Anatomic Dissection and CT Imaging of the Anterior Cruciate and Medial Collateral Ligament Footprint Anatomy in Skeletally Immature Cadaver Knees.

BACKGROUND: Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in skeletally immature patients are increasingly recognized and surgically treated. However, the relationship between the footprint anatomy and the physes are not clearly defined. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and define the footprint anatomy in relation to the physes in skeletally immature knees. METHODS: Twenty-nine skeletally immature knees from 16 human cadaver specimens were dissected and divided into 2 groups: group A (aged 2 to 5 y), and group B (aged 7 to 11 y). Metallic markers were placed to mark the femoral and tibial attachments of the ACL and MCL. Computed tomography scans were obtained for each specimen used to measure the distance from the center of the ligament footprints to the respective distal femoral and proximal tibial physes. RESULTS: The median distance from the ACL femoral epiphyseal origin to the distal femoral physis was 0.30 cm (interquartile range, 0.20 to 0.50 cm) and 0.70 cm (interquartile range, 0.45 to 0.90 cm) for groups A and B, respectively. The median distance from the ACL epiphyseal tibial insertion to the proximal tibial physis for groups A and B were 1.50 cm (interquartile range, 1.40 to 1.60 cm) and 1.80 cm (interquartile range, 1.60 to 1.85 cm), respectively. The median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20 cm (interquartile range, 1.00 to 1.20 cm) and 0.85 cm (interquartile range, 0.63 to 1.00 cm) for groups A and B, respectively. The median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05 cm (interquartile range, 2.63 to 3.30 cm) and 4.80 cm (interquartile range, 3.90 to 5.10 cm) for groups A and B, respectively. CONCLUSION: Surgical reconstruction is a common treatment for ACL injury. Computed tomography scanning of pediatric tissue clearly defines the location of the ACL and MCL with respect to the femoral and tibial physes, and may guide surgeons for physeal respecting procedures. CLINICAL RELEVANCE: In addition to ACL reconstruction, recent basic science and clinical research suggest that ACL repair may be more commonly performed in the future. MCL repair and reconstruction is also occasionally required in skeletally immature patients. This information may be useful to help surgeons avoid or minimize physeal injury during ACL/MCL reconstructions and/or repair in skeletally immature patients.

All-Epiphyseal Anterior Cruciate Ligament Femoral Tunnel Drilling: Avoiding Injury to the Physis, Lateral Collateral Ligament, Anterolateral Ligament, and Popliteus-A 3-Dimensional Computed Tomography Study.

PURPOSE: To investigate the relation of the at-risk structures (distal femoral physis, lateral collateral ligament, anterolateral ligament, popliteus, and articular cartilage) during all-epiphyseal femoral tunnel drilling. A second purpose was 2-fold: (1) to develop recommendations for tunnel placement and orientation that anatomically reconstruct the anterior cruciate ligament (ACL) while minimizing the risk of injury to these at-risk structures, and (2) to allow for maximal tunnel length to increase the amount of graft in the socket to facilitate healing. METHODS: Three-dimensional models of 6 skeletally immature knees (aged 7-11 years) were reconstructed from computed tomography and used to simulate all-epiphyseal femoral tunnels. Tunnels began within the ACL footprint and were directed laterally or anterolaterally, with the goal of avoiding injury to at-risk structures. The spatial relation between the ideal tunnel and these structures was evaluated. Full-length tunnels and partial length condyle sockets were simulated in the models using the same trajectories. RESULTS: An anterolateral tunnel could be placed to avoid direct injury to lateral structures. The safe zone on the anterolateral aspect of the femur was larger than that of a tunnel with a direct lateral trajectory (median 127 mm2 vs 83 mm2, P = .028). Anterolateral tunnels were longer than direct lateral tunnels (median 30 mm vs 24 mm, P = .041). Safe angles for anterolateral tunnels were 34° to 40° from the posterior condylar axis; direct lateral tunnels were drilled 4° to 9° from the posterior condylar axis. Sockets could be placed without direct injury to structures at risk with either orientation. CONCLUSIONS: An all-epiphyseal ACL femoral tunnel can be placed without causing direct injury to at-risk structures. A tunnel angled anterolaterally from the ACL origin is longer and has a larger safe zone compared with the direct lateral tunnel. CLINICAL RELEVANCE: The largest safe zone for femoral all-epiphyseal ACL drilling was (1) anterior to the lateral collateral ligament origin, (2) distal to the femoral physis, and (3) proximal to the popliteus tendon origin. A direct lateral tunnel may also be used, but has a smaller safe zone. Sockets or partial length tunnels may have a lower risk of injury to at-risk structures.

Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown. QUESTIONS/PURPOSES: We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis. METHODS: Fourteen skeletally immature knee specimens (median age, 8 years; range, 7-11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each specimen, along with origin, insertion, and dimensions, when applicable. The relationship of the anterolateral ligament origin to the lateral collateral ligament origin was recorded. RESULTS: The anterolateral ligament was identified in nine of 14 specimens. The tibial attachment point was consistently located in the same region on the proximal tibia, between the fibular head and Gerdy's tubercle; however, the femoral origin of the anterolateral ligament showed considerable variation with respect to the lateral collateral ligament origin. The median femoral origin of the anterolateral ligament was 10 mm (first interquartile 6 mm, third interquartile 13) distal to the distal femoral physis, whereas its median insertion was 9 mm (first interquartile 5 mm, third interquartile 11 mm) proximal to the proximal tibial physis. CONCLUSIONS: The frequency of the anterolateral ligament in pediatric specimens we observed was much lower than other studies on adult specimens; future studies might further investigate the prevalence, development, and functional role of the anterolateral ligament of the knee. CLINICAL RELEVANCE: This study expands our understanding of the anterolateral ligament and provides important anatomic information to surgeons considering anterolateral ligament reconstruction concomitantly with primary or revision ACL reconstruction in pediatric athletes.

The Anterolateral Ligament of the Knee: An Inconsistent Finding in Pediatric Cadaveric Specimens.

BACKGROUND: The anterolateral ligament (ALL) of the knee has been identified as a structure that limits internal rotation, and thus, affects the pivot shift mechanism. It has previously been reported in a high percentage of adult subjects. The purpose of the current study was to evaluate whether the ALL could be identified on pediatric cadaveric knee specimens and compare these findings to previously published reports. METHODS: Eight skeletally immature cadaver knee specimens were examined through gross dissection: ages 3 months, 4 months, 1 year, 2 years, 3 years, 3 years, 8 years, and 10 years. There were 3 male and 5 female (7 right, 1 left) specimens. The presence or absence of the ALL was documented in each specimen, through dissection, intermittent internal and external rotation of the tibia, and anterior translation of the tibia, to produce tension of the lateral collateral tissues and joint capsule. These dissections were performed by a group of fellowship-trained orthopaedic surgeons. RESULTS: The iliotibial band, entire lateral joint capsule, lateral collateral ligament, and popliteus were readily identified in each specimen. In 7 specimens, a distinct ALL structure was not identified during dissection. The ALL was identified in 1 of 8 specimens (1-year-old female, right knee). The ALL was further delineated under applied internal rotational stress. CONCLUSIONS: Previous research has suggested that this ligament is present in the majority of adult specimens. This finding was not reproduced in the current study of pediatric cadaveric specimens, where only one of 8 specimens had an identifiable ALL. This suggests that this ligament may develop later in life, after physiological loads are applied to the joint capsule. Further research in both adult and pediatric knees needs to be conducted to further elucidate the development of this ligament, and the role of this structure in knee stability. CLINICAL RELEVANCE: The ALL is a knee ligament that has been described in adults. However, it is unclear whether this structure is present or fully developed in younger populations. The current study sought to identify the ALL in pediatric cadaver knee specimens, identifying this structure in only one of 8 specimens. The findings of this study suggest that the ALL may be an inconsistent structure in the pediatric population.

The patellar insertion of the medial patellofemoral ligament in children: a cadaveric study.

BACKGROUND: The purpose of this study was to evaluate the medial patellofemoral ligament (MPFL) patellar insertion in skeletally immature anatomic specimens. METHODS: Nine pediatric cadaveric knee specimens were examined through gross dissection. Metallic markers were placed at the MPFL patellar insertion footprint. Computed tomographic scans for each specimen were analyzed. The MPFL insertion footprint width, patellar height, and patellar width were measured. The distance from the MPFL insertion footprint center to the midline of the patella was assessed. The proportion of the patella that the MPFL footprint inserted upon was calculated. RESULTS: The mean width of the MPFL patellar insertion footprint was 12 mm (range, 8 to 18 mm). The mean patellar height was 31 mm (range, 20 to 48 mm). The mean patellar width was 27 mm (range, 21 to 39 mm). The center of the MPFL insertion footprint was found to be a mean 4.7 mm (range, -2 to 10.5 mm) above the midline of the patella, with insertion centers occurring both above and below the midline. The MPFL insertion footprint spanned a mean 41% (24% to 63%) of the longitudinal width of the patella. CONCLUSIONS: Most adult studies report the MPFL insertion on the upper 1/2 to 2/3 of the patella. This series of skeletally immature subjects demonstrated that the center of the MPFL insertion was above and below the midpoint of the patella. The MPFL insertions of some of the younger specimens did extend into the distal 1/3 of the patella. The insertion of the older specimens was found in the proximal 2/3 of the patella, a similar location to most previous adult anatomic studies. CLINICAL RELEVANCE: This research suggests that the MPFL insertion on the patella may be at slightly different locations in some skeletally immature subjects compared with adults. The specimens dissected in the present study showed more variability than previously published reports, with some insertions extending into the distal 1/3 of the patella in the youngest subjects. These dissections may be useful to surgeons performing MPFL reconstructions in skeletally immature patients.

The relationship of the femoral physis and the medial patellofemoral ligament in children: a cadaveric study.

BACKGROUND: Patellar dislocations are common in skeletally immature athletes, and the medial patellofemoral ligament (MPFL) is an important primary restraint to lateral patellar translation. The relationship between the MPFL femoral origin footprint and femoral physis is unclear. The purpose of this study was to evaluate the MPFL femoral origin footprint and its relationship to the femoral physis in skeletally immature anatomic specimens. METHODS: Six skeletally immature cadaver knee specimens were examined through gross dissection (group A: 1, 11, and 11 mo; and group B: 8, 10, and 11 y). Metallic markers were placed at the center of the MPFL femoral origin footprint. Computed tomography scans for each specimen were analyzed. The MPFL footprint width, and the vertical distances from the center and proximal extent of the MPFL footprint to the medial aspect of the physis were measured. RESULTS: The mean width of the MPFL femoral origin footprint was 0.70 cm (0.48 to 1.09 cm) and 1.12 cm (1.03 to 1.29 cm) for groups A and B, respectively. The mean distance from the center of the MPFL origin footprint to medial aspect of the distal femoral physis was 0.90 cm (0.52 to 1.30 cm) and 0.40 cm (0.00 to 0.86 cm) distal to the physis for groups A and B, respectively. The mean distance from the proximal extent of the MPFL origin footprint to the medial aspect of the femoral physis was -0.55 cm (-0.28 to -1.03 cm) and 0.16 cm (-0.34 to 0.64 cm) for groups A and B, respectively. CONCLUSIONS: All subjects were found to have a center of the MPFL origin footprint at or below the physis. The proximal extent of the MPFL origin footprint was found to extend above the physis in the 2 older specimens. CLINICAL RELEVANCE: The relationship of the MPFL origin footprint to the femoral physis in the skeletally immature is not well understood. These dissections may be useful to surgeons performing MPFL reconstructions in skeletally immature patients.

MRI Features That Contribute to Decision-Making for Treatment of Capitellar OCD Lesions: An Expert Consensus Using the Delphi Method.

Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined. Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol. Study Design: A consensus statement. Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%. Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%). Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes.

Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group.

BACKGROUND: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. RESULTS: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049). CONCLUSION: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD. REGISTRATION: NCT01754298 (ClinicalTrials.gov identifier).

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

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.

Subscapularis tendon injuries in adolescents: a report of 2 cases.

BACKGROUND: Although shoulder injuries in adolescents are relatively common, injuries to the rotator cuff are relatively rare and not well characterized in the literature. We review 2 cases of adolescent subscapularis tendon avulsions treated surgically. METHODS: The 2 patients were high-level athletes, 1 is a baseball pitcher and the other is a boxer. Both were injured during participation in their respective sports. In each case, the diagnosis was made by magnetic resonance imaging. Patients underwent an open repair by a deltopectoral approach, using suture anchors for fixation. RESULTS: After surgery both patients regained full range of motion and returned to their previous levels of activity. Both patients scored 30 and 35 on the American Shoulder and Elbow Surgeons and University of California, Los Angeles shoulder instruments, respectively. CONCLUSIONS: Subscapularis tendon injuries in adolescents are rare. Diagnosis requires careful attention to the physical examination and imaging. A positive lift-off test, belly-press test, or increased passive external rotation should prompt an early magnetic resonance imaging. Good results and return to previous levels of activity can be achieved with open repair. LEVEL OF EVIDENCE: IV.

A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members.

BACKGROUND: Based on recent evidence of inconsistent outcomes after the closed treatment of adult midshaft clavicle fractures, the management of similar fracture patterns in adolescents is being reevaluated. The primary aim of this study is to report current treatment preferences for adolescent midshaft clavicle fractures among pediatric orthopaedic physicians and to determine if recent adult literature has influenced clinical decision making. METHODS: An invitation email to a cross-sectional, web-based survey was sent to all members of the Pediatric Society of North America. With reference to adolescent sex and age, respondents were prompted to indicate their treatment preference (operative vs. nonoperative) in 4 common midshaft clavicle fracture patterns. The respondents were also asked to indicate if the following factors: findings in current literature supporting operative fixation in adults, arm dominance, and/or athletic status, influenced their preference for operative versus nonoperative management. RESULTS: Of the 949 Pediatric Society of North America members, 302 responded in full (32% response rate). The majority of physicians preferred nonoperative treatment for all fracture patterns. A logistic regression analysis revealed: older adolescent age (12 to 15 y vs. 16 to 19 y.) and evidence in recent adult literature (influence vs. no influence) to be significantly (P < 0.01) predictive of physician preference toward operative fixation in angulated, displaced, and isolated segmental clavicle fracture patterns. Physician years of experience (< 5 y vs. > 5 y) significantly predicted treatment preferences in isolated segmental fractures only. CONCLUSIONS: The percentage of physicians in favor of operative fixation tended to increase in reference to older adolescents and more severe fracture patterns but, nonoperative management was preferred in all fracture patterns. Evidence in recent adult literature was found to be the most significant factor influencing treatment preferences in this survey. Randomized controlled trials are needed to evaluate the efficacy of primary operative fixation of midshaft clavicle fractures in adolescent populations. LEVEL OF EVIDENCE: Cross-sectional electronic survey; level V-expert opinion.

Metrics of OsteoChondral Allografts (MOCA) Group Consensus Statements on the Use of Viable Osteochondral Allograft.

BACKGROUND: Osteochondral allograft (OCA) transplantation has evolved into a first-line treatment for large chondral and osteochondral defects, aided by advancements in storage protocols and a growing body of clinical evidence supporting successful clinical outcomes and long-term survivorship. Despite the body of literature supporting OCAs, there still remains controversy and debate in the surgical application of OCA, especially where high-level evidence is lacking. PURPOSE: To develop consensus among an expert group with extensive clinical and scientific experience in OCA, addressing controversies in the treatment of chondral and osteochondral defects with OCA transplantation. STUDY DESIGN: Consensus statement. METHODS: A focus group of clinical experts on OCA cartilage restoration participated in a 3-round modified Delphi process to generate a list of statements and establish consensus. Questions and statements were initially developed on specific topics that lack scientific evidence and lead to debate and controversy in the clinical community. In-person discussion occurred where statements were not agreed on after 2 rounds of voting. After final voting, the percentage of agreement and level of consensus were characterized. A systematic literature review was performed, and the level of evidence and grade were established for each statement. RESULTS: Seventeen statements spanning surgical technique, graft matching, indications, and rehabilitation reached consensus after the final round of voting. Of the 17 statements that reached consensus, 11 received unanimous (100%) agreement, and 6 received strong (80%-99%) agreement. CONCLUSION: The outcomes of this study led to the establishment of consensus statements that provide guidance on surgical and perioperative management of OCAs. The findings also provided insights on topics requiring more research or high-quality studies to further establish consensus and provide stronger evidence.

Isolated avulsion fracture of the subscapularis tendon with medial dislocation and tear of biceps tendon in a skeletally immature athlete: a case report.

Isolated avulsion fracture of the subscapularis from the lesser tuberosity of the humerus is rare in the pediatric population and only a couple of cases have been described in the literature. In our case, a 13-year-old young man suffered an avulsion of the subscapularis tendon from the lesser tuberosity of the humerus, accompanied by medial dislocation of the biceps tendon with degeneration and tear. The diagnosis was delayed until he completed several weeks of physical therapy. Special tests performed earlier in the primary care clinic or emergency department could have prevented prolonged symptoms and allowed earlier surgical intervention.

Association Between Concussion History and Factors Relating to Cognitive, Behavioral, and Emotional Health Among American High School Athletes: A Cross-sectional Analysis.

BACKGROUND: The cognitive, behavioral, and emotional deficits that may be associated with sports-related concussions among adolescents are unclear. PURPOSE: To examine the association between reported concussion history and factors relating to cognitive, behavioral, and emotional health among a population-based sample of US high school-aged adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Participants included a representative sample of US high school student-athletes who reported a concussion history (in the past 12 months) and relevant behaviors/outcomes within 3 domains: cognitive (academics, difficulty concentrating), behavioral (drinking and driving, carrying a weapon, physically fighting, tobacco use, marijuana use, binge drinking), and emotional (symptoms of depression, suicidal thoughts/actions). The adjusted relative odds of experiencing 0 and at least 1, 2, 3, or ≥4 concussions were modeled while mutually adjusting for the behaviors of interest in addition to age, race/ethnicity, and sleep problems. Data were reported in sex stratum. RESULTS: A total of 13,268 participants were included in the unweighted data set. Overall, 14.5% (95% CI, 12.9%-16.2%) of female and 18.1% (95% CI, 16.4%-19.8%) of male student-athletes had at least 1 concussion in the past 12 months. As compared with those who reported not engaging in any of the behaviors deleterious to health or having had any of the negative health outcomes (composite score of 0), female athletes with composite scores of 1 to 4, 5 to 7, and 8 to 11 were 1.94 (95% CI, 1.55-2.43), 3.13 (95% CI, 2.30-4.33), and 6.05 (95% CI, 3.75-9.75) times more likely to have a recent history of concussions after accounting for relevant factors. As compared with those having a composite score of 0, male athletes with composite scores of 1 to 4, 5 to 7, and 8 to 11 were 2.03 (95% CI, 1.58-2.59), 3.80 (95% CI, 2.71-5.34), and 8.23 (95% CI, 4.91-13.77) times more likely to have a recent history of concussions after accounting for relevant factors. CONCLUSION: Self-reported concussions among US high school athletes is related to several deleterious health behaviors and outcomes. These associations should be confirmed in longitudinal analyses.

An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint.

BACKGROUND: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. PURPOSE: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. STUDY DESIGN: Consensus statement. METHODS: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. RESULTS: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. CONCLUSION: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.

Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics.

BACKGROUND: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented. PURPOSE: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable. RESULTS: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements. CONCLUSION: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model.

BACKGROUND: Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative. PURPOSE: To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures. STUDY DESIGN: Cross-sectional study. METHODS: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient's sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon's decision, as well as surgeon training background, years in practice, and risk-taking behavior. RESULTS: The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon's propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent's preference for surgical treatment. CONCLUSION: There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Epidemiology of Shoulder and Elbow Injuries Among United States High School Baseball Players: School Years 2005-2006 Through 2014-2015.

BACKGROUND: Shoulder and elbow injuries are common in young athletes, especially high school baseball players. Understanding the risk factors associated with baseball injuries is an essential first step in the development of injury prevention strategies. PURPOSE: To provide a comprehensive understanding of the epidemiology of shoulder and elbow injuries among high school baseball players in the United States. STUDY DESIGN: Descriptive epidemiological study. METHODS: Baseball-related injury data were obtained from the National High School Sports-Related Injury Surveillance Study using High School RIO (Reporting Information Online), an Internet-based sports injury surveillance system. Athletic trainers from high schools across the country uploaded data regarding athlete-exposures (AEs) (defined as practice or game participation) and shoulder and elbow injuries from the school years 2005-2006 through 2014-2015. RESULTS: A total of 241 shoulder injuries and 150 elbow injuries occurred during 1,734,198 AEs during the study period, for an overall shoulder injury rate of 1.39 per 10,000 AEs and an overall elbow injury rate of 0.86 per 10,000 AEs. The overall rates of injury were higher in competitions compared with practices for shoulders (rate ratio, 1.44; 95% CI, 1.11-1.85) and elbows (rate ratio, 2.15; 95% CI, 1.56-2.96). The majority of shoulder (39.6%) and elbow (56.9%) injuries were sustained by pitchers, and most injuries were chronic and caused by overuse. Position players were more likely to sustain injuries by contact with the playing surface or apparatus. For pitchers, muscle strains were the most common shoulder injuries (38.7%), while ligament sprains were the most common elbow injuries (42.7%). The majority of pitchers with shoulder (70.8%) and elbow (64.6%) injuries returned to play within 21 days. Among pitchers, a higher proportion of elbow injuries (11.4%) resulted in medical disqualification compared with shoulder injuries (5.6%). Among pitchers, the majority of shoulder (89.2%) and elbow (96.4%) injuries were managed nonsurgically. CONCLUSION: Shoulder and elbow injury rates and patterns in high school baseball players differed between field positions (pitchers vs position players) and by type of exposure (practice vs competition). This study suggests several areas of emphasis for targeted injury prevention interventions, most notably limiting fatigue and preventing overuse injuries.

Variation in the Medial Patellofemoral Ligament Origin in the Skeletally Immature Knee: An Anatomic Study.

BACKGROUND: The medial patellofemoral ligament (MPFL) is frequently reconstructed to treat recurrent patellar instability. The femoral origin of the MPFL is well described in adults but not in the skeletally immature knee. PURPOSE: To identify a radiographic landmark for the femoral MPFL attachment in the skeletally immature knee and study its relationship to the distal femoral physis. STUDY DESIGN: Descriptive laboratory study. METHODS: Thirty-six cadaveric specimens between 2 and 11 years old were dissected and examined (29 male and 7 female). Metallic markers were placed at the proximal and distal borders of the MPFL femoral origin footprint. Computed tomography scans with 0.625-mm slices in the axial, coronal, and sagittal planes were used to measure the maximum ossified height and ossified depth. The measurements were used to describe the position of the midpoint MPFL attachment with respect to the posterior-anterior and distal-proximal dimensions of the femoral condyle on the sagittal view and to describe the distance from the physis to the femoral origin of the MPFL. RESULTS: In 23 of 36 specimens, the femoral origin of the MPFL was distal to the physis. Thirteen of the 36 specimens had an MPFL origin at or proximal to the physis, with a more proximal MPFL origin consistently seen in older specimens. The distance of the MPFL origin to the physis ranged from 15.1 mm distal to the physis to 8.3 mm proximal to the physis. The mean midpoint of the MPFL femoral origin was located 3.0 ± 5.5 mm distal to the physis for all specimens. For specimens aged <7 years, the mean MPFL origin was 4.7 mm distal to the physis, and for specimens aged ≥7 years, the mean MPFL origin was 0.8 mm proximal to the femoral physis. The MPFL origin was more proximal and anterior for those aged ≥7 years and more distal and posterior for those aged <7 years. CONCLUSION: Surgical reconstruction of the MPFL is a common treatment to restore patellar stability. There appears to be significant variability in the origin of the MPFL in skeletally immature specimens. This study demonstrated that the MPFL origin was more proximal and anterior with respect to the physis in the older age group. The MPFL origin footprint may be customized for different age groups. CLINICAL RELEVANCE: This information shows anatomic variation of the MPFL origin with age, with older specimens having a footprint that was more proximal and anterior than younger specimens. Customization of the surgical technique might be considered based on patient age.