their procedure or surgery. Conclusions Patents appear receptive to general surgery residents’ involvement in their care in the community setting. This is reassuring as community practices may be more receptive to including residents in their practices, based upon these findings.

Executive control (EC) ability is increasingly emerging as an important predictor of post-stroke aphasia recovery. This study examined whether EC predicted immediate treatment gains, treatment maintenance and generalization after naming therapy in ten adults with mild to severe chronic post-stroke aphasia. Performance on multiple EC tasks allowed for the creation of composite scores for common EC, and the EC processes of shifting, inhibition and working memory (WM) updating. Participants were treated three times a week for five weeks with a phonological naming therapy; difference scores in naming accuracy of treated and untreated words (assessed pre, post, four- and eight-weeks after therapy) served as the primary outcome measures. Results from simple and multiple linear regressions indicate that individuals with better shifting and WM updating abilities demonstrated better maintenance of treated words at four-week follow-up, and those with better common EC demonstrated better maintenance of treated words at both four- and eight-week follow-ups. Better shifting ability also predicted better generalization to untreated words post-therapy. Measures of EC were not indicative of improvements on treated words immediately post-treatment, nor of generalization to untreated words at follow-up. Findings suggest that immediate treatment gains, maintenance and generalization may be supported by different underlying mechanisms.

Background: The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent athlete. Standard of care for conservative treatment, include activity modification and weight bearing protection. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness. Hypothesis/Purpose: The study hypothesis was that trans-articular (TAD) and retro-articular drilling (RAD) would demonstrate similar rates of healing, times to return to sports, and patient-reported outcome scores (PROs). Methods: Skeletally immature (n=113) patients presenting with radiograph indicated stable OCD of the MFC who did not demonstrate healing despite a minimum of 3 months of non-operative treatment were prospectively enrolled and randomized to TAD or RAD, for which 17 surgeon-investigators (at 14 centers, representing all major regions in the U.S.). Serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were due to lesion instability detected at the time of surgery, Results: Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, with the two groups being of similar age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant difference between TAD and RAD was detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD. 71% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 58% RAD patients at a mean of 1.06 years. Conclusion: While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement being achieved much sooner. While PROs were similar between drilling techniques, revision surgery rates were more than twice as common with RAD compared with TAD but the overall risk was low and the Absolute Risk was only 6%. [Table: see text]

Background: The ACL deficient knee is predisposed to anterior translation and internal rotation of the tibia. Hypothesis/Purpose: To show that knee deformity in an ACL deficient knee will produce a more vertical orientation of the lateral collateral ligament (LCL), allowing for the entire length of the LCL to be visualized on a single coronal slice (coronal LCL sign) on MRI, and that this sign is indicative of a greater risk for graft failure after ACL reconstruction. Methods: Charts were retrospectively reviewed to create 3 separate cohorts: normal ACL and no pathology involving the collateral ligaments (control cohort), ACL reconstruction without evidence for graft rupture, and ACL reconstruction with graft failure. Tibial translation and femorotibial rotation were measured on MRI, and posterior tibial slope was measured on lateral knee radiographs. Imaging was reviewed for the presence of the coronal LCL sign. Results: Deficient ACL (n=153) compared with intact ACL (n=70) was associated with significantly greater displacement regarding anterior translation (5.8mm internal rotation vs 0.3mm external rotation, pConclusion: Our study shows that the coronal LCL sign correlates with the presence of an ACL tear and functions as a surrogate for the extent of axial and sagittal deformity. Further, we show that tibia internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Whereas, the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). [Table: see text][Figure: see text]

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

Background This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884 ) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment. Methods Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs). Results AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern −1.15 [0.06] versus −0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels. Conclusions Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.

AIM To compare skeletal muscle mitochondrial enzyme activity and mitochondrial content between independently ambulatory children with cerebral palsy (CP) and typically developing children. METHOD Gracilis biopsies were obtained from 12 children during surgery (n=6/group, children with CP: one female, five males, mean age 13y 4mo, SD 5y 1mo, 4y 1mo-17y 10mo; typically developing children: three females, three males, mean age 16y 5mo, SD 1y 4mo, 14y 6mo-18y 2mo). Spectrophotometric enzymatic assays were used to evaluate the activity of mitochondrial electron transport chain complexes. Mitochondrial content was evaluated using citrate synthase assay, mitochondrial DNA copy number, and immunoblots for specific respiratory chain proteins. RESULTS Maximal enzyme activity was significantly (50-80%) lower in children with CP versus typically developing children, for complex I (11nmol/min/mg protein, standard error of the mean [SEM] 1.7 vs 20.7nmol/min/mg protein, SEM 4), complex II (6.9nmol/min/mg protein, SEM 1.2 vs 21nmol/min/mg protein, SEM 2.7), complex III (31.9nmol/min/mg protein, SEM 7.4 vs 72.7nmol/min/mg protein, SEM 7.2), and complex I+III (7.4nmol/min/mg protein, SEM 2.5 vs 31.8nmol/min/mg protein, SEM 9.3). Decreased electron transport chain activity was not the result of lower mitochondrial content. INTERPRETATION Skeletal muscle mitochondrial electron transport chain enzymatic activity but not mitochondrial content is reduced in independently ambulatory children with CP. Decreased mitochondrial oxidative capacity might explain reported increased energetics of movement and fatigue in ambulatory children with CP. What this paper adds Skeletal muscle mitochondrial electron transport chain enzymatic activity is reduced in independently ambulatory children with cerebral palsy (CP). Mitochondrial content appears to be similar between children with CP and typically developing children.

Background:Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear.Purpose/Hypothesis:To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort.Study Design:Case series; Level of evidence, 4.Methods:We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport.Results:Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection.Conclusion:Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

Background: Opioid consumption and patient satisfaction are influenced by a surgeon’s pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology. Hypothesis: We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone–patellar tendon–bone (BTB) ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient. Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block ( P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19). Conclusion: Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

Purpose To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger. Methods A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded. Results We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies. Conclusions There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently. Clinical Relevance A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

BACKGROUND Bilateral hip reconstructions with osteotomies are commonly required in patients with severe cerebral palsy (CP) and dysplasia. These procedures can be performed by staging each hip surgery, separated by weeks to months, or by addressing both hips in a single-event surgery. The optimal timing of such surgery is yet to be determined. The purpose of this study was to retrospectively compare major complications between the staged and single-event approaches. METHODS Medical records of patients who underwent bilateral hip osteotomies, with at least one side including a pelvic osteotomy, were retrospectively reviewed. Subjects were identified who had a diagnosis of nonambulatory CP (defined by Gross Motor and Functional Classification System level IV or V), and at least 1 year of clinical follow-up. All hips were treated by 1 of 7 surgeons: 2 surgeons who always performing single-event surgery and 5 who always perform staged surgeries. Complications were stratified by the Modified Clavien-Dindo Classification (grades 1 to 5). The primary outcome was major complications (grade ≥3), while minor complications, readmissions, reoperations, and resource utilization outcomes were investigated secondarily. RESULTS Sixty-five patients met our inclusion criteria: 35 received single-event surgery and 30 received staged surgery. The staged group had a higher rate of major complications per patient (0.30 vs. 0; P=0.013). Unplanned readmissions and reoperations were likewise increased in the staged group. Minor complication rates were high in both groups, with no differences observed between staged and single-event approaches (3.27 per patient vs. 2.91; P=0.952). There were no complications causing permanent disability or death. The total length of stay (6.2 vs. 4.0 d; P

Introduction: While Anterior Cruciate Ligament (ACL) injuries are common in female soccer players, the optimal graft option is currently unclear. Purpose: The purpose of this study was to compare outcomes of female soccer players undergoing an ACL reconstruction with either hamstring tendon autograft versus bone-patellar tendon-bone (BTB) autograft. Methods: A retrospective review of all skeletally mature adolescent female soccer players who underwent a primary ACL reconstruction with either hamstring tendon or BTB autograft between 2013 and 2016 was performed. Patients who had a multi-ligamentous reconstruction, a prior ACL injury, or had follow-up less than 2 years were excluded. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm, Single Assessment Numerical Evaluation (SANE), Tegner activity, visual analog pain, and satisfaction scores. Ability to return soccer as well as their pre-injury level of play and any reason that they could not return was documented. Results: Ninety-three female soccer players met the inclusion criteria of which 76% (41 BTB and 30 hamstring) were available for a minimum 2 year follow-up or had a documented graft failure prior to this time. The mean age of the cohort was 15.4±1.3 years. The BTB group had a Body Mass Index (BMI) that was significantly lower than the hamstring group (23±3 vs 25±4; p=0.02). There were no other differences in demographic, injury, or surgical variables between groups. Patient reported outcomes demonstrated that most patients did well with a mean Lysholm, SANE, Satisfaction, and pain scores of 92, 88, 8.9, and 1.1 respectively with no differences between groups. The BTB autograft group did achieve a significantly higher Tegner score (6.0 vs 4.3; p=0.004). Although not reaching significance, the BTB group had a greater percentage return to pre-injury level of play (44% vs 30%; p=0.31), or return to any level of soccer play (71% vs 53%; p=0.21 and. Of the patients that returned to soccer, 30% sustained another ACL injury (retear or contralateral tear) with no differences identified based on graft selection. Conclusion: Adolescent female soccer players undergoing an ACL reconstruction have relatively high satisfaction and outcome scores independent of autograft choice. Patients and families, however, need to be counseled that less than half of patients will return to their pre-injury level of sport and if an athlete attempts to return there is a high risk of further ACL injury.

Background:First-time patellar dislocation with an associated chondral or osteochondral loose body is typically treated operatively to address the loose fragment. The incidence of recurrent instability in this patient population if the medial patellofemoral ligament (MPFL) is not reconstructed is unknown.Purpose:To determine the recurrent instability rate in patients undergoing surgery for patellar instability with chondral or osteochondral loose bodies, as well as to identify and stratify risk factors for recurrent instability.Study Design:Case series; Level of evidence, 4.Methods:This was a retrospective analysis of adolescent patients treated operatively for acute patellar dislocation with associated chondral or osteochondral loose bodies between 2010 and 2016 at a single pediatric level I trauma center with minimum 2-year follow-up. Potential demographic, injury-related, radiographic, and surgical risk factors were recorded. The primary outcome variable was recurrent subluxation and/or dislocation. Secondary outcome variables included need for additional procedures, Kujala score, Single Assessment Numerical Evaluation (SANE) score, and patient satisfaction.Results:Forty-one patients were included. In total, 61% experienced recurrent instability at a mean follow-up of 4.1 years and 39% required subsequent MPFL reconstruction. Tibial tubercle-trochlear groove (TT-TG) distance greater than 15 mm was a risk factor for recurrent instability ( P = .03). Patients with TT-TG distance greater than 15 mm and greater than 20 mm had recurrent instability rates of 75% and 86%, respectively. MPFL repair did not reduce the rate of recurrent instability ( P = .87). Recurrent instability was associated with significantly worse mean Kujala (93.9 vs 83.0; P = .01), SANE (88.9 vs 73.1; P = .01), and patient satisfaction scores (9.4 vs 7.3; P = .002).Conclusion:If the MPFL is not reconstructed during index loose body treatment, children have a 61% recurrent instability rate. Patients with TT-TG distance greater than 15 mm, and particularly greater than 20 mm, are at highest risk for recurrent instability.

Cerebral palsy (CP) is the most common cause of pediatric neurodevelopmental and physical disability in the United States. It is defined as a group of motor disorders caused by a nonprogressive perinatal insult to the brain. Although the brain lesion is nonprogressive, there is a progressive, lifelong impact on skeletal muscles, which are shorter, spastic, and may develop debilitating contractures. Satellite cells are resident muscle stem cells that are indispensable for postnatal growth and regeneration of skeletal muscles. Here we measured the myogenic potential of satellite cells isolated from contractured muscles in children with CP. When compared with typically developing (TD) children, satellite cell-derived myoblasts from CP differentiated more slowly (slope: 0.013 (SD 0.013) CP vs. 0.091 (SD 0.024) TD over 24 h, P < 0.001) and fused less (fusion index: 21.3 (SD 8.6) CP vs. 81.3 (SD 7.7) TD after 48 h, P < 0.001) after exposure to low-serum conditions that stimulated myotube formation. This impairment was associated with downregulation of several markers important for myoblast fusion and myotube formation, including DNA methylation-dependent inhibition of promyogenic integrin-β 1D (ITGB1D) protein expression levels (−50% at 42 h), and ~25% loss of integrin-mediated focal adhesion kinase phosphorylation. The cytidine analog 5-Azacytidine (5-AZA), a demethylating agent, restored ITGB1D levels and promoted myogenesis in CP cultures. Our data demonstrate that muscle contractures in CP are associated with loss of satellite cell myogenic potential that is dependent on DNA methylation patterns affecting expression of genetic programs associated with muscle stem cell differentiation and muscle fiber formation.

BACKGROUND Anterior cruciate ligament (ACL) reconstruction failure is relatively common in young high-risk athletes. The purpose of this study was to examine a single center's 10-year experience with ACL reconstructions in pediatric and adolescent patients to better define short-term failure rates and risk factors for revision ACL surgery. METHODS This institutional review board-approved retrospective study included all patients who underwent a primary ACL reconstruction between 2002 and 2013. Chart and radiographic review was performed to assess patient demographic, injury, and surgical data including growth plate status, concomitant ligament/meniscus/cartilage injury, surgical procedures, femoral drilling technique, graft source and type, femoral and tibial fixation devices, and graft size. Graft failures had to be confirmed both with clinical examination and magnetic resonance imaging or the patient had to undergo a revision ACL reconstruction. Potential factors associated with failure were evaluated using either parametric or nonparametric analysis as appropriate. RESULTS A total of 561 ACL reconstructions were performed that met our inclusion criteria. The average patient age was 15.4 years (range, 5 to 19 y) and 53% of the patients were male. In all, 54 failures were identified for a 9.6% failure rate. Soft tissue grafts were twice as likely to fail compared with patellar tendon grafts (13% vs. 6%; P

Introduction Point-of-care ultrasound (US) has been shown to be a useful adjunct in assessment of various shock states and has been utilized to guide both resuscitation and post-resuscitation de-escalation. We aimed to characterize the use of bedside ultrasound examinations performed by advance practice providers (APPs) and attending physicians in a burn intensive care unit (BICU). Methods We introduced routine US by an APP into our BICU and evaluated our experience under an approved PI project. Daily beside US exams were performed utilizing a portable US machine with a cardiac probe and tissue filter. US exams included focused transthoracic echocardiography, assessment of inferior vena cava diameter with distensibility/collapsibility indices, and pulmonary evaluation. The images were archived to a centralized repository and reviewed daily during multi-disciplinary rounds. US data were utilized in conjunction with physical exam, radiographic, and laboratory findings for medical management decision making. Results Thirty-four exams of 34 patients have been conducted to date. 91% of US findings corresponded to physical, laboratory, and radiographic findings, and contributed positively to medical decision making. 9% of US findings either did not contribute to medical decision making or conflicted with physical exam, radiographic, or laboratory findings. Conclusions Our results demonstrate the feasibility of routine US by an APP in the BICU, and indicate that bedside US helps guide both resuscitative and post-resuscitative care. Applicability of Research to Practice It is well known that positive fluid balance is associated with worse clinical outcomes. We believe point-of-care US is a viable tool in preventing over-resuscitation as well as to guide post-resuscitative diuresis.

Purpose Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. Methods A 15-member panel, all established experts with at least nine years’ experience in the surgical management of children with CP, was created (mean of 20.81 years’ experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. Results For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. Conclusion This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. Level of Evidence Level IV

Cerebral palsy is not a disease, but a collection of disorders of the brain resulting from a malformation or injury as the final common pathway. A strict definition of CP is a difficult task to determine. This chapter overviews the history of the “cerebral palsies” and discuss a practical use of the current classification systems to benefit the provider caring for patients with CP.

Recent literature suggests that adults do not necessarily develop osteoarthritis if they have an osteochondral lesion of the talus (OLT). The purpose of this study was to determine if children with OLT are at risk to develop any radiographic evidence of early joint degeneration despite treatment efforts. Fifty-six ankles were identified over 6 years with stable OLT that underwent operative treatment. Preoperatively, each lesion was classified according to Berndt-Hardy for radiographs, Hepple for MRI, and Ferkel and Sgaglione for computed tomography. Radiographs were also evaluated for physeal status, OLT characteristics (location, border, size), and signs of osteoarthritis (Kellgren and Lawrence Scale). Despite incomplete treatment to radiographic resolution, the Kellgren-Lawrence scores still worsened in 23% of the children (pre-op score: mean 0.42 and median 0 versus post-op score: mean 0.69 and median 1). No risk factors (preoperative classification, age, physeal patency) were associated with advancing radiographic evidence of articular degeneration utilizing univariate analysis. However, a classification and regression tree analysis revealed that a patient age of 11.5 years old could be predictive of advancing Kellgren-Lawrence scores with one-third of older children worsening (P = 0.038). Despite active treatment of OLT, the ultimate prognosis is guarded with approximately one out of four children advancing their Kellgren and Lawrence score during treatment. In contrast to the natural history of adult OLT, the short-term advancement of degenerative disease in childhood OLT suggests a potentially different outcome and warrants further investigation into better treatment methods to preserve ankle health in these young patients.

Objectives: It is unclear what the optimal graft choice is for performing a transphyseal ACL reconstruction in a skeletally immature patient. The purpose of the current study was to evaluate outcomes and complications of skeletally immature patients undergoing an ACL reconstruction with hamstring tendon autograft versus quadriceps tendon autograft. Methods: Between 2012 and 2016, 104 skeletally immature patients from a single institution underwent a primary transphyseal ACL reconstruction with either quadriceps tendon autograft or hamstring tendon autograft based on surgeon preference. Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included Lysholm score, SANE score, pain score, satisfaction, return to sport, and complications such as graft tears and physeal abnormalities. Results: Ninety patients (87%) including 62 hamstring tendon reconstructions and 28 quadriceps tendon reconstructions were available for a minimum follow-up of 2 years. The mean age of the patients was 14.8±1.3 years. No differences in chronologic age, bone age, gender, patient size, or mechanism of injury were noted between patient groups. There were no differences in surgical variables except the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 mm vs 7.8 mm; pConclusion: Skeletally immature patients undergoing an ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, relatively high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. Although a relatively new graft source for skeletally immature ACL reconstructions, the quadriceps tendon is not only a viable graft option, but it may be superior to the hamstrings tendon when it comes to early graft failures.

In the United States, many children with cerebral palsy (CP) obtain health care coverage through managed Medicaid, but little is known about the current demographics or management of this high-need, complex population.To develop U.S. population-level information about the prevalence of CP, management patterns, and costs.Data (2013-2015) were analyzed from a managed Medicaid database with coverage of children and adolescents in 15 states. Analyses included demographic information and use of 10 prespecified CP management options often used to manage spasticity. Code-based algorithms were applied to indicate presence of spasticity and determine the likely ambulatory status.In this claims analysis, the prevalence estimate of CP was 1.78 per 1,000 patients. Most (69.8%) children with CP had spasticity, of which 20.8% had hemiplegia, 15.6% diplegia, 32.9% quadriplegia, and 30.5% CP unspecified. Overall, 42.4% of children with CP were not treated with any of the 10 CP management options via Medicaid. Among treated children, the most common management options were physical therapy (37.1%), orthotics (29.9%), oral baclofen (13.5%) and botulinum toxins (9.4%). Overall annualized Medicaid costs were higher for children with CP versus children in the overall database population ($22,383 vs. $1,358). Within the CP population, costs were higher for those children who were likely nonambulatory than for those who were likely ambulatory ($43,687 vs. $10,368, respectively).Most children with CP have spasticity, and the costs of care are high. This study highlights wide variation in the way CP is managed, with many young patients not receiving CP management options via Medicaid.This analysis was funded by Ipsen Biopharmaceuticals and conducted by Milliman. Pulgar and Bains were employees of Ipsen Biopharmaceuticals during the conduct of this study. Chambers is a consultant for OrthoPediatrics and an employee of the University of California. Pyenson and Ferro are employees of Milliman, as was Sawhney during the analysis. Gooch, Noritz, and Wright report no conflicts of interest. Part of this work was presented as a poster at TOXINS 2017: Basic Science and Clinical Aspects of Botulinum and Other Neurotoxins, held January 18-21, 2017, in Madrid, Spain.

Objectives To assess the outcomes and major complications in cats that require oesophageal and gastric endoscopic foreign body removal. Materials and methods The medical records of 52 cats with oesophageal and gastric foreign bodies that underwent endoscopic foreign body retrieval during a 13-year period (2006 to 2018) were retrospectively reviewed to characterise the clinical and radiographic signs, endoscopic findings, outcomes and major complications. Results Endoscopic foreign body retrieval was successful in 49 of the 52 cats (94.2%). Radiographs confirmed the foreign material in 24 of the 50 cats (48%). Major complications occurred in eight of the 52 cats (15.4%) and included pleural effusion (n=2), aspiration pneumonia (n=2), unsuccessful removal of foreign material with endoscopy (n=3), oesophageal stricture formation (n=3) and cardiopulmonary arrest (n=1). Cats with oesophageal foreign bodies were more likely to experience major complications than those with gastric foreign bodies. Clinical significance Endoscopic foreign body removal in cats was associated with good overall outcomes and a low complication rate in this study sample. These results will help veterinarians better understand the outcomes of endoscopic foreign body removal in cats.

Background:Although primary anterior cruciate ligament (ACL) reconstructions have been well studied in children and adolescents, the literature lacks information about revision ACL reconstructions in this population.Purpose:This study aims to analyze the outcomes of revision ACL surgeries in the pediatric population.Study Design:Case series; Level of evidence, 4.Methods:A retrospective study was performed on all revision ACL reconstructions performed at a single institution between 2009 and 2017. Patient demographic, injury, and operative data from both the initial surgery and the revision were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity score, visual analog scale for pain, Hospital for Special Surgery Pediatric Functional Activity Brief Scale score, patient satisfaction, ability to return to the same level of sport, and any additional injury and/or surgery. Outcomes of the revision surgeries were compared with our institution’s outcome database of primary ACL reconstructions.Results:During the study period, 60 revision ACL reconstructions were performed in 57 patients. Of these patients, 84% (n = 48) were available for a minimum 2-year follow-up and a mean follow-up of 4.4 years. A greater number of meniscal tears and cartilage injuries were documented in the revision cohort. Compared with the primary cohort, the revision cohort had lower SANE scores, Lysholm scores, and satisfaction. Furthermore, the revision cohort had a higher rate of graft failure than the primary cohort (21% vs 9%, respectively; P = .015), and only 27% of revision patients returned to the same level of sport. In a comparison of revision procedures performed with autograft versus allograft tissue, the autograft patients had higher Lysholm scores than the allograft patients (91 vs 83, respectively; P = .045) and trended toward a lower failure rate (11% vs 27%, respectively; P = .199).Conclusion:Adolescent patients undergoing revision ACL reconstruction had more meniscal and cartilage abnormalities, poorer functional outcomes, and higher graft failure rates than patients undergoing primary ACL reconstructions. Additionally, revision procedures performed with allograft tissue resulted in lower Lysholm scores and a trend toward higher failure rates. When an ACL graft fails in a young patient, strong consideration should be given to using autograft tissue for the revision.

Satellite cells (SC) are quiescent adult muscle stem cells critical for postnatal development. Children with cerebral palsy have impaired muscular growth and develop contractures. While flow cytometry previously demonstrated a reduced SC population, extracellular matrix abnormalities may influence the cell isolation methods used, systematically isolating fewer cells from CP muscle and creating a biased result. Consequently, the purpose of this study was to use immunohistochemistry on serial muscle sections to quantify SC in situ. Serial cross-sections from human gracilis muscle biopsies (n = 11) were labeled with fluorescent antibodies for Pax7 (SC transcriptional marker), laminin (basal lamina), and 4',6-diamidino-2-phenylindole (nuclei). Fluorescence microscopy under high magnification was used to identify SC based on labeling and location. Mean SC/100 myofibers was reduced by ∼70% (p

Introduction: Children with cerebral palsy (CP) exhibit increased energy expenditure during movement, but whether this is due in part to decrements in skeletal muscle mitochondrial oxidative capacity is unknown. Accordingly, we compared fiber-type specific succinate dehydrogenase (SDH) activity in children with CP with typically developing (TD) children. Methods: SDH activity and myofiber areas of type 1 and 2A fibers were measured in semitendinosus biopsies of both groups (n = 5/group). Results: SDH activity was ∼35% higher in type 1 compared with type 2A fibers, but there were no differences between groups. Average myofiber area was 45% smaller in CP versus TD (P

Parents of children with disabilities encounter stresses unlike those of families with typically developing children. Medical professionals must appreciate that they are not only treating the child but also the family. A state-of-the-art understanding of their patient's disability is implied, but they must also understand the dynamics of raising a child with a disability, appreciate the different models of health care delivery, and provide guidance in transition to adulthood in healthcare as well as life (education, living arrangements, conservancy, etc). An awareness of the physical and mental health impacts on the parents of a child with a chronic disability should also be appreciated.

The purpose of this seminar was to review a large range of lower extremity and neuromuscular disorders. Because of the diversity of the topics covered, including clubfoot and vertical talus treatment, management of Legg-Calve-Perthes disease, and limb lengthening in dwarfism, this review will focus on the neuromuscular subsection reviewing the current management of the muscular dystrophies, myelomeningocele, and cerebral palsy.

Muscle contractures that occur after upper motor neuron lesion are often surgically released or lengthened. However, surgical manipulation of muscle length changes a muscle's sarcomere length (Ls ), which can affect force production. To predict effects of surgery, both macro- (fascicle length (Lf )) and micro- (Ls ) level structural measurements are needed. Therefore, the purpose of this study was to quantify both Ls and Lf in patients with cerebral palsy (CP) as well as typically developing (TD) children. Soleus ultrasound images were obtained from children with CP and TD children. Lf was determined and, with the joint in the same position, CP biopsies were obtained and formalin fixed, and Ls was measured by laser diffraction. Since soleus Ls values were not measurable in TD children, TD Ls values were obtained using three independent methods. While average Lf did not differ between groups (CP=3.6±1.2 cm, TD=3.5±0.9 cm; p>0.6), Ls was dramatically longer in children with CP (4.07±0.45 µm vs. TD=2.17±0.24 µm; p

Background: It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient. Purpose: To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities. Results: A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037). Conclusion: Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Background: Small-diameter hamstring tendons are frequently encountered during anterior cruciate ligament (ACL) reconstructions in patients with short stature or those who are skeletally immature. The role of augmenting these small-diameter autografts with allograft is unclear. Purpose: To assess clinical outcomes and failure rates in adolescent patients with small hamstring tendon autografts (Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review of all primary ACL reconstructions performed with hamstring autografts identified 385 patients, of whom 50 (13%) had a quadrupled (semitendinosus-gracilis) graft size less than 7 mm. Patients were grouped based on the surgeon’s preference either to augment these grafts with allograft (augmented group; n = 26) or to accept the smaller autograft (nonaugmented group; n = 24). Preoperative demographic, injury, and intraoperative data were documented. All patients were contacted to obtain information about outcome scores, subsequent procedures, and complications. Forty patients (20 in each group) were available for 2-year follow-up. Results: The mean age of the entire cohort was 15.7 years (range, 12-18 years), and 38% were male. No between-group differences were found with respect to any of the preoperative or intraoperative variables except extremity side. The mean graft size for the augmented group was 8.9 mm and for the nonaugmented group was 6.4 mm. At a mean follow-up of 3 years, 6 (30%) of the patients in the augmented group had a graft failure, whereas only 1 (5%) in the nonaugmented group had a failure ( P = .04). Five of the 6 augmented failures occurred within 1 year of surgery, whereas the single failure in the nonaugmented group occurred 2.7years postoperatively. No differences were noted in the reported outcomes between patients in the augmented and nonaugmented groups who did not experience graft failure (Lysholm score, 88 vs 92; Tegner score, 6.4 vs 6.3; single-assessment numeric evaluation score, 86 vs 86; satisfaction, 8.4 vs 8.9, respectively). Conclusion: Adolescents undergoing an ACL reconstruction frequently have small hamstring tendon autograft size. The augmentation of these small grafts with allograft does not reduce graft failure rates and may in fact lead to higher retear rates, with earlier graft failure.

Background:Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems.Purpose:To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories—3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC).Results:The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good.Conclusion:The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD.