Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

BACKGROUND: The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. PURPOSE: To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. RESULTS: Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. CONCLUSION: Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

Femorotibial rotation is Linearly Associated with Tibial Tubercle-Trochlear Groove Distance: A Cadaveric Study.

OBJECTIVES: A tibial tubercle-trochlear groove (TT-TG) distance of 20 millimeters (mm) is typically used when determining whether tibial tubercle medialization is performed for surgical treatment of patellar instability. Without knowledge of the variability of an individual's TT-TG distance influenced by through-the-knee femorotibial rotation, the use of a specific TT-TG distance during pre-operative planning for patellar instability may lead to incorrect decisions on the use of tibial tubercle medializtion. We hypothesized that knee joint IE rotation is related to the TT-TG distance. METHODS: Eight independent human cadaveric knee specimens (age: 32 ± 6 years; 4 males, 4 females) were utilized. A robotic manipulator (ZX165U, Kawasaki Robotics, Wixom, MI, USA) instrumented with a universal force/moment sensor was used to determine knee joint IE rotation under applied moments of ±5 newton-meters (Nm) at full extension. Two independent reviewers selected the trochlear groove and tibial tuberosity points on computerized tomography (CT) images of each specimen to define TT-TG. To determine the influence of knee joint IE rotation on TT-TG distance, three-dimensional (3D) models generated from CT scans were registered to tibiofemoral kinematics. Linear regression was performed to determine the relationship between knee joint IE rotation and TT-TG distance. The regression coefficient and standard error of measurement (α = 0.05), and coefficient of determination (r2) were reported. RESULTS: At 0° of rotation, the mean TT-TG distance was 14.2 ± 5.0 mm. Knee joint IE rotation averaged 23.0 ± 4.2°. For every degree of knee joint IE rotation, TT-TG distance changed by 0.52 mm. CONCLUSION: TT-TG distance was linearly dependent on knee joint IE rotation changing by 0.52 mm for every degree of knee joint IE rotation. Thus, an offset of IE rotation of 10° would lead to a change in TT-TG distance of 5.2 mm, enough to alter surgical decision-making for/or against tibial tubercle medialization. LEVEL OF EVIDENCE: IV: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Measurement of TT-TG can change with sequential MRIs due to variations in tibiofemoral rotation in patellofemoral instability patients.

PURPOSE: There are various anatomic risk factors for patellofemoral instability (PFI) that help guide surgical treatment, including the tibial tubercle to trochlear groove (TT-TG) distance. However, no study has analysed the temporal changes in TT-TG prior to surgical intervention. This study sought to understand the variations in TT-TG over time for pediatric patients suffering from PFI prior to surgical intervention. The authors hypothesised that the TT-TG would substantially change between time points. METHODS: Patients undergoing medial patellofemoral ligament (MPFL) reconstruction between 2014 and 2019 by one of two fellowship-trained orthopaedic surgeons were identified. Patients were included if they had two preoperative magnetic resonance imaging (MRI) performed on the same knee within 7.5 months of each other prior to any surgical intervention and had an initial TT-TG greater than 10 mm. RESULTS: After considering 251 patients for inclusion, 21 patients met the final inclusion criteria. The mean age was 14.5 ± 2.5 years and 61.9% were female. TT-TG was initially noted to be 15.1 ± 1.8 mm. At mean time after sequential MRIs of 5.0 ± 1.9 months, TT-TG was noted to be 16.7 ± 3.2 mm. The differences between initial and subsequent TT-TG ranged from a 21.2% decrease to a 61.1% increase, with a mean difference of an 11.3% increase. Comparison between initial and subsequent TT-TG values demonstrated a significant difference (p = 0.017). Change in tibiofemoral rotation ranged from -9.2° to 7.5°. When comparing the change in TT-TG to change in tibiofemoral rotation, a significant correlation was found (p = 0.019). CONCLUSION: Despite only a mean time between MRIs of 5 months, variations in TT-TG ranged from a decrease of 21.2% to an increase of 61.1%. The significant relationship between the changes in TT-TG and changes in tibiofemoral rotation between MRIs suggest that TT-TG measurements may vary due to variations in tibiofemoral rotation at the time of individual MRIs. LEVEL OF EVIDENCE: Level IV.

Patients With Significant Medical Comorbidities May Benefit from Unicompartmental Knee Arthroplasty Over Total Knee Arthroplasty.

Many studies have compared outcomes in total knee arthroplasty (TKA) versus unicompartmental knee arthroplasty (UKA); however, to the authors' knowledge, there is no study evaluating complication rates in patients with significant comorbidities. The purpose of this retrospective study was to compare the incidence of postoperative complications, readmission and reoperation rates, length of stay (LOS), and discharge location for patients with significant medical comorbidities undergoing TKA versus UKA. Using the NSQIP database from 2008 to 2018, patients were identified by CPT code (27447 or 27446) and admission diagnostic code of primary osteoarthritis and included in the study if they had an American Society of Anesthesia score greater than or equal to 3. Chi-square test was used to compare categorical variables and t-test for continuous variables. Multivariate regression was used to compare outcomes of interest between groups. A total of 167,054 patients were analyzed with 97.3% undergoing TKA. TKA patients had a greater overall complication rate than those undergoing UKA (p < 0.001). Readmission rates were approximately 1.5 times higher in TKA compared with UKA (p = 0.002), while no statistically significant difference was discovered in reoperation rates (p = 0.868). TKA was also associated with decreased rates of same day discharge, discharge within 24 hours of surgery, and discharge home (p < 0.001, <0.001, and <0.001, respectively). This study found an increase in complication rates, readmission rates, and LOS, along with a lower likelihood of discharge home when undergoing a TKA. These findings suggest that patients with significant medical comorbidities at baseline may benefit from UKA over TKA when anatomically indicated.

Patient- and xenograft-derived organoids recapitulate pediatric brain tumor features and patient treatments.

Brain tumors are the leading cause of cancer-related death in children. Experimental in vitro models that faithfully capture the hallmarks and tumor heterogeneity of pediatric brain cancers are limited and hard to establish. We present a protocol that enables efficient generation, expansion, and biobanking of pediatric brain cancer organoids. Utilizing our protocol, we have established patient-derived organoids (PDOs) from ependymomas, medulloblastomas, low-grade glial tumors, and patient-derived xenograft organoids (PDXOs) from medulloblastoma xenografts. PDOs and PDXOs recapitulate histological features, DNA methylation profiles, and intratumor heterogeneity of the tumors from which they were derived. We also showed that PDOs can be xenografted. Most interestingly, when subjected to the same routinely applied therapeutic regimens, PDOs respond similarly to the patients. Taken together, our study highlights the potential of PDOs and PDXOs for research and translational applications for personalized medicine.

Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial.

BACKGROUND: In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. QUESTIONS/PURPOSES: Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? METHODS: This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. RESULTS: There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). CONCLUSION: During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. LEVEL OF EVIDENCE: Level I, therapeutic study.

The Perils of Sleeper Plates in Multiple Hereditary Exostosis: Tibial Deformity Overcorrection Due to Tether at Empty Metaphyseal Hole.

BACKGROUND: Hemi-epiphysiodesis is the mainstay of treatment for angular deformities at the knee in children with multiple hereditary exostosis (MHE). Upon deformity correction, the metaphyseal screw may be removed from the hemi-epiphysiodesis plate, the sleeper plate technique, with anticipated reimplantation of the metaphyseal screw should the original deformity recur. The aim of the present study is to compare the incidence of complications with the sleeper plate technique with complete plate removal in an MHE cohort. METHODS: Patients under the age of 18 with MHE who underwent hemi-epiphysiodesis of the proximal tibia and/or distal femur between February 1, 2016, and February 6, 2022 with a minimum 2-year follow-up or follow-up to skeletal maturity were identified via ICD-10 codes. Patient charts and radiographic images were reviewed to assess for the bone(s) treated, the use of sleeper plates, and whether any complication occurred, including overcorrection from bony ingrowth at the empty holes or deformity recurrence. RESULTS: In 13 patients, 19 knees underwent hemi-epiphysiodesis at 30 sites; 13 distal femoral and 17 proximal tibial. Of 30 plates, 18 (60%) were removed completely upon deformity correction and 3 (10%) did not require removal due to skeletal maturity. Four of 13 (30.8%) femoral plates and 5 of 17 (29.4%) tibial plates were left as sleeper plates. All 5 tibial sleeper plates developed bony ingrowth into the empty metaphyseal screw hole, which led to unintended progressive deformity overcorrection. In the majority of cases, the deformity was addressed by the removal of the plate and exophytic bone and hemi-epiphysiodesis on the other side of the affected proximal tibia with subsequent resolution of the deformity. CONCLUSIONS: All tibial sleeper plates developed bony ingrowth into the screwless metaphyseal hole. The bony ingrowth functioned as a tether, resulting in progressive deformity overcorrection. Sleeper plates should be avoided at the proximal tibia in patients with MHE, and extreme caution should be exercised when considering this technique at the distal femur or other sites. LEVELS OF EVIDENCE: Level III-retrospective comparative study.

How Do Orthopedic Surgeons Stay Up-to-Date With the Literature? A Survey.

Background: With the rise of social media and other web-based platforms, there has been a shift in how medical research findings are disseminated. Questions/Purposes: We sought to investigate how often orthopedic surgeons use different knowledge-seeking methods and how confident they were in their ability to stay up-to-date. Methods: We distributed a 23-question survey to 120 orthopedic surgeons employed at a single tertiary-care metropolitan orthopedic hospital. The survey collected the surgeons' use of reference managers, RSS feeds, and preferred methods of staying up-to-date. Respondents were asked to report the number of hours they spent staying up-to-date per week and their success with keeping up with orthopedic specialty literature. Results: A total of 85 physicians responded (median age, 52 years); 83% of respondents who spent 3 or more hours a week in keeping up-to-date with the literature said they felt successful in doing so, while 40% of participants who spent less than 1 hour a week said they felt successful. Fifty-five percent of surgeons under the median age used social media, while only 29% of surgeons over the median age used social media. Conclusions: This survey suggests that spending only 1 to 2 hours per week was enough to make the orthopedic surgeons we surveyed feel confident that they were keeping up with the literature in their specialty. These findings also suggest that it may be more important for surgeons to choose a convenient method of literature review that will enable them to maximize time spent reading, rather than attempting to use any one source.

Concomitant anterior medializing osteotomy and MPFL reconstruction improves patellar tilt when compared to MPFL reconstruction alone.

PURPOSE: Understanding how surgical procedures influence anatomic factors associated with patellofemoral instability can help guide surgeons when planning treatments for individual patients. This study sought to understand how patellar tilt is affected in adolescent patients with elevated pre-operative tibial tuberosity to trochlear groove (TT-TG) values undergoing medial patellofemoral ligament reconstruction (MPFLR) with or without an anterior medializing osteotomy (AMZ). METHODS: Utilizing a prospective database of 274 patellofemoral instability patients who underwent MPFLR ± AMZ by one of two orthopedic surgeons at a single institution, those who underwent MPFLR + AMZ were identified. Pre-operative and post-operative magnetic resonance imaging (MRI) were used to measure TT-TG distance, while radiographs were used to measure patellar tilt (tilt). Patients were matched based on age at surgery (within 2 years) and pre-operative TT-TG distance (within 2 mm) to a comparison cohort of patients who underwent isolated MPFLR (iMPFLR) without osseous procedures. RESULTS: A total of 56 patients were analyzed (28 per group). The mean age of the cohort was 15.5 ± 2.0 years and was similar between both groups (15.9 ± 1.9 versus 15.1 ± 2.0 years [n.s]). When comparing the two cohorts, significant pre- to post-operative decreases in patellar tilt for both MPFLR + AMZ (6.6 degrees, p < 0.001) and iMPFLR (3.9 degrees, p = 0.013) were noted. While there were no differences in pre-operative patellar tilt (21.2 ± 3.5 versus 21.1 ± 3.4 [n.s]), post-operatively, MPFLR + AMZ had significantly less patellar tilt than iMPFLR (13.2 ± 5.5 versus 16.5 ± 4.4, p = 0.017). CONCLUSIONS: This study found that patellar tilt significantly improved in participants undergoing either MPFLR + AMZ or iMPFLR. In addition, those undergoing MPFLR + AMZ were found to have significantly lower post-operative tilt than those undergoing iMPFLR. If patellar tilt is found pre-operatively to be significantly elevated and a risk for future dislocations, these findings suggest that surgeons might strongly consider MPFLR with AMZ to further address the increased tilt. LEVEL OF EVIDENCE: III.

Simultaneous anterior cruciate ligament reconstruction and implant-mediated guided growth to correct genu valgum in skeletally immature patients.

OBJECTIVES: Adolescents with anterior cruciate ligament (ACL) tears can present with concomitant lower extremity coronal plane angular deformity (CPAD) that both predispose to injury as well as may increase the risk of graft rupture following ACL reconstruction (ACLR). The goal of this study was to examine the safety and efficacy of concomitant ACLR with implant-mediated guided growth (IMGG) compared to isolated IMGG procedures in paediatric and adolescent patients. METHODS: Operative records of all paediatric and adolescent patients (age ≤ 18 years) that underwent simultaneous ACLR and IMGG by one of two paediatric orthopaedic surgeons between 2015 and 2021 were retrospectively reviewed. A comparison cohort of isolated IMGG patients was identified and matched based on bone age within one year, sex, laterality, and fixation type (i.e. transphyseal screw vs. tension band plate and screw construct). Pre- and post-operative mechanical axis deviation (MAD), angular axis deviation (AAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were recorded. RESULTS: A total of 9 participants who underwent concomitant ACLR and IMGG (ACLR â€‹+ â€‹IMGG) were identified, with 7 of these participants meeting the final inclusion criteria. The participants had a median age of 12.7 (IQR â€‹= â€‹12.1 - 14.2) years and median bone age of 13.0 (IQR â€‹= â€‹12.0 - 14.0) years. Of the 7 participants that underwent ACLR and IMGG, 3 underwent a modified MacIntosh procedure with ITB autograft, 2 received quadriceps tendon autograft, and 1 underwent hamstring autograft reconstruction. There were no significant differences in the amount of correction obtained between ACLR â€‹+ â€‹IMGG and matched IMGG subjects with respect to any measurement variable (MAD difference: p â€‹= â€‹0.47, AAD difference: p â€‹= â€‹0.58, LDFA difference: p â€‹= â€‹0.27, MPTA difference: p â€‹= â€‹0.20). There were also no significant differences in alignment variables per unit time between cohorts (MAD/month: p â€‹= â€‹0.62, AAD/month â€‹= â€‹0.80, LDFA/month â€‹= â€‹0.27, MPTA/month â€‹= â€‹0.20). CONCLUSION: The results of the current study indicate that concomitant ACLR and lower extremity CPAD correction is a safe approach to treat CPAD concomitantly with ACLR in young patients who present with an acute ACL tear. Furthermore, one can expect reliable correction of CPAD after combined ACLR and IMGG, no different than the correction obtained in the setting of IMGG alone. LEVEL OF EVIDENCE: III.

High Rates of Successful Return to Competitive Athletics After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Regardless of Distal Fusion Level: A Prospective Cohort Study.

STUDY DESIGN: Prospective cohort. OBJECTIVE: To determine if distal spinal fusion level is associated with postoperative sport participation after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The concept of "saving a level" during PSF for AIS refers to minimizing the distal extent of lumbar fusion to theoretically allow for increased postoperative spinal mobility and a more predictable return to athletic activity, as well as minimizing the risk of degenerative disc disease. There are few prospective studies evaluating the correlation between distal fusion level and timing of return to sports. MATERIALS AND METHODS: Adolescent patients undergoing PSF for AIS between 2009 and 2019 were approached at their presurgical visit to participate in this prospective study. Participants were followed for a minimum of 2 years after surgery. Sports participation (classified by sport type and level of competitiveness) and radiographic data were collected at the initial visit. At each postoperative visit, it was noted whether patients returned to the same sport type and level of competitiveness. RESULTS: After an a priori power calculation was performed, a total of 106 participants were included in the analysis with a mean age of 14 ± 2 years. Distal fusion levels ranged from T11 to L4. There was no significant association between distal fusion level and return to the same level of sports participation ( P = 0.192). Of the participants, 93% returned to sports with no significant differences by distal fusion level ( P = 0.081). Distal fusion level demonstrated no difference in return to preoperative sport ( P = 0.486) or return to the same type of sport ( P = 0.247). CONCLUSIONS: This study found no association between distal fusion level and postoperative sports participation. Even though many patients may elect to change sports, nearly all patients returned to sports, and the majority of patients returned to the same level of sports competition or higher after PSF for AIS.

Higher Grit Scores Are Associated With Earlier Increases in Knee Flexion Following Anterior Cruciate Ligament Reconstruction With Meniscus Repair in Pediatric Patients.

BACKGROUND: The Grit Scale is used to measure grit, defined by Duckworth and colleagues as the disposition to show perseverance and passion for long-term goals. It has been shown that psychological factors like motivation, coachability, and coping with adversity are correlated with faster readiness for return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigates the association between pediatric patients' baseline grit scores and; preoperative Patient-reported Outcomes Measurement Information System (PROMIS) Pain scores and the recovery of range of motion (ROM) after ACLR. The investigators hypothesized that higher preoperative grit scores would predict lower preoperative pain scores and earlier return of knee ROM in patients undergoing ACLR. METHODS: This is a retrospective cohort study. Pediatric patients who underwent primary ACLR were assigned the pediatric Grit Scale. Patients were subdivided by meniscal procedures due to differences in postoperative protocols. ACLR alone or with meniscectomy (ACLR ± meniscectomy) were grouped together and ACLR with meniscal repair (ACLR + meniscus repair) represented the other cohort. Patients above the 50th grit percentile were considered "high grit". Patients below the 50th percentile were considered "low grit". Baseline PROMIS pain intensity and interference were collected. ROM was compared by grit cohort using the Mann-Whitney U test with a significance threshold of P ≤ 0.05. RESULTS: A total of 58 patients undergoing ACLR were analyzed: 20 ACLR ± meniscectomy and 38 ACLR + meniscus repair. The mean age was 15.0 ± 2.1 years with 41.4% of participants identifying as females. No significant difference was noted between baseline PROMIS pain intensity and interference and grit score ( P = 0.82, P = 0.91, respectively). Three months postoperatively, for those in the ACLR + meniscus repair cohort, low grit ROM was 130 degrees (interquartile range = 10 degrees), whereas high grit ROM was 135 degrees (interquartile range = 8 degrees) ( P = 0.006). CONCLUSIONS: This study found no differences in pain scores at presentation between grit cohorts but found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Quicker ROM recovery in patients with high grit may be a leading indicator of these patients' likelihood to achieve other postoperative milestones and meet criteria for RTS more quickly; the relationship between grit and readiness for RTS should be further investigated. LEVEL OF EVIDENCE: Level IV; retrospective cohort study.

Impact of Pediatric Orthopaedic Fellowship Training on Pediatric Supracondylar Humerus Fracture Treatment and Outcomes: A Meta-analysis.

BACKGROUND: Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes. METHODS: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI. RESULTS: This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury. CONCLUSIONS: Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients. LEVEL OF EVIDENCE: Level III; Meta-analysis.

The lateral femoral notch sign decreases in paediatric patients following anterior cruciate ligament reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) ruptures are common amongst paediatric patients, especially those participating in competitive sports. While magnetic resonance imaging (MRI) is typically used to confirm the diagnosis, certain radiologic findings can be indicative of an ACL tear, including a lateral femoral notch sign (LFNS) > 1.5 mm (mm). No study has focussed on understanding the resolution pattern of the LFNS in paediatric patients following ACL reconstruction (ACLR). The aim of this study is to determine whether the depth of the LFNS regresses following ACLR. The authors hypothesize that following ACLR, the LFNS will resolve. METHODS: All patients who were treated for acute ACL rupture by one of two paediatric orthopaedic surgeons between 2015 and 2020 were collected; 321 patients with the age of 5-18 were collected. Patients were excluded if they underwent previous ipsilateral knee surgeries and if they did not have pre-operative knee radiographs; 274 patients met inclusion criteria. LFNS was measured on pre-operative (PreOp) and most recent post-operative (PostOp) radiographs. A comparison cohort of patients with an LFNS <1.5 mm matched by age within 1.5 years, sex, and laterality was also collected. The median difference was calculated by taking the difference between PreOp LFNS and PostOp LFNS of each participant and finding the median of those values. RESULTS: A total of 274 pre-operative radiographs were analysed for an LFNS depth >1.5 mm. Seventeen radiographs met these criteria with a median age of 16.3 years and a median depth of 1.70 mm. Of the 17 radiographs, 8 (47.1%) of participants were skeletally immature. The median LFNS depth at most recent follow-up and median percent decrease were 1.50 mm and 28%, respectively. Only 11.8% of patients demonstrated no change in LFNS depth from PreOp to PostOp imaging. Wilcoxon signed-rank test indicated that the PreOp LFNS was significantly greater than the PostOp LFNS (p < 0.001). Mann-Whitney U tests with cases and the comparison cohort demonstrated no difference in the percent decrease (p = 0.106). CONCLUSION: This study sought to understand the resolution of the LFNS depth following initial ACL rupture. At a median of 7.67 months following ACLR, the LFNS depth decreased significantly by 0.60 mm. These findings suggest that following ACL rupture, the paediatric LFNS has the potential to resolve. Future studies should aim to further assess the resolution pattern of the LFNS with advanced imaging, such as MRI.

Techniques in Pediatric Anterior Cruciate Ligament Reconstruction.

In recent years, the frequency of anterior cruciate ligament (ACL) tears and ACL reconstruction (ACLR) in skeletally immature patients has increased. Because distal femoral and proximal tibial physes account for the majority of lower-extremity growth, surgical technique and graft selection are crucial to minimize iatrogenic physeal injury. Combined extra- and intra-articular, all-epiphyseal, and transphyseal with soft-tissue grafts are the most common ACLR techniques used in children. Combined extra- and intra-articular ACLR typically is offered to prepubescent patients with ≥2 years of growth remaining. This technique uses iliotibial band (ITB) autograft passed over the lateral femoral condyle and fixed to the anterior tibial periosteum. All-epiphyseal ACLR is similarly used in patients with ≥2 years of growth remaining, provided sufficient epiphyseal maturity to accommodate an all-epiphyseal socket because both the femoral and tibial tunnels are contained within the epiphyses. In postpubertal patients with <2 years of growth remaining, transphyseal ACLR using a soft-tissue autograft (typically hamstring or quadriceps tendon) and metaphyseal femoral fixation can be performed. This minimizes risk of physeal injury. In borderline patients with approximately 2 years of growth remaining, an additional option includes partial transphyseal ACLR, which uses a soft-tissue graft and a transphyseal tibial tunnel, but an all-epiphyseal or over-the-top femoral graft trajectory. Recently, transphyseal ITB ACLR and hybrid transphyseal hamstring with combined over-the-top ITB ACLR also have been described. Existing clinical studies focused on pediatric and adolescent ACL reconstructions have reported a wide range of graft rupture rates for these techniques (4.3%-25%), with contralateral ACL injury rates of 2.9% to 15.6%. Ongoing multicenter research is underway to directly compare surgical techniques for this demographic and quantify graft rupture rates and other clinical outcomes.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes Using All-Epiphyseal Techniques.

All-epiphyseal anterior cruciate ligament reconstruction (AE ACLR) has become an alternative technique for skeletally immature patients with a significant amount of growth remaining. This technique involves graft fixation within the epiphysis without crossing the physis. Either quadriceps tendon or hamstring autograft can be used when performing this procedure. Previous studies have shown that the complication rate is not higher in AE techniques versus previously developed techniques. Additionally, in our hands, the revision rate was found to be significantly lower in an AE ACLR compared with patients who had a transphyseal ACLR.

The language of all medical publications and spine publications from 1950 to 2020.

Background: Excellent research in all fields, including spine surgery, exists in many different regions and languages. This study seeks to determine the relative number of spine related peer-reviewed publications throughout the world based on language. Methods: Peer-reviewed publications from the eleven most prolific languages in regard to both the number of peer-reviewed spine publications indexed in PubMed and total peer-reviewed publications from 1950-2020 were identified in PubMed. Results: 29,711,547 peer-reviewed publications were analyzed for the languages of interest with 870,404 (3.0%) of those being spine related peer-reviewed publications. Between 1988 and 2019, non-English language peer-reviewed publications decreased annually for both all peer-reviewed publications and spine related peer-reviewed publications by 44% and 36%, respectively. All medical and spine specific peer reviewed publications in English compared to non-English publications have increased by 7.22 and 6.35 times since 1988, respectively. While the ratio of non-English to English spine related publications decreased in all eleven countries, the percentage of the number of spine specific publications written in Chinese (462%), Portuguese (378%), and Spanish (88%) have increased by the listed percentages. Conclusion: While the proportion of peer-reviewed publications in the field of spine surgery written in English have increased over the past several decades, there are many non-English language peer-reviewed publications each year, particularly in Chinese. Although the rapid increase in the proportion of English spine related publications is beneficial to English speaking physicians and researchers, further research is necessary to understand the impact on non-English speaking physicians and researchers.

Early Outcome Trends of Unicompartmental Knee Arthroplasty in Patients With Morbid Obesity: A Potential for Outpatient Surgery.

BACKGROUND: Elevated body mass index (BMI) was previously considered a contraindication to unicompartmental knee arthroplasty (UKA). This study sought to determine if outcomes following UKA in patients with elevated BMI have improved over the years. We hypothesized that operative times and length of stay (LOS) following UKA would significantly decrease, while discharge to home rates would increase across all BMI cohorts, especially those with a BMI > 40. METHODS: Using the National Surgical Quality Improvement Program registry, surgical cases categorized using the Current Procedural Terminology code 27446 for UKA with a recorded height and weight were included. Three BMI cohorts were created: BMI I (BMI < 30), BMI II (30 ≤ BMI ≤ 40), and BMI III (BMI > 40). Each BMI group was subclassified temporally by year of operation: Years A (2006-2009), Years B (2010-2014), and Years C (2015-2019). RESULTS: A total of 14,114 patients were included. For BMI III, both operative time (P < .001) and LOS (P < .001) significantly decreased over the Years cohorts. Discharge home rates increased from 88.3% to 94.4% in BMI III (P = .001). All BMI cohorts saw similar changes in discharge patterns, 30-day readmissions, and reoperations within 30 days in recent years. CONCLUSION: This study found that operative times and LOS have decreased significantly in patients with morbid obesity over the past 14 years, while more patients are being discharged home without being readmitted or reoperated on in the first month. As surgeons continue to improve their operative and reconstructive techniques, this study suggests that patients with elevated BMI should be considered candidates to undergo UKA procedures in ambulatory surgery centers or in hospitals with a rapid recovery unit.

Patellar instability: will my patella dislocate again?

PURPOSE OF REVIEW: The incidence of patellar instability in pediatric patients ranges is 50-100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population. RECENT FINDINGS: In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment. SUMMARY: Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.

Changes in Pediatric Sports Injury Presentation During the COVID-19 Pandemic: A Multicenter Analysis.

BACKGROUND: The current coronavirus 2019 (COVID-19) pandemic has prompted a multitude of public health response measures including social distancing, school cancellations, and cessation of organized sports. PURPOSE: To examine the impact of COVID-19 and corresponding public health measures on the characteristics of common pediatric musculoskeletal injuries associated with sports. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a multicenter retrospective cohort study comparing patients with sports injuries presenting to 3 geographically diverse level I pediatric trauma hospitals and outpatient orthopaedic surgery clinics in the United States during the COVID-19 pandemic and a prepandemic period at the same institutions. Patients were included if they presented for care between February 15 and July 15 in 2020 (pandemic cohort) or between March 15 and April 15 in 2018 and 2019 (prepandemic cohort). RESULTS: Included were 1455 patients with an average age of 12.1 ± 4.5 years. When comparing patients presenting in 2018 and 2019 with those presenting in 2020, we observed a decrease in mean age during the pandemic (12.6 ± 4.0 vs 11.0 ± 5.2 years; P = .048). Additionally, a decrease in the proportion of injuries attributed to sports (48.8% vs 33.3%; P < .001) and those occurring at school (11.9% vs 4.0%; P = .001) was observed. The proportion of injuries attributable to clavicle fractures increased during the early stages of the pandemic (13.2% vs 34.7%; P < .001). There was no statistically significant delay to care in injuries presenting during the pandemic (41.5 ± 141.2 vs 19.23 ± 79.1 days; P = .175). CONCLUSION: Across 3 tertiary care institutions, patients were seen without significant delay during the pandemic. We observed a significant decline in pediatric musculoskeletal injuries associated with sports during the COVID-19 pandemic. This decrease has been accompanied by a shift in both injury type and mechanism.