How Is Variability in Femoral and Acetabular Version Associated With Presentation Among Young Adults With Hip Pain?

BACKGROUND: Acetabular and femoral version contribute to hip pain in patients with femoroacetabular impingement (FAI) or dysplasia. However, definitions and measurement methods of femoral version have varied in different studies, resulting in different "normal" values being used by clinicians for what should be the same anatomic measurement. This could result in discrepant or even inappropriate treatment recommendations. QUESTIONS/PURPOSES: In patients undergoing hip preservation surgery, (1) what is the range of acetabular and femoral version at presentation, and how much do two commonly used measurement techniques (those of Murphy and Reikerås) differ? (2) How are differences in acetabular and femoral version associated with clinical factors and outcomes scores at the time of presentation? METHODS: This was a retrospective analysis of data gathered in a longitudinally maintained database of patients undergoing hip preservation at a tertiary care referral center. Between June 2020 and December 2021, 282 hips in 258 patients were treated for an isolated labral tear (9% [26 hips]), hip dysplasia (21% [59 hips]), FAI (52% [147 hips]), mixed FAI and dysplasia (17% [47 hips]), or pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 1% [3 hips]) with hip arthroscopy (71% [200 hips]), periacetabular osteotomy (26% [74 hips]), surgical hip dislocation (2.5% [7 hips]), or femoral derotation osteotomy (0.5% [1 hip]). We considered those with complete radiographic data (CT including the pelvis and distal femur) and patient-reported outcome scores as potentially eligible. Exclusion criteria were age younger than 18 or older than 55 years (5 hips, 3 patients), signs of hip osteoarthritis (Tönnis grade ≥ 2; 0), pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 3 hips, 3 patients), previous femoral or acetabular osteotomy (2 hips, 2 patients), avascular necrosis of the femoral head (0), history of neuromuscular disorder (Ehlers-Danlos syndrome; 3 hips, 3 patients) or rheumatoid disease (ankylosing spondylitis; 1 hip, 1 patient), and when CT did not include the knees (19 hips, 19 patients). Based on these criteria, 249 hips in 227 patients were included. Of patients with bilateral symptomatic hips, one side was randomly selected for inclusion, leaving 227 hips in 227 patients for further analysis. The patients' median age (range) was 34 years (19 to 55 years), the median BMI (range) was 27 kg/m2 (16 to 55 kg/m2), and 63% (144) were female; they were treated with hip arthroscopy (in 74% [168]) or periacetabular osteotomy (in 23% [52]). Patients underwent a CT scan to measure acetabular version and femoral version using the Murphy (low < 10°; normal: 10° to 25°; high > 25°) or Reikerås (low < 5°; normal: 5° to 20°; high > 20°) technique. The McKibbin index was calculated (low: < 20°; normal: 20° to 50°; high > 50°). Based on the central acetabular version and femoral version as measured by Murphy, hips were grouped according to their rotational profile into four groups: unstable rotational profile: high (high acetabular version with high femoral version) or moderate (high acetabular version with normal femoral version or normal acetabular version with high femoral version); normal rotational profile (normal acetabular version with femoral version); compensatory rotational profile (low acetabular version with high femoral version or high acetabular version with low femoral version); and impingement rotational profile (low acetabular version with low femoral version): high (low acetabular version with low femoral version) or moderate (low acetabular version with normal femoral version or normal acetabular version with low femoral version). Radiographic assessments were manually performed on digitized images by two orthopaedic residents, and 25% of randomly selected measurements were repeated by the senior author, a fellowship-trained hip preservation and arthroplasty surgeon. Interobserver and intraobserver reliabilities were calculated using the correlation coefficient with a two-way mixed model, showing excellent agreement for Murphy technique measurements (intraclass correlation coefficient 0.908 [95% confidence interval 0.80 to 0.97]) and Reikerås technique measurements (ICC 0.938 [95% CI 0.81 to 0.97]). Patient-reported measures were recorded using the International Hip Outcome Tool (iHOT-33) (0 to 100; worse to best). RESULTS: The mean acetabular version was 18° ± 6°, and mean femoral version was 24° ± 12° using the Murphy technique and 12° ± 11° with the Reikerås method. Eighty percent (181 of 227) of hips had normal acetabular version, 42% (96 of 227) to 63% (142 to 227) had normal femoral version per Murphy and Reikerås, respectively, and 67% (152 to 227) had a normal McKibbin index. Patients with an impingement profile (low acetabular version or femoral version) were older (39 ± 9 years) than patients with an unstable (high acetabular version or femoral version; 33 ± 9 years; p = 0.004), normal (33 ± 9 years; p = 0.02), or compensatory (high acetabular version with low femoral version or vice versa; 33 ± 7 years; p = 0.08) rotational profile. Using the Murphy technique, femoral version was 12° greater than with the Reikerås method (R2 0.85; p < 0.001). There were no differences in iHOT-33 score between different groups (impingement: 32 ± 17 versus normal 35 ± 21 versus compensated: 34 ± 20 versus unstable: 31 ± 17; p = 0.40). CONCLUSION: Variability in femoral version is twice as large as acetabular version. Patients with an impingement rotational profile were older than patients with a normal, compensatory, or unstable profile, indicating there are other variables not yet fully accounted for that lead to earlier pain and presentation in these groups. Important differences exist between measurement methods. This study shows that different measurement methods for femoral anteversion result in different numbers; if other authors compare their results to those of other studies, they should use equations such as the one suggested in this study. LEVEL OF EVIDENCE: Level III, prognostic study.

The relationship of pain catastrophizing with postoperative patient-reported outcome measures in adults with pre-arthritic hip disease.

The association between preoperative pain catastrophizing and postoperative patient-reported outcome measures of patients with pre-arthritic hip disease was evaluated. All patients scheduled for joint-preserving surgeries of the hip (JPSH) at our institution were approached. Patient demographics (age, sex, body mass index (BMI)), pain intensity (Numeric Pain Scale (NPS)) and pain catastrophizing (Pain Catastrophizing Scale (PCS)) were collected preoperatively. Patient function (12-Item International Hip Outcome Tool (iHot-12)) and physical and mental health (Patient-Reported Outcomes Measurement Information System (PROMIS-10) mental/physical) were collected preoperatively, three-month and one-year postoperatively. The analysis consisted of multivariate linear regression models fitted for continuous scores of outcome measures at three-month and one-year. Correlation between preoperative PCS and iHot-12 was assessed using the Pearson correlation coefficient. A total of 274 patients completed the PCS and were included in the multivariate linear regression models. Most patients were females (66.8%), mean age was 33 (SD 9), mean BMI was 26.5 (SD 5.8) and most were diagnosed with femoro-acetabular impingement (46.0%) and underwent arthroscopy (77.0%). There were statistically significant correlations between PCS and iHot-12 (preoperatively -0.615, P < 0.001; three-month -0.242, P = 0.002). Statistically significant associations were found for function (three-month PCS P = 0.046, age P = 0.014, NPS P = 0.043; one-year BMI P = 0.005, NPS P = 0.014), physical health (three-month BMI, P = 0.002, NPS P = 0.008; one-year BMI P = 0.002, NPS P = 0.013) and mental health (three-month BMI P = 0.047; one-year BMI P = 0.030). There is an association between function and preoperative pain catastrophizing in patients with pre-arthritic hip disease undergoing JPSH. When considering confounding variables, preoperative pain catastrophizing is associated with short-term recovery.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Arthroscopic suture fixation of tibial spine fractures.

A tibial spine fracture refers to an intraarticular fracture of the osseous insertion of the anterior cruciate ligament at the proximal tibia, commonly seen in pediatric and adolescent patients. This fracture is classified based on the degree of displacement and the presence or absence of an intact posterior hinge point. For significantly displaced fractures, surgical reduction and fixation are often recommended. Both open and arthroscopic approaches have been described. This technical note describes our technique for arthroscopic-assisted reduction and fixation of tibial spine fractures using trans-osseous tunnels and suture fixation over a bone bridge. This technique restores native anatomy, provides fracture compression, and has favorable biomechanical properties, allowing for early range of motion.

Burosumab for the treatment of cutaneous-skeletal hypophosphatemia syndrome.

Cutaneous-skeletal hypophosphatemia syndrome (CSHS) is a rare bone disorder featuring fibroblast growth factor-23 (FGF23)-mediated hypophosphatemic rickets. We report a 2-year, 10-month-old girl with CSHS treated with burosumab, a novel human monoclonal antibody targeting FGF23. This approach was associated with rickets healing, improvement in growth and lower limb deformity, and clinically significant benefit to her functional mobility and motor development. This case report provides evidence for the effective use of FGF23-neutralizing antibody therapy beyond the classic FGF23-mediated disorders of X-linked hypophosphatemia and tumor-induced osteomalacia.

Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review.

PURPOSE: To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest. METHODS: Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores. RESULTS: Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR. CONCLUSION: Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal. LEVEL OF EVIDENCE: Level IV.

Canakinumab in addition to phosphate-binding and phosphaturia-inducing therapy were effective in achieving remission in a child with a large familial calcinotic tumour.

We describe the clinical evolution of a patient with tumoral calcinosis due to a pathogenic variant in the GALNT3 gene presented with a large mass overlying her left hip associated complicated by inflammatory flares. Therapy (sevelamer, acetazolamide, and probenecid) was unsuccessful in preventing tumour surgeries, therefore, interleukin-1ß monoclonal antibody therapy was added; this was successful in the prevention of tumour re-growth. This case highlights the importance of assessing and treating the inflammatory aspect of calcinotic tumour.

Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.

Mitigating the Denosumab-Induced Rebound Phenomenon with Alternating Short- and Long-Acting Anti-resorptive Therapy in a Young Boy with Severe OI Type VI.

Osteogenesis imperfecta (OI) type VI, a recessively inherited form of OI caused by mutations in SERPINF1, is a severe form distinguished by osteomalacia on bone histomorphometry. We describe a boy with severe OI type VI who was initially treated with intravenous (IV) zoledronic acid (ZA) at 1.4 years of age; however, a year later he transitioned to denosumab 1 mg/kg sub-cutaneously every three months in an effort to decrease fracture rates. After two years on denosumab, he presented with symptomatic hypercalcemia due to the denosumab-induced, hyper-resorptive rebound phenomenon. Laboratory parameters at the time of the rebound were as follows: elevated serum ionized calcium (1.62 mmol/L, N 1.16-1.36), elevated serum creatinine due to hypercalcemia-induced muscle catabolism (83 µmol/L, N 9-55), and suppressed parathyroid hormone (PTH) (< 0.7 pmol/L, N 1.3-5.8). The hypercalcemia was responsive to low-dose IV pamidronate, with a rapid decline in serum ionized calcium, and otherwise normalization of the aforementioned parameters within 10 days. To benefit from the powerful, albeit short-term, anti-resorptive effect of denosumab without further rebound episodes, he was treated thereafter with denosumab 1 mg/kg alternating every three months with IV ZA 0.025 mg/kg. Five years later, he remained on dual alternating anti-resorptive therapy without further rebound episodes, and an overall improvement in his clinical status. This novel pharmacological approach of alternating short- and long-term anti-resorptive therapy every three months has not previously been described. Our report suggests this strategy may be an effective method for prevention of the rebound phenomenon in select children for whom denosumab may be beneficial.

Lateral Patellar Instability.

➤: Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology. Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient. ➤: Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity. ➤: Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment. ➤: Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability. ➤: Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation. ➤: Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta. ➤: The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding. ➤: Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30° to improve patient outcomes and reduce recurrence rates.

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

BACKGROUND: Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine. METHODS: An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in. RESULTS: Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%). CONCLUSIONS: Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old. LEVEL OF EVIDENCE: Level of evidence IV.

Effect of Osteochondroplasty on Time to Reoperation After Arthroscopic Management of Femoroacetabular Impingement: Analysis of a Randomized Controlled Trial.

Background: A subset of patients with femoroacetabular impingement (FAI) fail arthroscopic management. It is not clear which patients will fail surgical management; however, several surgical and patient factors, such as type of procedure and age, are thought to be important predictors. Purpose: This time-to-event analysis with a 27-month follow-up analysis compared the effect of (1) arthroscopic osteochondroplasty with or without labral repair versus (2) arthroscopic lavage with or without labral repair on the time to reoperation in adults aged 18 to 50 years with FAI. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Eligible participants had been randomized in a previous study trial to a treatment of arthroscopic osteochondroplasty or arthroscopic lavage with or without labral repair. Using the comprehensive data set from the Multinational Femoroacetabular Impingement Randomized controlled Trial, all reoperations until 27 months after surgery were identified. The analysis was conducted using a Cox proportional hazards model, with percentage of patients with a reoperation evaluated in a time-to-event analysis as the outcome. The independent variable was the procedure, with age and impingement subtype explored as potential covariates. The effects from the Cox model were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha level of .05. Results: A total of 108 patients in the osteochondroplasty group and 106 patients in the lavage group were included. The mean age of the patients included in the study was 36 ± 8.5 years. Overall, 27 incident reoperations were identified within the 27-month follow-up, with an incidence rate of 6 per 100 person-years. Within the osteochondroplasty group, 8 incident reoperations were identified (incidence rate, 3.4 per 100 person-years), while within the lavage group, 19 incident reoperations were identified (incidence rate, 8.7 per 100 person-years). The hazard of reoperation for patients undergoing osteochondroplasty was 40% of that of patients undergoing lavage (HR, 0.40 [95% CI, 0.17-0.91] P = .029). Conclusion: This study demonstrated that for adults between the ages of 18 and 50 years with FAI, arthroscopic osteochondroplasty was associated with a 2.5-fold decrease in the hazard of reoperation at any point in time compared with arthroscopic lavage. Registration: NCT01623843 (ClinicalTrials.gov identifier).

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review.

INTRODUCTION: Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION: Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (CRD42021226934).

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis.

BACKGROUND: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality. PURPOSE: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). RESULTS: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location. CONCLUSION: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.

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.

Management and Outcomes of Clinical Scaphoid Fractures in Children.

Background: Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. Methods: A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Results: Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Conclusions: Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.

Validation of the French version of the Self-Administered International Hip Outcome Tool-12 Questionnaire and determination of the Minimal Clinically Important Difference (MCID) in the French speaking population.

BACKGROUND: Patient-Reported Outcomes tools are becoming the gold standard in the evaluation of results in orthopaedic surgery. In 2012, the International Hip Outcome Tool-12 (iHOT-12) was developed. This self-administered questionnaire was designed to address the day-to-day clinical setting with faster completion and easier patient flow. In 2021, a French translation of the iHOT-33 questionnaire, from which the iHOT-12 is derived, proved to be valid. Since there is not data in French regarding iHOT-12, we performed a prospective study aiming to answer: (1) is this French version of the iHOT-12 questionnaire as valid, (2) can the minimal clinically important difference (MCID) value for patients undergoing hip arthroscopy for femoro-acetabular impingement (FAI) be defined? HYPOTHESIS: It is hypothesized that the iHOT-12-Fr would be valid and responsive to change in a cohort treated for FAI. PATIENTS AND METHODS: Using the COSMIN recommendations, a multicentric prospective cohort study was conducted to evaluate the reliability, validity, responsiveness and MCID of the iHOT-12-Fr. RESULTS: In total, 101 patients were recruited for participation in the project. The reliability of the iHOT-12-Fr questionnaire was assessed with the intraclass correlation coefficient (ICC=0.84) and the internal consistency with a Cronbach's alpha (α=0.86). The standard error of measurement (SEM=6.7) and the smallest detectable change (SDC=1.8) were calculated. Construct validity was evaluated with Pearson's correlation coefficients (r) by comparing the iHOT-12-Fr with the iHOT-33-Fr (r=0.96), the Hip disability and Osteoarthritis Outcome Score-Fr (r=0.68) and Nonarthritic Hip Score-Fr (r=0.82). Responsiveness was shown with a standardized effect size of 1.18, standardized response mean of 0.73, responsiveness ratio of 1.4 and an MCID of 11 points. DISCUSSION: Metrological qualities of the iHOT-12-Fr are comparable to the original version and other versions translated into different languages. This study proves that the French translation of the iHOT-12 is valid, reliable and compares to the original iHOT-12. LEVEL OF EVIDENCE: IV prospective study.

Pediatric Acetabular Osteomyelitis Treated With Hip Arthroscopy.

Osteomyelitis of the acetabulum is a rare condition accounting for only 12% of pelvic osteomyelitis cases. This report describes a previously healthy 10-year-old girl with subacute acetabular osteomyelitis and subsequent development of secondary septic arthritis of the hip. The patient presented with 3 weeks of groin pain, elevated erythrocyte sedimentation rate and C-reactive protein, synovial thickening of the hip on ultrasonography and diffuse signal uptake in the acetabulum on magnetic resonance imaging. Despite antibiotic therapy, her symptoms worsened clinically, and repeat Magnetic resonance imaging images showed worsening of the osteomyelitis with likely extension through the acetabulum and into the joint. A hip aspirate was positive for Fusobacterium, an atypical anaerobe. Hip arthroscopy, with identification of the site of extrusion and then extensive débridement and irrigation, was successful in helping to control and ultimately eradicate the infection. The patient regained normal hip function and returned to full activities. This case demonstrates how hip arthroscopy can serve as an important surgical treatment modality for acetabular osteomyelitis with intraarticular extension in addition to septic arthritis of the hip.

Validation of the French version of the self-administered international hip outcome tool-33 questionnaire.

INTRODUCTION: To evaluate the effectiveness of new treatments, whether conservative or surgical, a self-administered questionnaire for hip pain targeted at physically active patients 18 to 60 years of age, named the international Hip Outcome Tool-33 (iHOT-33), was developed and validated in 2012. Since there is no French version available and we are acutely aware of transcultural variations, we conducted a prospective study to: 1) translate, and then 2) validate this questionnaire into international French. HYPOTHESIS: The iHOT-33-Fr questionnaire is a valid and reliable tool for evaluating hip pain in a young, francophone population. MATERIALS AND METHODS: Translation of the questionnaire was done according to the standardized method described by Beaton and the final version of the iHOT-33-Fr was validated using the COSMIN methodology. The data were collected prospectively at multiple sites. The reliability of the iHOT-33-Fr questionnaire was evaluated using the intraclass correlation coefficient (ICC) and its internal consistency using Cronbach's alpha. The standard error of measurement and minimum detectable change were calculated. The construct validity was evaluated using Pearson's correlation coefficient by comparing the iHOT-33-Fr with the Hip disability and Osteoarthritis Outcome Score (HOOS-Fr) and Nonarthritic Hip Score (NAHS-Fr). RESULTS: In all, 101 patients filled out the questionnaires. The ICC was 0.87. The Cronbach alpha was 0.95. The standard error of measurement was 6.4 and the minimum detectable change was 1.8. The correlation between the iHOT-33-Fr and the HOOS-Fr was 0.86, while the correlation between the iHOT-33-Fr and the NAHS-Fr was 0.75. DISCUSSION: Our results show that the metrological qualities of the iHOT-33-Fr are comparable to those of the original version and the versions translated into other languages. This study demonstrates that the iHOT-33-Fr is valid, reproducible and comparable to the original iHOT-33. It can be used by francophone surgeons treating symptomatic hip disease in young, active patients. LEVEL OF EVIDENCE: IV.