The Number of Patellar Dislocation Events Is Associated With Increased Chondral Damage of the Trochlea.

BACKGROUND: Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established. PURPOSE: To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures. STUDY DESIGN: Cross-sectional study; Level of evidence, 2. METHODS: A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions. RESULTS: A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence (P = .17) or grade (P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations (P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001). CONCLUSION: This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment.

Isolated Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability Regardless of Tibial Tubercle-Trochlear Groove Distance and Patellar Height: Minimum 5-Year Outcomes.

BACKGROUND: It remains unclear which subset of patients with recurrent patellofemoral instability would benefit from a concomitant bony realignment procedure in addition to a medial patellofemoral ligament (MPFL) reconstruction. PURPOSE: To provide midterm results for patients who underwent an isolated MPFL reconstruction as part of an ongoing prospective trial. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with recurrent patellar instability were prospectively enrolled in an institutional registry beginning in March 2014. Exclusion criteria included history of a previous surgery for patellar instability, an off-loadable (inferior/lateral) chondral defect, anterior knee pain ≥50% of their chief complaint, and a "jumping J" sign. All patients underwent primary, unilateral, isolated MPFL reconstruction regardless of their bony anatomic characteristics. Patient-reported outcome measures (PROMs), episodes of recurrent instability, and ability to return to sport were obtained annually. Radiographic measurements of baseline radiographs and MRI were obtained at baseline. RESULTS: A total of 138 patients underwent isolated MPFL reconstruction between March 2014 and December 2019. The mean radiographic measurements were tibial tubercle-trochlear groove, 15.1 ± 4.9 mm; Caton-Deschamps index, 1.14 ± 0.16; patellar trochlear index, 46.9% ± 15.1%; trochlear depth index, 2.5 ± 1.2 mm; tibial tubercle to lateral trochlear ridge, -8.4 ± 5.7 mm; and patellar tendon to lateral trochlear ridge, 5.7 ± 6.2 mm. Trochlear dysplasia, defined as a trochlear depth index <3 mm, was present in 79/125 (63%) patients. A total of 50 patients reached ≥5 years, of whom 40 (80%) completed follow-up PROMs. A total of 119 patients reached ≥2 years, of whom 89 (75%) completed follow-up PROMs. Six patients (5%) reported recurrent instability with a mean time of 2.97 years after surgery. All PROMs improved over time except for the Pediatric Functional Activity Brief Scale (Pedi-FABS), which had no change. At 2 years, the mean changes from baseline for Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life subscale (QOL), Pedi-FABS, International Knee Documentation Committee (IKDC) score, KOOS Physical Function Short Form (PS), and Kujala score were 42.1, 0.6, 35.1, -23.5, and 32.3, respectively. All changes had P values <.001 except for Pedi-FABS, which showed no change and had P > .999. At 5 years, the mean changes from baseline for KOOS-QOL, Pedi-FABS, IKDC, KOOS-PS, and Kujala score were 42.6, -2.8, 32.6, -21.5, and 31.6, respectively. All changes had P values <.001 except for Pedi-FABS, which showed no change and had P > .453. In total, 89% of patients returned to sport with a mean of 9.1 months. CONCLUSION: Midterm outcomes for patients who underwent isolated MPFL reconstruction were favorable and were maintained at 5 years. Outcomes for the expanded cohort of patients with a minimum 2-year follow-up support previously published results.

HIV broadly neutralizing antibody escapability drives the therapeutic efficacy of vectored immunotherapy.

Broadly neutralizing antibodies (bNAbs) have shown great promise for prevention and treatment of HIV infection. Breadth of bNAb neutralization, measured in vitro across panels of diverse viral isolates, is often used as a predictor of clinical potential. However, recent prevention studies demonstrate that the clinical efficacy of a broad and potent bNAb (VRC01) is undermined by neutralization resistance of circulating strains. Using HIV-infected humanized mice, we find that therapeutic efficacy of bNAbs delivered as Vectored ImmunoTherapy (VIT) is a function of both the fitness cost and resistance benefit of mutations that emerge during viral escape, which we term 'escapability'. Applying this mechanistic framework, we find that the sequence of the envelope V5-loop alters the resistance benefits of mutants that arise during escape, thereby impacting the therapeutic efficacy of VIT-mediated viral suppression. We also find that an emtricitabine-based antiretroviral drug regimen dramatically enhances the efficacy of VIT, by reducing the fitness of mutants along the escape path. Our findings demonstrate that bNAb escapability is a key determinant to consider in the rational design of antibody regimens with maximal efficacy and illustrates a tractable means of minimizing viral escape from existing bNAbs.

A Curricular Model for Simulation Within Orthopaedic Residency Training.

Introduction: American Board of Orthopaedic Surgery/American Council on GraduateMedical Education Residency Review Committee training requirements have necessitated the need for the adoption of simulation education into existing programmatic requirements. Current guidelines focus only on interns at a potentially significant cost to programs; both in total dollar amount and time. Methods: The authors aim to provide a model that can maximize utility for all resident levels, manage cost by maximizing the use of cadaveric material, and allow integration of varied industry support. Results: The Oregon Health & Science University Orthopaedic education program has developed a high-fidelity training curriculum that (1) is applicable to both junior and senior residents (2) has minimized the cost per resident with the reuse of cadaveric specimens and (3) has nurtured partnerships with industry stakeholders to reduce bias in training by collaborating with most major industry representatives. Conclusion: The simulation curriculum outlined in this manuscript may serve as a reference for other programs and institutions to develop their own residency educational curriculum models.

Resident Performance on the Fundamentals of Arthroscopic Surgery Training (FAST) Workstation Does Not Predictably Improve With Postgraduate Year.

Purpose: To identify differences in performance on the Fundamentals of Arthroscopic Surgery Training (FAST) workstation between residents across different postgraduate years and training sites. Methods: During the 2018-2019 academic year, 102 orthopaedic surgery residents from 4 training sites completed 6 FAST modules. Failure was defined as either completion time exceeding benchmark time or commission of task-specific errors. With the exception of knot tying, each module was completed by participants twice-once with each hand serving as the camera hand. Time to completion (except for knot tying) and errors were recorded for each of the modules. Completion times and failure rates were compared between postgraduate years, seniority groups, and training sites. Results: In all modules for which time was recorded, except for the suture-passage module, there was no significant difference in time to completion based on seniority (P < .01 for suture passage and P > .05 for all others). Significant differences in completion time were observed between sites for all modules except for the suture-passage module (P = .957 for suture passage and P < .05 for all others). Site predicted failure by at least 1 measure (time or technical error) for all modules (P < .05) except for number probing and suture passage. Failure rate across training years varied for each module. Conclusions: Time to completion and rate of failure did not predictably decrease with level of training. Training site proved to be a significant predictor of performance. Factors such as hand dominance and familiarity with the equipment proved to be important considerations for some modules. Clinical Relevance: Objective assessment of arthroscopic skills among orthopaedic trainees is difficult. Using reproducible methodology to assess trainees on specific skills at all postgraduate years and at multiple training sites may provide important information about orthopaedic training.

Antibody-mediated prevention of vaginal HIV transmission is dictated by IgG subclass in humanized mice.

HIV broadly neutralizing antibodies (bNAbs) are capable of both blocking viral entry and driving innate immune responses against HIV-infected cells through their Fc region. Vaccination or productive infection results in a polyclonal mixture of class-switched immunoglobulin G (IgG) antibodies composed of four subclasses, each encoding distinct Fc regions that differentially engage innate immune functions. Despite evidence that innate immunity contributes to protection, the relative contribution of individual IgG subclasses is unknown. Here, we used vectored immunoprophylaxis in humanized mice to interrogate the efficacy of individual IgG subclasses during prevention of vaginal HIV transmission by VRC07, a potent CD4-binding site-directed bNAb. We find that VRC07 IgG2, which lacks Fc-mediated functionality, exhibited substantially reduced protection in vivo relative to other subclasses. Low concentrations of highly functional VRC07 IgG1 yielded substantial protection against vaginal challenge, suggesting that interventions capable of eliciting modest titers of functional IgG subclasses may provide meaningful benefit against infection.

School Nurses Practices Promoting Self-Management and Healthcare Transition Skills for Adolescents with Chronic Conditions in Urban Public Schools: A Mixed Methods Study.

Background: Adolescents and young adults (AYA) with chronic conditions should acquire self-management skills as part of their healthcare transition (HCT) from pediatric to adult-focused care. HCT/self-management skills have the potential to help mitigate health disparities among minority AYA with chronic conditions. This study investigated school nurses' practices promoting HCT/self-management skills in urban public schools. Methods: Seventy-nine nurses from three urban school districts in Massachusetts completed a survey of 32 Likert-type questions on HCT/self-management skills, eight demographic questions, and five open-ended practice questions assessing how often they have asked students with chronic conditions about HCT/self-management skills, based on the UNC TRxANSITION IndexTM. Results: Among the 79 school nurses who participated (response rate 76%), 67% never or rarely assessed students' knowledge of HCT/self-management, and 90% would use a tool that promotes/measures HCT/self-management skills. Conclusion: In our study sample, most school nurses acknowledged the importance of assessing HCT/self-management skills. The majority favored using a tool to promote these skills.

Evaluation of a Tool to Measure the Demands of Immigration.

BACKGROUND: The Demands of Immigration (DI) scale consists of six subscales and is designed to measure demands that negatively affect emotional health of immigrants. PURPOSE: The purpose of this review is to (a) examine the DI scale's language versions and translation procedures; and (b) evaluate reliability and validity of the DI scale based on studies subsequent to its initial development. METHODS: Published studies were identified through CINAHL Complete, MEDLINE, Social Sciences Premium Collection and PsycInfo. RESULTS: Seventeen quantitative studies reported the DI scale's reliability (internal consistency and test-retest) and/or validity (content and construct). Correlations among the DI subscales and key variables (e.g., job satisfaction, acculturation, depression, perceived support, and resilience) support its construct validity. CONCLUSION: The DI scale is a reliable and valid tool for measuring demands or challenges that immigrants face.

Congenital Hypothyroidism.

Congenital hypothyroidism (CH) is a disorder of thyroid hormone deficiency which develops secondary to incomplete thyroid development or inadequate thyroid hormone production. State-mandated newborn screening throughout the United States has increased the detection rate of CH, allowing for early intervention. Although the overall mortality rate of CH is low, delayed or omitted treatment can lead to devastating neurocognitive outcomes. As such, CH is regarded as the leading cause of preventable intellectual disability in children. Early identification, facilitated by astute neonatal nursing and medical care, is contingent upon an active working knowledge of the disease process and awareness of the limitations of the newborn screen.

Orthopaedic Resident Arthroscopic Knot-Tying Skills Are Improved Using a Training Program and Knot-Tying Workstation.

PURPOSE: To quantify an orthopaedic trainee's ability to tie arthroscopic knots before and after a short cadaveric-based arthroscopy training period using a commercially available knot-tying workstation. METHODS: During a weeklong cadaveric arthroscopic training camp, 15 third- and fourth-year orthopaedic residents were evaluated using a commercially available benchtop knot-tying workstation. At the beginning of the week (baseline), each participant was asked to tie 3 knots of his or her choice backed up by 3 half-hitches using nonabsorbable suture. Successful knots fit the sizer and elongated less than 3 mm after application of a 15-lb load. Afterward, residents watched a video demonstrating a sample knot and were encouraged to practice over the ensuing days. At the end of the week (post-training), residents were asked to tie 3 knots. The time to completion and success of each knot were recorded. To compare baseline and post-training knot success, t tests and χ2 analysis were performed. RESULTS: During baseline testing, residents successfully tied 26.7% of their knots (12 of 45 knots) in 352 ± 116 seconds (mean ± standard deviation). During post-training testing, residents successfully tied 66.7% of knots (30 of 45 knots, P = .00014) in 294 ± 63 seconds (P = .023), showing significant improvement in the time and ability to tie arthroscopic knots. CONCLUSIONS: With a short cadaveric-based training period, orthopaedic trainees showed a significant improvement in their ability to tie arthroscopic knots on a commercially available benchtop knot-tying workstation. Given the initial low percentage of successfully tied knots and the limited opportunities for trainees to improve, trainees should be encouraged to practice and improve their skills. CLINICAL RELEVANCE: With training, residents can improve arthroscopic knot-tying abilities, which may allow them to successfully perform this critical task in the operating room.

Exosomal proteomic signatures correlate with drug resistance and carboplatin treatment outcome in a spontaneous model of canine osteosarcoma.

BACKGROUND: Osteosarcoma patients often experience poor outcomes despite chemotherapy treatment, likely due in part to various mechanisms of tumor cell innate and/or acquired drug resistance. Exosomes, microvesicles secreted by cells, have been shown to play a role in drug resistance, but a comprehensive protein signature relating to osteosarcoma carboplatin resistance has not been fully characterized. METHODS: In this study, cell lysates and exosomes from two derivatives (HMPOS-2.5R and HMPOS-10R) of the HMPOS osteosarcoma cell line generated by repeated carboplatin treatment and recovery, were characterized proteomically by mass spectrometry. Protein cargos of circulating serum exosomes from dogs with naturally occurring osteosarcoma, were also assessed by mass spectrometry, to identify biomarkers that discriminate between good and poor responders to carboplatin therapy. RESULTS: Both cell lysates and exosomes exhibited distinct protein signatures related to drug resistance. Furthermore, exosomes from the resistant HMPOS-2.5R cell line were found to transfer drug resistance to drug-sensitive HMPOS cells. The comparison of serum exosomes from dogs with a favorable disease-free interval [DFI] of > 300 days, and dogs with < 100 days DFI revealed a proteomic signature that could discriminate between the two cohorts with high accuracy. Furthermore, when the patient's exosomes were compared to exosomes isolated from carboplatin resistant cell lines, several putative biomarkers were found to be shared. CONCLUSIONS: The findings of this study highlight the significance of exosomes in the potential transfer of drug resistance, and the discovery of novel biomarkers for the development of liquid biopsies to better guide personalized chemotherapy treatment.

Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort.

BACKGROUND: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. PURPOSE: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability. RESULTS: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements). CONCLUSION: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.

Development of a Multivariable Model Based on Individual Risk Factors for Recurrent Lateral Patellar Dislocation.

BACKGROUND: Nonoperative treatment after first-time patellar dislocation is the standard of care. There is evidence that certain patients may be at high risk for recurrent instability. The aim of this study was to develop a multivariable model to guide management of patients based on their individual risk of recurrent dislocation. METHODS: A multivariable model was developed using 291 patients from 4 institutions to identify which patients were at higher risk for recurrent patellar dislocation within 2 years. This model was informed by a univariable logistic regression model developed to test factors based on the patient's history, physical examination, and imaging. The discriminatory ability of the model to classify who will or will not have a recurrent dislocation was measured using the area under the receiver operating characteristic curve (AUC). RESULTS: Age, a history of a contralateral patellar dislocation, skeletal immaturity, lateral patellar tilt, tibial tubercle-trochlear groove (TT-TG) distance, Insall-Salvati ratio, and trochlear dysplasia were the most important factors for recurrent patellar dislocation. Sex, mechanism of injury, Caton-Deschamps ratio, sulcus angle, inclination angle, and facet ratio were not factors for recurrent dislocation. The overall AUC for the multivariable model was 71% (95% confidence interval [CI]: 64.7% to 76.6%). CONCLUSIONS: Optimizing the management of lateral patellar dislocation will improve short-term disability from the dislocation and reduce the long-term risk of patellofemoral arthritis from repeated chondral injury. This multivariable model can identify patients who are at high risk for recurrent dislocation and would be good candidates for early operative treatment. Further validation of this model in a prospective cohort of patients will inform whether it can be used to determine the optimal treatment plan for patients presenting with an initial patellar dislocation. Until validation of the model is done with new patients, it should not be used in clinical practice. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

When Is an Orthopedic Intern Ready to Take Call?

OBJECTIVE: While orthopedic residency training varies among programs, an inevitable phenomenon is a transition for interns from consistent oversight to independent call with indirect supervision. It is therefore crucial to reliably assess trainees' ability to perform basic procedures. The objective of the study was to evaluate the utility of a novel Orthopaedic Intern Skills Assessment (OISA) to assess skill level. DESIGN: In a cohort study, participants were evaluated on their ability to complete eleven skills in a simulated environment. Using a standardized patient and/or cadaveric specimen, we assessed skeletal traction, joint aspiration, joint injection, laceration repair, ankle brachial index measurement, compartment pressure monitoring, upper and lower extremity splinting, informed consent, spine trauma exam, and cervical spine clearance abilities. SETTING: The assessment took place in a medical simulation lab at the Oregon Health & Science University in Portland, Oregon. PARTICIPANTS: Third- or fourth-year medical students interested in orthopedics, incoming interns (preinterns), and residents within 1 month of completing their intern year (postinterns) were invited to participate in the study. All interested individuals were included. Of the 20 individuals contacted, 14 (70%) consented: 4 medical students (40%), 5 preinterns (100%), and 5 postinterns (100%). All consenting individuals finished their participation in the research. RESULTS: Postintern skill completion rate was significantly higher than preinterns (p = 0.006) and medical students (p < 0.001). Completion rates for preinterns were also significantly higher rate than medical students (p = 0.035). CONCLUSIONS: Our OISA found that postinterns had reached a basic orthopedic skill level expected of a junior resident without in-house supervision. Our OISA also highlighted areas of training that needed further attention, which will help orthopedic training programs verify an appropriate level of skill as trainees' progress from a supervised intern year to taking indirectly supervised junior resident call, and help identify areas where increased training is needed.

Female Residents Give Themselves Lower Scores Than Male Colleagues and Faculty Evaluators on ACGME Milestones.

OBJECTIVE: Orthopedic surgery is one of the specialties with the lowest number of women residents and practicing surgeons. The gender discrepancy in orthopedic residency training may drive a competency bias. We asked whether female orthopedic surgery residents score themselves lower on the Accreditation Council for Graduate Medical Education (ACGME) Milestones than their male counterparts, and lower than their faculty evaluators. DESIGN: We conducted a retrospective review of ACGME Milestone data from faculty and residents over a 4-year period. The data were analyzed using a snapshot of PGY2 (n = 20 residents) and PGY4 (n = 19 residents) scores, and using a Generalized Estimation Equation (GEE) to account for additional data points from the same residents over the 4-year data collection period. SETTING: Assessment scores were compiled from a single orthopedic surgery residency at Oregon Health & Science University from 2014 to 2017. PARTICIPANTS: The residency program has 5 residents in each program year (PGY1 through PGY5); a total of 25 residents during each year of the study were included. RESULTS: On average, female residents scored themselves lower than both their male counterparts and their faculty mentors. Female PGY2 self-evaluation scores were lower than males in both patient care (p = 0.005) and medical knowledge (p < 0.001). When the GEE model was applied to 99 responses from 41 residents over a 4-year period, there were no gender-related differences in resident self-evaluation scores and in faculty scores of male and female residents, with the exception of meniscal tear. For this milestone, faculty rated female residents lower than males. Furthermore, the differences between faculty evaluation scores and resident self-evaluation scores were significantly lower for males than for females for 4 of the clinical domains, as well as the systems-based practice domains of cost and communication. CONCLUSIONS: Our results indicate female residents are at risk for a competency bias during training, as reflected by evaluations using the ACGME Milestones.

Comparison of Ligament Isometry and Patellofemoral Contact Pressures for Medial Patellofemoral Ligament Reconstruction Techniques in Skeletally Immature Patients.

BACKGROUND: Adult medial patellofemoral ligament (MPFL) reconstruction techniques are not appropriate for the skeletally immature patient given the proximity of the distal femoral physis. Biomechanical consequences of reconstructions aimed at avoiding the physis have not been adequately studied. PURPOSE: To quantify the biomechanical effects of MPFL reconstruction techniques intended for skeletally immature patients. STUDY DESIGN: Controlled laboratory study. METHODS: Four MPFL reconstruction techniques were evaluated using a computationally augmented cadaveric model: (1) Schoettle point: adult-type reconstruction; (2) epiphyseal: socket distal to the femoral physis; (3) adductor sling: graft wrapped around the adductor tendon; (4) adductor transfer: adductor tendon transferred to patella. A custom testing frame was used to cycle 8 knees for each technique from 10° to 110° of flexion. Patellofemoral kinematics were recorded using a motion camera system, contact stresses were recorded using Tekscan pressure sensors, and MPFL length was computed using an inverse kinematics computational model. Change in MPFL length, patellar facet forces, and patellar kinematics were compared using generalized estimating equation modeling. RESULTS: Schoettle point reconstruction was the most isometric, demonstrating isometry from 10° to 100°. The epiphyseal technique was isometric until 60°, after which the graft loosened with increasing flexion. The adductor sling and adductor transfer techniques were significantly more anisometric from 40° to 110°. Both grafts tightened with knee flexion and resulted in significantly more lateral patellar tilt versus the intact state in early flexion and significantly higher contact forces on the medial facet versus the epiphyseal technique in late flexion. CONCLUSION: In this cadaveric simulation, the epiphyseal technique allowed for a more isometric ligament until midflexion, when the patella engaged within the trochlear groove. The adductor sling and adductor transfer grafts became tighter in flexion, resulting in potential loss of motion, pain, graft stretching, and failure. Marginal between-condition differences in patellofemoral contact mechanics and patellar kinematics were observed in late flexion. CLINICAL RELEVANCE: In the skeletally immature patient, using an epiphyseal type MPFL reconstruction with the femoral attachment site distal to the physis results in a more isometric graft compared with techniques with attachment sites proximal to the physis.

COVID-19 in Australia: Impacts on Separated Families, Family Law Professionals, and Family Courts.

Around the globe, many families are experiencing significant anxieties linked to COVID-19. These include health concerns and economic pressures, both of which are frequently taking place against a backdrop of various levels of social isolation. In addition, many parents have been juggling home schooling requirements in the face of radically different work arrangements including the loss of employment altogether. Unsurprisingly, additional challenges and stresses are emerging for separated families, family law professionals, and family courts. In this article - written at a point-in-time in a rapidly evolving COVID-19 context - we reflect on key challenges for separated families in Australia, and some of the emerging professional responses.

Surgical Simulation Maximizing the Use of Fresh-Frozen Cadaveric Specimens: Examination of Tissue Integrity Using Ultrasound.

BACKGROUND: Arthroscopic surgical simulation, including the use of cadaveric tissue, is valuable for training orthopedic surgery residents. However, it is unclear how often fresh-frozen cadaveric tissue can be reused to provide a reproducible model for developing arthroscopic skills. OBJECTIVE: We determined the usefulness of ultrasound in evaluating tissue degradation in fresh-frozen shoulder and knee joints used for surgical simulation. METHODS: Between February 7 and April 11, 2017, orthopedic residents participated in 6 wet lab sessions during 1 rotation. Knee and shoulder specimens were subjected to ultrasound using a SonoSite Edge machine and a linear probe after each freeze-and-thaw cycle. Degradation of each structure was determined based on standards created for living tissue and comparisons to previous images of the same tissue before initial use. RESULTS: Ultrasonographic assessment of the 2 knee and 2 shoulder specimens revealed lost integrity in subcutaneous fat and muscle with evidence of increased hypoechoicity and loss of normal fiber orientation and density in all specimens examined. Tendons, ligaments, cartilage, iliotibial band, and bone did not lose integrity during freezing and thawing. Ultrasonographic assessment revealed no loss of joint structure integrity. However, the intra-articular work assigned for the simulation curriculum had been carried out to a degree that by the third use, little opportunity remained for further arthroscopic practice on that specimen. CONCLUSIONS: In this study, ultrasound findings showed that fresh-frozen shoulder and knee specimens maintained structural integrity useful for simulation training after 3 cycles of freezing.