Prevalence of Hypertension in Pediatric Tibia Vara and Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) and tibia vara (Blount disease) are associated with childhood obesity. However, the majority of obese children do not develop SCFE or tibia vara. Therefore, it is hypothesized that other obesity-related biological changes to the physis, in addition to increased biomechanical stress, potentiate the occurrence of SCFE and tibia vara. Considering that hypertension can impose pathologic changes in the physis similar to those observed in these obesity-related diseases we set out to determine the prevalence of hypertension in patients with SCFE and tibia vara. METHODS: Blood pressure measurements were obtained in 44 patients with tibia vara and 127 patients with SCFE. Body mass index and blood pressure were adjusted for age, sex, and height percentiles utilizing normative distribution data from the CDC. These cohorts were compared with age-matched and sex-matched cohorts derived from an obesity clinic who did not have either bone disease. A multivariable proportional odds model was used to determine association. RESULTS: The prevalence of prehypertension/hypertension was significantly higher in the tibia vara (64%) and SCFE cohort (64%) compared with respective controls (43%). Patients diagnosed with either SCFE or tibia vara had 2.5-fold higher odds of having high blood pressure compared with age-matched and sex-matched obese patients without bone disease. Sex, age, and race did not have a significant effect on a patient's blood pressure. CONCLUSIONS: This is the first study to establish that the obesity-related bone diseases, SCFE and tibia vara, are significantly associated with high blood pressure. These data have immediate clinical impact as they demonstrate that children with obesity-related developmental bone disease have increased prevalence of undiagnosed and untreated hypertension. Furthermore, this prevalence study supports the hypothesis that hypertension in conjunction with increased biomechanical forces together potentiate the occurrence of SCFE and tibia vara. If proven true, it is plausible that hypertension may represent a modifiable risk factor for obesity-related bone disease. LEVEL OF EVIDENCE: Level III-case-control study.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results.

PURPOSE: The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity. METHODS: We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised. RESULTS: Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions. CONCLUSIONS: Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and III studies.

Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement.

BACKGROUND: The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. The quadriceps tendon is the least utilized and least studied of the potential autograft options. PURPOSE: To determine if the quadriceps tendon has the anatomic characteristics to produce a graft whose length and volume are adequate, reproducible, and predictable when compared with the other commonly used autografts. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Axial proton density magnetic resonance imaging (MRI) scans of 60 skeletally mature patients (30 male and 30 female) were evaluated. Volumetric analysis of 3-dimensional models of the patellar and quadriceps tendons was performed before and after the removal of a 10 mm-wide graft from both tendons. Length, thickness, and width measurements of the quadriceps tendon were made at predetermined locations. Anthropometric data were collected, and subgroup analysis, sex analysis, and linear regression were performed. RESULTS: The mean percentage of volume remaining after removal of a 10 mm-wide graft from the patellar tendon was 56.6%, compared with 61.3% when harvesting an 80 mm-long graft of the same width from the quadriceps tendon. The intra-articular volume of the proposed quadriceps tendon graft was 87.5% greater than that of the patellar tendon graft. The mean length of the quadriceps tendon was 73.5 ± 12.3 mm in female patients and 81.1 ± 10.6 mm in male patients. These measurements were most highly correlated with patient height. The width of the quadriceps tendon decreased as one proceeded proximally from its insertion, and the thickness of the quadriceps tendon remained relatively constant. CONCLUSION: The quadriceps tendon has the anatomic characteristics to produce a graft whose length and volume are both reproducible and predictable, while yielding a graft with a significantly greater intra-articular volume than a patellar tendon graft with a similar width.

Continuous Passive Motion, Early Weight Bearing, and Active Motion following Knee Articular Cartilage Repair: Evidence for Clinical Practice.

OBJECTIVE: To systematically review the literature regarding postoperative rehabilitation for articular cartilage repair: (1) does the use of continuous passive motion (CPM) enhance healing, and if so, what parameters should be applied? (2) Can active range of motion (AROM) be used in place of or with CPM? (3) When can individuals safely resume weight bearing (WB) following repair? DATA SOURCES: A search using Medline, SportsDiscus, and CINAHL databases was performed with the following keywords: articular cartilage, AROM, CPM, microfracture, osteochondral allograft, autologous chondrocyte implantation, rehabilitation, weight bearing, and knee. STUDY SELECTION: Basic science or clinical outcomes examining the effects of CPM, AROM, or WB on knee articular cartilage healing. DATA EXTRACTION: Selected articles were rated using the Strength of Recommendation Taxonomy (SORT) to determine evidence for clinical application. DATA SYNTHESIS: Sixteen articles met selection criteria: 12 were basic science studies; 4 were clinical studies. Basic science evidence supporting CPM exists. However, few patient-oriented outcomes have been documented resulting in a SORT rating of C. Early WB and AROM received a SORT rating of B based on limited clinical research and patient-oriented outcomes. CONCLUSIONS: Basic science evidence supports CPM to maintain ROM, reduce pain, and promote healing. Patient-oriented research is needed to strengthen CPM's recommendation. Limited evidence exists regarding early WB and AROM post cartilage repair. There is insufficient evidence to confidently address when to begin WB for maximum healing. Appropriate basic science and patient-oriented research are needed for rehabilitation protocols to maximize benefits of cartilage repair procedures.

Osteochondral allografts: state of the art.

The use of osteochondral allografts to treat focal osteochondral lesions continues to gain popularity, supported by long-term results. Clinicians must be knowledgeable concerning the possible risks of disease transmission, graft rejection, infection, and graft failure to advise the patient and obtain an informed consent. With advancing scientific and clinical research, future operative indications will likely continue to expand. A significant amount of literature regarding storage methods has recently been published; it is hoped that continued research will lead to techniques for prolonged graft storage to prevent availability concerns.