Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction.

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Opioid Use in Pediatric Patients After Common Orthopaedic Surgeries.

BACKGROUND: The use and misuse of opioid medications is an epidemic and public health emergency. There are currently no standard guidelines for treating perioperative pain in the pediatric population. The purpose of this study is to describe opioid use among pediatric patients after common orthopaedic surgeries. METHODS: Patients between 5 and 20 years of age undergoing one of 7 common orthopaedic surgeries between the years 2018 to 2020 were prospectively studied. Patients and their families completed a medication logbook to track all doses of pain medication and associated pain scores. RESULTS: Three hundred forty-two patients completed the study, including 174 females and 168 males with a mean age of 14.0 years (range, 5 to 20 y). A total of 4351 tablets or liquid doses of the narcotic medication, 44% of the total prescribed, were consumed. Of the prescribed medication,56% remained unused. Nonsteroidal anti-inflammatory drug use was identified to be the only independent predictor of less narcotic use, with a mean of 5.1 tablets ( P = 0.003) and 1.7 days ( P < 0.01) less opioid consumed among these patients. Thirty-two (9.4%) patients consumed 100% of their prescriptions. Nonmedicinal methods of pain control, most commonly ice, were used by 77% of patients, and this was highly variable between procedures. Physicians were cited as a source of medication information by only 50% of patients, with high variability between procedures. CONCLUSIONS: Opioid medication use in children and adolescents after orthopaedic surgery is significantly less than the number of tablets prescribed, with 56% of the medication prescribed remaining unused in the postoperative period. Duration of narcotic use was longer than anticipated with a wide SD (4.7 d +/-3 d).We recommend orthopaedic surgeons responsibly prescribe pain medications using evidence-based data or the results of their own experience monitoring medication consumption. In addition, and important in the setting of the "opioid epidemic," physicians must counsel patients and families on postoperative pain expectations and appropriate medication use. LEVEL OF EVIDENCE: Level IV, prospective case series.

Multiligament Knee Injuries in Young Athletes.

Evaluation and management of multiligament knee injuries (MLKI) require a comprehensive understanding of anatomy and biomechanics. In addition to a thorough history and physical examination, stress radiographs provide a reliable method to assess knee stability. Single-stage anatomic reconstruction techniques should be performed, as they restore native knee kinematics and enable early knee range of motion and superior outcomes.

A Quartet of Elastic Stable Intramedullary Nails for More Challenging Pediatric Femur Fractures.

INTRODUCTION: The insertion of 2 elastic stable intramedullary nails (ESINs) is a common treatment for pediatric femur fractures. However, the use of this technique in length-unstable or metadiaphyseal fractures has historically been associated with higher complication rates. To improve stability, the addition of a third ESIN has been assessed biomechanically and clinically, but the addition of a fourth nail has only been evaluated biomechanically. The purpose of this study is to report our surgical technique and radiographic outcomes using a quartet of ESINs in pediatric femur fractures. METHODS: A retrospective review was performed of pediatric patients with length-unstable or metadiaphyseal femur fractures who were treated with 4 ESINs by a single surgeon from 2008 to 2013. Nails were inserted in a retrograde manner, 2 each from medial and lateral starting points. Patients were followed clinically and radiographically until the union and routine removal of hardware. Primary outcomes included fracture union, sagittal, and coronal plane alignment, and complications. RESULTS: Fourteen patients underwent quartet ESIN placement. Two patients were excluded: one for early loss to follow-up and another with a diagnosis of osteogenesis imperfecta. The average patient age was 9.3 years (range, 4 to 14 y) and weight was 47 kg (range, 21 to 95 kg). All fractures achieved radiographic union at mean 5.5 months (range, 2 to 9 mo). Hardware was removed at a mean of 9.4 months (range, 2 to 22 mo) following implantation. At final mean follow-up of 18 months, patients and families reported no functional limitations. There were no hardware failures or revision surgeries. There were no limb length discrepancies or malalignment at the time of final radiographic follow-up. There were 2 minor complications-1 patient with pain secondary to nail migration resulting in prominence at the knee and another with refracture following a fall. The stable refracture occurred before complete fracture union and hardware removal and went on to the union without the need for any additional treatment. CONCLUSIONS: Treatment with a quartet of ESINs should be considered for skeletally immature children with length-unstable or metadiaphyseal femur fractures. In this series, all fractures achieved union without major complications or hardware failure. This modification to traditional elastic nailing techniques is an option for the surgeon to consider as an alternative to rigid intramedullary nailing, submuscular plating, or external fixation. LEVEL OF EVIDENCE: Level IV.

Pigmented Villonodular Synovitis of the Knee: An Underappreciated Source of Pain in Children and Adolescents.

BACKGROUND: Pigmented villonodular synovitis (PVNS) is a benign proliferative synovial disorder most commonly described in adults. The purpose of this study is to describe the presentation and management of a large single-center series of pediatric patients with PVNS of the knee. METHODS: A retrospective review was performed of consecutive pediatric patients treated for PVNS at a single institution from 2001 to 2016. Inclusion criteria were patients below 20 years of age with surgical treatment of histologically proven PVNS of the knee. Review of the electronic medical record was utilized to gather demographic data, clinical presentation, affected joint, imaging findings, treatment, and disease persistence. RESULTS: Over the 16-year study period, 17 pediatric patients with an average age of 11 years (range, 3 to 19 y) were treated for PVNS of the knee. The average duration of symptoms before orthopaedic evaluation was 16 months. More than half of the children were misdiagnosed with a variety of rheumatologic or orthopaedic conditions before their diagnosis of PVNS. On the basis of magnetic resonance imaging (MRI), PVNS was included as a potential diagnosis in 12 of 17 patients (71%). A total of 27 surgeries were performed in 17 patients. Ten patients were treated with a single surgery and 2 patients were treated with staged biopsy followed by synovectomy. Five patients required ≥2 therapeutic surgeries. The majority of procedures were arthroscopic synovectomies (89%). One patient required open resection of a mass in the posterior compartment of the knee and 1 patient had a manipulation under anesthesia for arthrofibrosis. Ten patients were noted to have nodular disease, 4 diffuse, and 3 mixed. At an average 15-month follow-up, 15 patients (88%) were considered to be disease-free based on clinical examination and/or follow-up MRI. Two patients (12%) had MRI studies following their last surgery with findings consistent with persistent PVNS, but only a single patient had persistent symptoms. CONCLUSIONS: This case series of pediatric patients with PVNS of the knee represents the largest single-center cohort in the literature. Although previously considered a disease of young adult patients, PVNS should be considered in pediatric patients with an insidious onset of joint swelling with or without pain. Symptoms may be present for months to years before diagnosis. Patients are frequently misdiagnosed, most commonly with rheumatologic diseases, bleeding disorders, or septic arthritis. MRI with gradient echo sequences is the diagnostic imaging study of choice and arthroscopic synovectomy produces good outcomes with low rates of symptomatic disease persistence. LEVEL OF EVIDENCE: Level IV.

Reliability of Radiographic Assessments of Adolescent Midshaft Clavicle Fractures by the FACTS Multicenter Study Group.

OBJECTIVES: There is a recent trend toward increased surgical treatment of displaced midshaft clavicle fractures in adolescents. The primary purpose of this study was to evaluate the intrarater and interrater reliability of clavicle fracture classification systems and measurements of displacement, shortening, and angulation in adolescents. The secondary purpose was to compare 2 different measurement methods for fracture shortening. METHODS: This study was performed by a multicenter study group conducting a prospective, comparative, observational cohort study of adolescent clavicle fractures. Eight raters evaluated 24 deidentified anteroposterior clavicle radiographs selected from patients 10-18 years of age with midshaft clavicle fractures. Two clavicle fracture classification systems were used, and 2 measurements for shortening, 1 measurement for superior-inferior displacement, and 2 measurements for fracture angulation were performed. A minimum of 2 weeks after the first round, the process was repeated. Intraclass correlation coefficients were calculated. RESULTS: Good to excellent intrarater and interrater agreement was achieved for the descriptive classification system of fracture displacement, direction of angulation, presence of comminution, and all continuous variables, including both measurements of shortening, superior-inferior displacement, and degrees of angulation. Moderate agreement was achieved for the Arbeitsgemeinschaft für Osteosynthesefragen classification system overall. Mean shortening by 2 different methods were significantly different from each other (P < 0.0001). CONCLUSIONS: Most radiographic measurements performed by investigators in a multicenter, prospective cohort study of adolescent clavicle fractures demonstrated good-to-excellent intrarater and interrater reliability. Future consensus on the most accurate and clinically appropriate measurement method for fracture shortening is critical.

Tissue sparing total femoral arthroplasty: technical note.

It is predicted that the number of revision hip and knee arthroplasties will double by the years 2026 and 2015, respectively. As the burden of end-stage prosthetic disease increases, there will be a greater potential need for total femoral arthroplasty. This report describes a patient with a femoral neck fracture nonunion with an ipsilateral multiply revised failed total knee arthroplasty treated by a tissue sparing total femoral arthroplasty. The technique is described, and potential benefits are reviewed.