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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: 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: 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: Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors’ integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity. Study Design: Cohort study; Level of evidence, 2. Methods: All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric–Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score. Results: A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (–4.551, P = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score. Conclusion: Increased narcotic use surrounding surgery, physical therapy location within the authors’ health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.

Background: Little has been reported in the literature regarding surgical treatment of posterior cruciate ligament (PCL) injuries in pediatric patients. Purpose/Hypothesis: The purpose was to evaluate presentation, injury pattern, outcomes, and complications of surgically managed PCL injuries in pediatric patients. It was hypothesized that pediatric patients would have good patient-reported outcomes and no significant radiographic changes or complications. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using PubMed, Medline, EMBASE, Scopus, and Cochrane databases between 1975 and December 16, 2019. Search terms included “posterior cruciate ligament,” “peel-off injury,” “avulsion,” “PCL,” “pediatric,” “skeletally immature,” and “adolescent.” Included were studies on pediatric patients with PCL injuries managed operatively. Exclusion criteria included case reports, studies not reporting clinical results, reviews, abstract or conference papers, or papers not in the English language. Quality assessment was performed on all included studies using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Results: Four articles comprising 43 knees in 42 patients met the criteria and were included. Motor vehicle accidents were the most common mechanism of injury (39.5%; n = 17/43), followed by sports-related injuries (35%; n = 15/43). All studies commented on tear pattern, with the following distribution: 42% (n = 18/43) midsubstance tears, 37% (n = 16/43) tibial avulsions, and 21% (n = 9/43) femoral avulsions. Overall, good patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score and Pediatric International Knee Documentation Committee, Tegner, and Lysholm scores) and return to activity, as well as satisfactory posterior stability (KT-1000 arthrometer, posterior drawer test, and kneeling radiographs) and range of motion, were reported. There was no significant leg-length discrepancy or angular deformity reported. Arthrofibrosis was reported in 7% of postoperative knees and was the most commonly reported complication. Osteoarthritis was reported in 21% (n = 9/43) of knees. The average MINORS score was 7 (range, 6-8) for noncomparative studies and 10 for comparative studies. Conclusion: Good patient-reported outcomes and return to activity can be obtained using repair or reconstruction. This evidence was limited by the quality of the included studies and overall small sample size; however, this review serves as a baseline for futures studies on PCL repair/reconstruction in pediatric patients.

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.

Objectives: Meniscus tears are a common and significant source of knee dysfunction in active young adult patients, and no high-quality prospective cohort or RCTs studies exist evaluating patient-reported outcomes in patients in this age group with ligamentously stable knees. Our objective was to identify patient-reported outcomes and patient-specific risk factors from a prospective cohort with a minimum of one-year follow-up following meniscal repair or excision in patients with ligamentously stable knees. We hypothesized that both groups would have significant improvement in outcomes; patients undergoing meniscal repair would have a higher reoperation rate; and articular cartilage injuries, subsequent knee surgery, and certain demographic characteristics would be significant risk factors to inferior outcomes at one year. Methods: Between February 2015 and December 2017, ligamentously stable meniscal procedures were enrolled and prospectively followed using the outcomes management evaluation system (OME) at Cleveland Clinic. Patients aged 23-39 preoperatively completed a series of validated outcome measurements including the Knee Injury and Osteoarthritis Outcome Score for both Pain (KOOS Pain) and Quality of Life (KOOS QoL). At the time of surgery, physicians documented all intra-articular findings, treatment, and surgical techniques utilized. Patients were followed at minimum of 1-year postoperatively through the OME platform and asked to complete the same outcome instruments done at baseline as well as a question designed to evaluate the Patient Acceptable Symptom State (PASS). The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of outcomes. Results: A total of 371 patients aged 23-39 underwent meniscus excision or repair during the study period. One hundred ninety-four met inclusion criteria, and one-year follow-up was obtained on 72% (n = 139) of the cohort (67% male; median age 32). Both KOOS Pain and KOOS QoL improved significantly at one-year for the entire cohort. Fourteen percent of the cohort (9% on the ipsilateral knee, 5% on the contralateral knee) underwent subsequent surgery at a minimum of one-year postoperatively. The patient-specific risk factors for worse one-year outcomes included preoperative baseline mental capacity score (VR-12 MCS), lower baseline KOOS QoL score, and the intraoperative finding of any grade 3 or 4 chondral changes. Conclusion: Young adult patients with ligamentously stable knees undergoing meniscal surgery have significantly improved patient-reported outcomes regardless of excision or repair; however, 14% of patients underwent additional knee surgery at a minimum of one-year postoperatively. The risk factors for worse outcomes include lower baseline mental health score, lower baseline KOOS QoL score, and any grade 3 or 4 chondromalacia scene.

Objectives: In high school and college athletes, the results of isolated meniscectomy compared to meniscal repair in ligamentously stable knees is unknown. Our objective was to compare patient-reported outcomes and reoperation rates at a minimum 1 year of follow-up for high school and college athletes undergoing isolated meniscal repair compared to meniscectomy. We hypothesized that both groups would see significant improvement in outcomes with meniscectomy having higher reported outcomes and a lower reoperation rate compared to meniscal repair. Methods: Patients aged 13-22 years old undergoing meniscal surgery at a single institution between 2015-2017 were prospectively enrolled and followed in our outcomes management evaluation system (OME). Pre-operatively, patients’ baseline demographics and patient-reported outcomes (PROMs) specific to meniscal pathology were collected, including Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and quality of life (QoL) subsets. Post-operatively, intra-operative findings and treatments were recorded from OME. Patients were contacted and completed a minimum 1- or 2-year patient-reported outcome measures survey. Embedded in the post-operative survey was a question designed to evaluate the Patient Acceptable Symptom State (PASS). Patients were also specifically asked if they had undergone any subsequent surgeries to either knee since their primary procedure as a preliminary assessment of early failure. Results: A total of 145 patients were enrolled (70% male; median age, 18 years). One-year minimum PROMs were obtained on 73% (n=106) of the cohort. The results are displayed in the table and figure. KOOS QoL (see figure) and pain scores at minimum 1-year follow-up were not significantly different between meniscal repair compared to meniscectomy. Reoperation rate was 7.5% overall with no significant difference noted between the groups. No individual variables, including body mass index (BMI), smoking, level of education, mental health status, or grade 3 or 4 cartilage lesions were found not to be significant risk factors for outcome in either group. A PASS was achieved in 82% of the meniscectomy group and 71% of the meniscal repair group. Conclusion: High school and college athletes undergoing isolated meniscal surgery had equally significant improvements in minimum 1-year PROMs regardless of whether they underwent meniscectomy or meniscal repair. Preliminary reoperation rates were similar amongst the two treatment groups and the majority of both groups achieved a patient acceptable symptom state. No individual variable was identified as a modifiable risk factor to poor outcome after isolated meniscal surgery in this age group. [Figure: see text]

Background:Machine learning (ML) allows for the development of a predictive algorithm capable of imbibing historical data on a Major League Baseball (MLB) player to accurately project the player's future availability.Purpose:To determine the validity of an ML model in predicting the next-season injury risk and anatomic injury location for both position players and pitchers in the MLB.Study Design:Descriptive epidemiology study.Methods:Using 4 online baseball databases, we compiled MLB player data, including age, performance metrics, and injury history. A total of 84 ML algorithms were developed. The output of each algorithm reported whether the player would sustain an injury the following season as well as the injury’s anatomic site. The area under the receiver operating characteristic curve (AUC) primarily determined validation.Results:Player data were generated from 1931 position players and 1245 pitchers, with a mean follow-up of 4.40 years (13,982 player-years) between the years of 2000 and 2017. Injured players spent a total of 108,656 days on the disabled list, with a mean of 34.21 total days per player. The mean AUC for predicting next-season injuries was 0.76 among position players and 0.65 among pitchers using the top 3 ensemble classification. Back injuries had the highest AUC among both position players and pitchers, at 0.73. Advanced ML models outperformed logistic regression in 13 of 14 cases.Conclusion:Advanced ML models generally outperformed logistic regression and demonstrated fair capability in predicting publicly reportable next-season injuries, including the anatomic region for position players, although not for pitchers.

Background: The young athletic population makes up the largest portion of shoulder instability and, when treated nonoperatively, has a recurrent dislocation rate as high as 71%. It is unknown how the outcomes of those who have a recurrent dislocation are affected versus those who have a stabilization procedure after a first-time dislocation. Purpose: To report the postoperative outcomes of patients with first-time dislocations versus patients with recurrent dislocations before surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Current Procedural Terminology codes were used to identify patients who had arthroscopic Bankart repair between 2003 and 2013. A total of 173 eligible patients were identified across 8 fellowship-trained surgical practices. The first phase of the study was a retrospective chart review. Patients were identified as having a first-time dislocation or as having recurrent dislocations when they had >1 dislocation before surgical intervention. The second phase consisted of a survey to record a Simple Shoulder Test score and return to sport and to report postoperative instability and whether patients had further surgery on the shoulder. Results: A total of 121 patients participated, providing 70% follow-up at an average of 51 months. There were 53 patients in the recurrent dislocation group and 68 in the first-time dislocation group. The postoperative instability rate was 29% in the first-time dislocation group and 62% in the recurrent dislocation group; this difference was significant ( P < .001). The odds of postoperative instability were 4 times higher in the recurrent dislocation group (odds ratio = 4.14). The first-time dislocation group reported a 7% rate of repeat operation to address instability, whereas the recurrent dislocation group reported a rate of 32%; this difference was significant ( P < .001). The odds of needing additional surgery on the index shoulder was 6 times higher in the recurrent dislocation group (odds ratio = 6.01). Conclusion: Patients with first-time dislocations had lower postoperative instability rates and reoperation rates when compared with patients with recurrent dislocations before surgery. Young patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation.

Introduction The objectives of this study are (1) to develop a provider-friendly, evidence-based data capture system for lower-limb orthopaedic surgeries and (2) to assess the performance of the data capture system on the dimensions of agreement with operative note and implant log, consistency of data, and speed of provider input. Methods A multidisciplinary team developed a database and user interfaces for Android and iOS operating systems. Branching logic and discrete fields were created to streamline provider data input. One hundred patients were randomly selected from the first four months of data collection (February to June 2015). Patients were limited to those undergoing anterior cruciate ligament reconstruction, meniscal repair, partial meniscectomy, or a combination of these procedures. Duplicate data on these 100 patients were collected through chart review. These two data sets were compared. Cohen's kappa statistic was used to assess agreement. Results The database and smartphone data capture tool show almost perfect agreement (kappa > 0.81) for all data tested. In addition, data are more comprehensive with near-perfect provider completion (100% for all data tested). Furthermore, provider data entry is extremely efficient (median 151-second completion time). Conclusion A well-designed database and user-friendly interface have greater potential for research utility, clinical efficiency, and, thus, cost-effectiveness when compared with standard voice-dictated operative notes. Widespread utilization of such tools can accelerate the pace and improve the quality of orthopaedic clinical research. Level of evidence Level IV.

Background: Patient-reported outcome measures are commonly used to measure knee pain and functional impairment. When structural abnormality is identified on examination and imaging, arthroscopic partial meniscectomy and chondroplasty are commonly indicated for treatment in the setting of pain and decreased function. Purpose: To evaluate the relationship between patient characteristics, mental health, intraoperative findings, and patient-reported outcome measures at the time of knee arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Between February 2015 and October 2016, patients aged 40 years and older who were undergoing routine knee arthroscopy for meniscal and cartilage abnormality, without reconstructive or restorative procedures, were prospectively enrolled in this study. Routine demographic information was collected, and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Quality of Life (QoL), and Physical Function Short Form (PS) subscales and the mental and physical component subscales of the Veterans RAND 12-Item Health Survey (VR-12 MCS and VR-12 PCS) were administered preoperatively on the day of surgery. Intraoperative findings were collected in a standardized format. Patient demographics, intraoperative findings, and the VR-12 MCS were used as predictor values, and a multivariate analysis was conducted to assess for relationships with the KOOS and VR-12 as dependent variables. Results: Of 661 eligible patients, baseline patient-reported outcomes and surgical data were used for 638 patients (97%). Lower scores on both subscales of the VR-12 were predicted by female sex, positive smoking history, fewer years of education, and higher body mass index (BMI). All KOOS subscales were negatively affected by lower VR-12 MCS scores, female sex, lower education level, and higher BMI in a statistically meaningful way. Positive smoking history was associated with worse scores on the KOOS-PS. Abnormal synovial status was associated with worse KOOS-Pain. Conclusion: The demographic factors of sex, smoking status, BMI, and education level had an overwhelming impact on preoperative KOOS and VR-12 scores. Of interest, mental health as assessed by the VR-12 MCS was also a consistent predictor of KOOS scores. The only intraoperative finding with a significant association was abnormal synovial status and its effect on KOOS-Pain scores.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper’s knee due to the high prevalence seen in the athletic community. In many published reports, the name “patellar tendinopathy” is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Background: The length of most patient-reported outcome measures creates significant response burden, which hampers follow-up rates. The Patient Acceptable Symptom State (PASS) is a single-item, patient-reported outcome measure that asks patients to consider all aspects of life to determine whether the state of their joint is satisfactory; this measure may be viable for tracking outcomes on a large scale. Hypothesis: The PASS question would identify clinically successful anterior cruciate ligament reconstruction (ACLR) at 1-year follow-up with high sensitivity and moderate specificity. We defined “clinically successful” ACLR as changes in preoperative to postoperative scores on the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale and the KOOS knee-related quality of life subscale in excess of minimal clinically important difference or final KOOS pain or knee-related quality of life subscale scores in excess of previously defined PASS thresholds. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients enrolled in a prospective longitudinal cohort completed patient-reported outcome measures immediately before primary ACLR. At 1-year follow-up, patients completed the same patient-reported outcome measures and answered the PASS question: “Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?” Results: A total of 555 patients enrolled in our cohort; 464 were eligible for this study. Of these, 300 patients (64.7%) completed 1-year follow-up, of whom 83.3% reported satisfaction with their knee after surgery. The PASS question demonstrated high sensitivity to identify clinically successful ACLR (92.6%; 95% CI, 88.4%-95.6%). The specificity of the question was 47.1% (95% CI, 35.1%-59.5%). The overall agreement between the PASS and our KOOS-based criteria for clinically successful intervention was 81.9%, and the kappa value indicated moderate agreement between the two methods (κ = 0.44). Conclusion: The PASS question identifies individuals who have experienced clinically successful ACLR with high sensitivity. The limitation of the PASS is its low specificity, which we calculated to be 47.1%. Answering “no” to the PASS question meant that a patient neither improved after surgery nor achieved an acceptable final state of knee health. The brevity, interpretability, and correlation of the PASS question with significant improvements on various KOOS subscales make it a viable option in tracking ACLR outcomes on a national or global scale.

Background: Two versions of the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form currently exist: the original version (1999) and a recently modified pediatric-specific version (2011). Comparison of the pediatric IKDC with the adult version in the adult population may reveal that either version could be used longitudinally. Hypothesis: We hypothesize that the scores for the adult IKDC and pediatric IKDC will not be clinically different among adult patients aged 18 to 50 years. Study Design: Randomized crossover study design. Level of Evidence: Level 2. Methods: The study consisted of 100 participants, aged 18 to 50 years, who presented to orthopaedic outpatient clinics with knee problems. All participants completed both adult and pediatric versions of the IKDC in random order with a 10-minute break in between. We used a paired t test to test for a difference between the scores and a Welch’s 2-sample t test to test for equivalence. A least-squares regression model was used to model adult scores as a function of pediatric scores, and vice versa. Results: A paired t test revealed a statistically significant 1.6-point difference between the mean adult and pediatric scores. However, the 95% confidence interval (0.54-2.66) for this difference did not exceed our a priori threshold of 5 points, indicating that this difference was not clinically important. Equivalence testing with an equivalence region of 5 points further supported this finding. The adult and pediatric scores had a linear relationship and were highly correlated with an R2 of 92.6%. Conclusion: There is no clinically relevant difference between the scores of the adult and pediatric IKDC forms in adults, aged 18 to 50 years, with knee conditions. Clinical Relevance: Either form, adult or pediatric, of the IKDC can be used in this population for longitudinal studies. If the pediatric version is administered in adolescence, it can be used for follow-up into adulthood.

Injuries and disorders of the patellofemoral joint in the adolescent athlete can encompass a wide spectrum of symptomatology and pathology. Anterior knee pain is a common presenting symptom in sports medicine clinics, and can have numerous underlying etiologies. This activity-related pain may be the manifestation of enthesopathy, tendinopathy, fat pad impingement, or numerous other conditions, but is more commonly related to more subtle skeletal and muscular imbalances. Treatment is typically nonoperative in nature, and excellent results are reported with physical therapy. Patellofemoral instability usually has a more dramatic onset in the form of dislocation or subluxation events, commonly experienced during athletics. Concomitant injuries to the patellofemoral articular cartilage are common. Again, treatment is typically nonoperative initially, but recurrent or recalcitrant instability may necessitate reconstructive or realignment procedures. Skeletal maturity often dictates what procedures can be safely attempted.

With the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. This review focuses on overuse and traumatic injuries of the shoulder and elbow in young athletes. In particular we discuss little league shoulder, glenohumeral internal rotation deficit, glenohumeral instability, superior labrum anterior posterior lesions, Little League elbow, Panner disease, osteochondritis dissecans of the capitellum, posteromedial elbow impingement, and posterolateral rotatory instability of the elbow. There is a significant emphasis on the evaluation and management of upper extremity injury in the overhead thrower.

Background: Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility. Purpose/Hypothesis: The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including “no” to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries. Study Design: Cohort study; Level of evidence, 2. Methods: Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed. Results: A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries ( P < .05). Responders’ mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores ( P < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure. Conclusion: Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.

In the United States, youth participation in sports continues to increase yearly. This increase in participation, in conjunction with the trend toward early sports specialization and year round training, has led to a similar increase in athletically developed injuries. These injuries vary in nature and acuity, with the type of injury often related to the athlete's age, sport, and level of training. Endurance athletes are at an elevated risk of injury as they frequently push their body to the limit during their arduous training. Pediatric endurance athletes can be particularly vulnerable, especially to overuse injuries, given their unique and ever-changing physiological state. It is important to understand the specific challenges facing not only the physical, but also the emotional well-being of these pediatric endurance athletes to maximize performance while minimizing injury and potential long-term sequelae.

A thorough understanding of anterior cruciate ligament (ACL) function and the effects of surgical interventions on knee biomechanics requires robust technologies and simulation paradigms that align with clinical insight. In vitro orthopedic biomechanical testing for the elucidation of ACL integrity doesn't have an established testing paradigm to simulate the clinical pivot shift exam on cadaveric specimens. The study aim was to develop a robotically simulated pivot shift that represents the clinical exam. An orthopedic surgeon performed a pivot shift on an instrumented ACL-deficient cadaver leg to capture 6 degree-of-freedom motion/loads. The same knee was mounted to the robot and the sensitivity of the motion/loading profiles quantified. Three loading profile candidates that generated positive pivot shifts on the instrumented knee were selected and applied to 7 ACL-intact/deficient specimens and resulted in the identification of a profile that was able to induce a positive pivot shift in all ACL-deficient specimens ( p < 0.001). The simulated shifts began at 22 ± 8° and ended at 33 ± 6° of flexion with the average magnitude of the shifts being 12.8 ± 3.2 mm in anterior tibial translation and 17.6 ± 4.3° in external tibial rotation. The establishment and replication of a robotically simulated clinical pivot shift across multiple specimens show the robustness of the loading profile to accommodate anatomical and experimental variability. Further evaluation and refinement should be undertaken to create a useful tool in evaluating ACL function and reconstruction techniques. Statement of clinical significance: Creation and successful demonstration of the simulated clinical pivot shift validates a profile for robotic musculoskeletal simulators to analyze ACL related clinical questions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2601-2608, 2019.

Objective This study tested validity, accuracy, and efficiency of the Orthopaedic Minimal Data Set Episode of Care (OME) compared with traditional operative report in arthroscopic surgery for shoulder instability. As of November 2017, OME had successfully captured baseline data on 97% of 18 700 eligible cases. Materials and Methods This study analyzes 100 cases entered into OME through smartphones by 12 surgeons at an institution from February to October 2015. A blinded reviewer extracted the same variables from operative report into a separate database. Completion rates and agreement were compared. They were assessed using raw percentages and McNemar’s test (with continuity correction). Agreement between nominal variables was assessed by unweighted Cohen’s kappa and a concordance correlation coefficient measured agreement between continuous variables. Efficiency was assessed by median time to complete. Results Of 37 variables, OME demonstrated equal or higher completion rates for all but 1 and had significantly higher capture rates for 49% (n = 18; P 0.61) for 51% (n = 17) for the 33 nominal variables. All continuous variables assessed (n = 4) demonstrated poor agreement (concordance correlation coefficient Conclusions The OME smartphone data capture system routinely captured more data than operative report and demonstrated acceptable agreement for nearly all nominal variables, yet took

Background: Osteochondritis dissecans (OCD) of the elbow is a problematic condition that affects a fair number of young athletes. One treatment option is the use of osteochondral autografts, which are commonly taken from donor sites on the less weightbearing surfaces of the knee. Purpose: To use magnetic resonance imaging (MRI) to assess the cartilage depths of sites in the knee and elbow that are commonly used as donor and recipient sites to optimize depth matching for osteochondral autograft procedures. Study Design: Descriptive laboratory study. Methods: All knee and elbow MRI scans acquired from 3-T machines in patients aged 16 to 25 years within a single hospital system were reviewed. Studies were excluded if there had been previous surgery on the joint or if there were significant chondral defects in the areas to be measured. All cartilage depth measurements were independently performed by 3 different physicians to the nearest 0.01 mm. At the elbow, 6 locations on the capitellum and 2 on the trochlea were chosen. At the knee, 4 locations along the anterior-lateral femoral condyle, 5 surrounding the intercondylar notch, and 1 on both the medial- and lateral-posterior femoral condyles were chosen. Results: There were 111 knee MRI (74 male, 37 female) and 94 elbow MRI (85 male, 9 female) scans that met all inclusion criteria. The average cartilage depths from each investigator were then averaged to provide an overall mean depth at each location. All average cartilage depths within the knee were thicker than those in the elbow, where the averaged mean thickness of all the 8 measured sites was 1.27 mm (range, 0.78-1.63 mm). Within the knee, the thinnest areas of cartilage, and therefore closest matches, were discovered at the posterior pole of the medial femoral condyle (mean ± SD, 1.95 ± 0.46 mm) and at the distal-most anterior-lateral femoral condyle (1.85 ± 0.46 mm). The average variance between the mean cartilage depths measured by each investigator for each location was 0.12 mm in the elbow and 0.22 mm in the knee. Conclusion: Average cartilage depths in the knee were thicker than those in the elbow at all sites measured. The thinnest areas in the knee were the posterior aspect of the medial femoral condyle and the distal-most aspect of the anterior-lateral femoral condyle. Clinical Relevance: This study provides the surgeon with meaningful data on average cartilage depths at common donor sites in the knee and recipient sites in the elbow.

In the general population, the overall incidence of acute patellar dislocation is 5.8 per 100,000 people in the United States1. The rate of patellar dislocation is estimated to be highest in the age group of ten to seventeen years, with reported rates of 29% to 43%1-3. Women have a 33% increased prevalence of acute patellar dislocation compared with men1. Patellar instability typically occurs in patients with several anatomic risk factors, including both soft-tissue and osseous abnormalities. Conlan et al. studied twenty-five cadaveric specimens to analyze soft-tissue restraints associated with patellar instability and found the medial patellofemoral ligament to be a critical medial soft-tissue restraint in preventing lateral instability4. Furthermore, biomechanical and radiographic findings have led many surgeons to state that disruption of the medial patellofemoral ligament is the “essential lesion” required for patellar dislocation1,4-7. Disruption of the medial patellofemoral ligament was diagnosed on magnetic resonance imaging (MRI) in twenty-six (96%) of twenty-seven patients8; the lesion most commonly occurs at the femoral attachment site9,10 (Fig. 1). In addition, the deep capsular layer, the medial patellomeniscal ligament, and the medial patellotibial ligament all have been found to contribute to the soft-tissue stabilization of the patella against lateral …

Magnetic resonance imaging (MRI) is a commonly used tool for the diagnosis of intra-articular knee pathologies. Although many studies have reported the accuracy of MRI in the adult population, fewer studies have investigated these tests in younger patients. Furthermore, these studies have shown a higher variability in both the sensitivity and the specificity of MRI for these knee injuries in this age group. Advancements in MRI technology, such as the 3-Tesla (3T) MRI magnet, have shown promising results for musculoskeletal injury diagnosis in adults. This study aims to evaluate 3 T MRI for the diagnosis of intra-articular knee pathologies in a pediatric and adolescent patient population.The records of 116 patients (119 knees) under the age of 20 years who underwent 3 T MRI studies of the knee and subsequent knee arthroscopy were reviewed retrospectively. The MRI report from the musculoskeletal radiology staff, the interpretation from the staff orthopedic surgeon, and the operative note dictations were compared, with a focus on meniscus and anterior cruciate ligament (ACL) pathologies. Seventeen orthopedic staff reads were not obtainable. Arthroscopy was used as the gold standard for diagnosis.The average age at MRI exam was 16.0 years and at surgery was 16.2 years. Using the musculoskeletal radiologist interpretation, the sensitivity and the specificity of 3 T MRI were 81.0% and 90.9% for medial meniscus injuries, 68.8% and 93% for lateral meniscus injuries, and 97.9% and 98.6% for ACL injuries, respectively. The orthopedic surgeon's interpretation of 3 T MRI had a sensitivity and specificity of 75.7% and 92.4% for medial meniscus injuries, 69.8% and 98.3% for lateral meniscus injuries, and 100% and 98.6% for ACL injuries, respectively. Posterior horn tears had the greatest discrepancies.When performed on pediatric and adolescent patients, newer 3 T MRI studies have excellent accuracy for diagnosing ACL tears. These studies also show a higher accuracy for the diagnosis of medial meniscal tears than lateral meniscal tears.Diagnostic study--Level 2.

Injuries to the pediatric and adolescent athlete are becoming more common as increasing numbers of this patient population are participating in year-round sporting activities. As these figures continue to rise, there have been an escalating number of patients with both traumatic and nontraumatic, sports-related knee injuries presenting to orthopedic surgeons for evaluation. Anterior cruciate ligament injuries in these patients, specifically in the skeletally immature, represent a complex problem. Treatment of these patients requires a thorough understanding of anatomy and physiology of the pediatric patient, the natural history of this injury, and knowledge of the potential complications of surgical intervention. This review will address these topics and will describe the presentation, diagnosis, and most commonly used surgical techniques currently being used with these patients. Future directions and advances in care of these injuries will also be discussed.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy in the non-athlete population. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the previous part we reviewed: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In this part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Background: With childhood sports opportunities continuing to increase at an enormous rate along with participation starting at younger ages, the number of female participants in sports has increased in paramount fashion over the past few decades. A review of the current literature reveals a very small number of studies (Purpose: To retrospectively evaluate the incidence of various injuries and injury rates for different gymnast levels among young precollegiate female gymnasts over a 21-year period, from 1985 to 2005. Study Design: Descriptive epidemiological study. Methods: This institutional review board–approved study retrospectively evaluated young, precollegiate female gymnasts over a 21-year period. Gymnasts were stratified into 1 of 4 competition levels based on the number of hours spent training. In addition to the frequency of injuries and hours trained, data collected on each gymnast included the following: age at the time of injury, body part injured, laterality of the injury, and diagnosis. Results: Over the 21-year period, 3681 new injuries were evaluated by a single physician. The injury incidence (2.155 per 1000 exposure hours) was slightly lower when compared with previously reported injury rates. There were 1,452,574 total exposure hours documented from training facility records. The injury rate per 1000 exposure hours was 2.859 for elite, 2.820 for high-level, 1.667 for intermediate, and 0.687 for novice gymnasts. The lower extremity was injured more often than the upper extremity (60.9% compared with 22.6% of total injuries). This difference was statistically significant across all levels. Conclusion: The injury incidence in this study was 2.155 per 1000 exposure hours. This was slightly lower when compared with previously reported injury rates. Although those studies only lasted 3 years or less, the injury rates can be directly compared because they are reported as injuries per 1000 training hours. Clinical Relevance: With the variability in data available and limited studies reported, a conclusive analysis is needed because of the long-term effects of injury seen on gymnasts, such as early degenerative disorders, cost of injury treatment, and reduction of well-being. In our 21-year study, we found the incidence of injury was slightly lower than that shown in prior shorter studies. In addition, we were able to evaluate specific injuries seen in this population over that time period. Also, this extended study revealed the longitudinal nature of a series of injuries over a period of time that has not been seen in other studies, thus giving insight into the effects of increased gymnastics in the young, female, adolescent population, which could be potentially used in guidelines for gymnasts in the future.

Background: The International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form is a patient-reported outcome with adult (1998) and pediatric (2011) versions validated at different ages. Prior longitudinal studies of patients aged 13 to 17 years who tore their anterior cruciate ligament (ACL) have used the only available adult IKDC, whereas currently the pediatric IKDC is the accepted form of choice. Purpose/Hypothesis: This study compared the adult and pediatric IKDC forms and tested whether the differences were clinically significant. The hypothesis was that the pediatric and adult IKDC questionnaires would show no clinically significant differences in score when completed by patients aged 13 to 17 years. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 100 participants aged 13 to 17 years with knee injuries were split into 2 groups by use of simple randomization. One group answered the adult IKDC form first and then the pediatric form. The second group answered the pediatric IKDC form first and then the adult form. A 10-minute break was given between form administrations to prevent rote repetition of answers. Study design was based on established methods to compare 2 forms of patient-reported outcomes. A 5-point threshold for clinical significance was set below previously published minimum clinically important differences for the adult IKDC. Paired t tests were used to test both differences and equivalence between scores. By ordinary least-squares models, scores were modeled to predict adult scores given certain pediatric scores and vice versa. Results: Comparison between adult and pediatric IKDC scores showed a statistically significant difference of 1.5 points; however, the 95% CI (0.3-2.6) fell below the threshold of 5 points set for clinical significance. Further equivalence testing showed the 95% CI (0.5-2.4) between adult and pediatric scores being within the defined 5-point equivalence region. The scores were highly correlated, with a linear relationship ( R2 = 92%). Conclusion: There was no clinically significant difference between the pediatric and adult IKDC form scores in adolescents aged 13 to 17 years. This result allows use of whichever form is most practical for long-term tracking of patients. A simple linear equation can convert one form into the other. If the adult questionnaire is used at this age, it can be consistently used during follow-up.

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient. [ Orthopedics. 2015; 38(3):e240–e243.]

One hundred and ninety-nine total hip arthroplasties were performed, between 1983 and 1987, in 173 patients by three surgeons using the initial design of the porous-coated anatomic prosthesis. The acetabular component was a preassembled, metal-backed polyethylene device, with beads sintered to the metal backing to allow bone ingrowth and two pegs for initial fixation. Twenty-three acetabular components (12 percent) failed because of either migration or severe osteolysis. The radiographic appearance of osteolysis was positively associated with the duration that the implant had been in situ (p0.001). The prevalence of osteolysis was also significantly greater in acetabular components with an outer diameter of fifty-five millimeters or less (a polyethylene thickness of 8.5 millimeters or less) (p = 0.03). Thirteen hips were revised at a mean of 69.5 months (range, thirty-three to ninety-one months) after the index operation. Examination of the retrieved acetabular components revealed extensive polyethylene damage on the articular and back surfaces of the liners. Cracks in the polyethylene rim of the liner and deformation of the anti-rotation notch in the polyethylene rim were common findings. The density of the polyethylene was greater than expected, and more particles than anticipated had not fused with the surrounding polyethylene. The results of this study suggest that factors related to both the design and the material contributed to the failure of these porous-coated anatomic acetabular components.

Objectives: The shoulder is the most common joint dislocation effecting roughly 2% of the general population. Males are effected to a higher degree that females at a ratio of 3:1.1-2 The young, athletic population make up the largest portion of shoulder instability, and treated nonoperatively have a recurrent dislocation rate approaching 50%.3-5 Owens et. al recently published a cohort looking at 45 college athletes with an in season shoulder instability event. 73% of athletes returned to play in season. Only 36% of athletes completed the season without re-injury and 64% of athletes had a recurrent instability event.6 It is unknown how the outcomes of those who go on to have a recurrent dislocation in season are effected versus those who have a stabilization procedure after a first time dislocation. The objective of the current study is to report the postoperative outcomes of first time dislocators versus patients with recurrent dislocations prior to surgery. Methods: CPT codes were used to identify patients who had arthroscopic Bankart repair between 2003-2013. 439 patients aged 16-30 years were identified across 8 fellowship trained surgical practices. The first phase of the study was a retrospective chart review to obtain patient demographics, number of reported preoperative dislocations, review imaging, and number of anchors placed. Patients were identified as first time dislocators or as recurrent dislocators when they had more than one dislocation prior to surgical intervention. The second phase consisted of a survey to obtain a simple shoulder test score, whether they returned to sport, postoperative instability events and further surgery on the shoulder. Postoperative instability was defined as a subluxation or dislocation reported by the patient survey in the postoperative period. Of the 439 patients identified, 296 were excluded for revision surgery, open repair, posterior instability, multidirectional instability, HAGL lesion, labral tears involving the biceps anchor and refusal to participate. This left 144 patients eligible for the study. Results: 121 patients participated for a follow up rate of 85% at an average of 51 months post surgery. There were 53 patients in the recurrent dislocation group and 68 in the first time dislocation group. The average age in both groups was 19yrs. The postoperative instability rate in the first time dislocator group was 9%. The postoperative instability rate in the recurrent dislocator group was 47%. This was statistically significant with pConclusion: First time dislocators had lower postoperative instability rates and reoperation rates when compared to patients with recurrent dislocations prior to surgical intervention. The SST scores were significantly different between groups. Young, athletic patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation.

Authors’ Response: We greatly appreciate the viewpoints of Dr Jaiman concerning the timing/use of the 4.5-mm reamer when utilizing a flexible reamer for establishing a femoral tunnel. Using a flexible reamer system is very advantageous in creating a low femoral tunnel especially in the current context of concomitant anterolateral ligament (ALL) reconstruction or posterolateral corner reconstruction, as can often be needed with revision anterior cruciate ligament (ACL) surgery. Furthermore, avoiding knee hyperflexion facilitates placement of the femoral guide pin, as visualization and graft passage is almost never compromised as is often seen with straight pins/reamers placed using the necessary hyperflexion to avoid a short femoral tunnel. Furthermore, with modern flexible reamers and experience, the ACL tunnel length is maximized, with most condylar distances 35 to 40 mm with use of standard offset guides. As the reader suggests, utilizing the appropriate graft size reamer first is quite acceptable as it does seat the femoral tunnel/socket when the pin is placed ideally. We often utilize this first step. However, in those situations when the nitinol pin is too posterior or low on the lateral wall, using the 4.5-mm reamer first across the intercondylar distance allows adjustability of the femoral tunnel anteriorly or superiorly without having to replace the flexible pin. In our experience, redirecting a slightly low or posterior nitinol wire can be difficult as the nitinol pin often drops into the same track. Furthermore, there are advantages to knowing the condylar width (especially if too short or in the case of a less experienced surgeon) before seating the femoral tunnel. If the surgeon does elect to ream first with the 4.5-mm reamer, the femoral tunnel can still be seated in an accurate position, despite the mobility. One advantage of reaming with the 4.5-mm first, in our experience, is that it allows the flexible final-sized reamer to seat itself within the condyle in the scenario where the pin is too posterior. We agree that placement of the final socket centered on the bifurcate ridge is most critical, and we often ream with the final-sized reamer first then follow with the 4.5-mm reamer. We discussed in the article reaming with the 4.5-mm reamer first as it is a very nice technical trick to adjust the final socket without having to replace the nitinol pin when the initial attempt/placement could be adjusted slightly anteriorly or superiorly, which is often the case. When using a bone-tendon-bone autograft, this technique modification helps avoid posterior wall blow out from a posteriorly placed nitinol wire. Although using the final-sized reamer first works extremely well when the pin is placed accurately, we find that reaming with the 4.5-mm reamer first prevents the larger, final-sized reamer from kinking on the nitinol wire and is often easier to ream. With our change to the Stryker flexible system we have not had reamer or wire breakage regardless of the order of reaming. As to the use of the tibial guide, the proper selection of tibial angle we agree can be variable and is best adjusted to replicating the ACL tibial footprint. We find the 55° setting very useful when performing hamstrings autografts but have utilized other angles of approach, when appropriate, as suggested by the readers’ comment.

There has been a significant increase in youth sports participation and athletic activities over the past 3 decades. With the increase in participation, there has been a commensurate rise in the number of sports-related injuries. A majority of these injuries are due to overuse as athletes frequently compete in multiple sports with year round competition and training. As higher demands are placed on these young athletes, the likelihood of injury during and individual's playing career continues to increase. This review will focus on both overuse and traumatic injuries of the upper extremity in the adolescent athlete. A significant emphasis will be placed on the evaluation and management of soft tissue and bony injuries in the overhead throwing athlete. The review will conclude with a discussion on common wrist and hand injuries seen in this population.

Anatomic reconstruction of the anterior cruciate ligament (ACL) has been shown to improve stability of the knee, particularly rotational stability, potentially leading to superior clinical outcomes and a shorter return to sport. Nonanatomic ACL reconstruction has been linked to graft failure and abnormal cartilage loading thought to contribute to progression of degenerative joint disease. Use of the far anteromedial portal (FAMP) to uncouple the tibial and femoral tunnels has led to improved reproduction of the femoral footprint and facilitates drilling of the femoral tunnel in an anatomic position. The use of the FAMP and straight reamer systems introduces its own set of potential complications, including short femoral tunnels and peroneal nerve injury. These potential complications have been addressed by drilling the femoral tunnel in a hyperflexed position, which can lead to difficulty with positioning the operative extremity, visualization, and identification of anatomic landmarks. The purpose of this case report was to review the advantages and technical aspects of using a flexible reamer system and the FAMP to achieve an anatomic ACL reconstruction while avoiding potential complications and pitfalls. Flexible reamer systems allow an additional way of uncoupling the tibial and femoral tunnels to clearly visualize and establish an anatomic starting point within the femoral footprint of the native ACL while avoiding the complications associated with knee hyperflexion and straight reamers with the far anteromedial portal. In the authors’ experience, an anatomic reconstruction of the ACL can be achieved safely using flexible reamers while avoiding some of the difficulties seen with straight reamers used in conjunction with an uncoupled, far anteromedial approach.

Background: There is a paucity of information regarding the effect of lesion location on surgical outcomes in the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. Purpose: To survey the literature for conclusions that can be drawn regarding the effect of lesion location on treatment of capitellar OCD lesion. The hypothesis was that lesion severity and the need for more aggressive surgical interventions are increased for lesions that are located laterally on the capitellum. Study Design: Systematic review; Level of evidence, 4. Methods: All studies from the past 20 years were determined using a literature search of PubMed, Scopus, and Cochrane databases. Included studies were clinical studies that specifically commented on the location of the OCD defect on the capitellum. Excluded studies were case reports, review articles, and those that did not include information regarding the location of the OCD lesion on the capitellum. Results: Six studies met the inclusion criteria. Autograft reconstruction was found to yield reliable outcomes regardless of lesion location, as 87% (26/30) of lateral lesions had excellent or good outcomes using the Timmerman and Andrews score, while 91% (21/23) of central lesions had excellent or good outcomes. There was a trend toward improved outcomes with more aggressive surgical management of lateral lesions, specifically those involving the lateral cartilage margin. The failure rate for nonreconstructive operative management for lateral lesions was noted to be significant, as failure rates for peg fixation of lateral lesions was seen to be as high as 44% (4/9) in one of the studies. Conclusion: Studies regarding capitellar OCD lesion location, as it relates to symptom severity and surgical outcome, are limited. The literature suggests that lesions located on the lateral capitellum—particularly those involving the lateral cartilage margin—require more aggressive surgical management than those located medially. A refinement of the Takahara classification is proposed, which includes lesion location as a factor influencing surgical decision making.