Allograft Anterior Cruciate Ligament Reconstruction Fails at a Greater Rate in Patients Younger Than 34 Years.

Purpose: To characterize the secondary anterior cruciate ligament (ACL) injury rates after primary allograft anterior cruciate ligament reconstruction (ACLR) and to identify the age cut-score at which the risk of allograft failure decreases. Methods: All patients who underwent primary ACLR within a single orthopaedic department between January 2005 and April 2020 were contacted at a minimum of 2 years post-ACLR to complete a survey regarding complications experienced post-surgery, activity level, and perceptions of knee health. Patients were excluded for incidence of previous ACLR (ipsilateral or contralateral) and/or age younger than 14 years. Relative proportions were calculated, binary regression analysis was performed, and receiver operating characteristic analysis was used to identify the threshold age for maximal sensitivity and specificity to predict high risk of allograft failure, defined as undergoing revision ACLR. Results: Of the 939 surveys completed, 398 patients underwent primary allograft ACLR (mean age 39.5 years; range 16.0-66.1 years; 54.3% female). The secondary ACL injury rate was 11.6% (5.8% ipsilateral revision ACLR, 5.8% contralateral ACL injury). Male and female patients had similar revision (5.5% male, 6.0% female, P = .82) and contralateral ACL injury rates (6.6% male, 5.1% female, P = .52). Receiver operating characteristic analysis indicated that age ≤34 years was threshold for differentiating high risk of allograft failure (area under the curve 0.65, 95% confidence interval 0.55-0.76; P = .014). Patients aged ≤34 years had a greater secondary injury rate than patients >34 years (20.4% (10.2% revision ACLR, 10.2% contralateral ACL injury) versus 6.9% (3.5% revision ACLR, 3.5% contralateral ACL injury; P < .001). Binary regression analysis demonstrated that decreasing age was associated with increased risk of graft failure (χ2 = 7.9, P = .02.). Conclusions: Allograft ACLR showed similar failure rates between sexes but displayed suboptimal graft failure outcomes in younger and active patients. By age 34 years, the increased revision risk for younger patients diminished. Level of Evidence: Level IV, therapeutic case series.

Editorial Commentary: Limited Preoperative Range of Motion Is Associated With Range of Motion Deficits After Anterior Cruciate Ligament Reconstruction: "If the Knee Is Not Straight, Wait".

Optimal timing of anterior cruciate ligament reconstruction (ACLR) remains under debate. Prolonging time between injury and ACLR risks damaging the meniscus and chondral surface, as well as delays return to play. Early ACLR may be associated with postoperative stiffness or arthrofibrosis. We emphasize that optimal timing for ACLR depends on criterion-based return of knee range of motion and quadriceps strength, not a quantitative temporal period. The length of time is far less important that the quality of prereconstruction care provided. Prereconstruction care includes "prehabilitation," including prone hangs focusing on optimizing knee range of motion, postinjury effusion resolution, and mentally preparing the patient for postoperative expectations. Defining preoperative criteria for proceeding with surgery is crucial to decrease the risk of arthrofibrosis. Some patients meet these criteria within 2 weeks, whereas others linger to 10 weeks. Reduction in arthrofibrosis requiring surgical intervention is multifactorial and not solely dependent on the length of time between injury and intervention.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

Cartilage-penetrating hyaluronic acid hydrogel preserves tissue content and reduces chondrocyte catabolism.

Articular cartilage injuries have a limited healing capacity and, due to inflammatory and catabolic activities, often experience progressive degeneration towards osteoarthritis. Current repair techniques generally provide short-term symptomatic relief; however, the regeneration of hyaline cartilage remains elusive, leaving both the repair tissue and surrounding healthy tissue susceptible to long-term wear. Therefore, methods to preserve cartilage following injury, especially from matrix loss and catabolism, are needed to delay, or even prevent, the deteriorative process. The goal of this study was to develop and evaluate a cartilage-penetrating hyaluronic-acid (HA) hydrogel to improve damaged cartilage biomechanics and prevent tissue degeneration. At time zero, the HA-based hydrogel provided a 46.5% increase in compressive modulus and a decrease in permeability after simulated degeneration of explants (collagenase application). Next, in a degenerative culture model (interleukin-1ß [IL-1ß] for 2 weeks), hydrogel application prior to or midway through the culture mitigated detrimental changes to compressive modulus and permeability observed in non-treated explants. Furthermore, localized loss of proteoglycan was observed in degenerative culture conditions alone (non-treated), but hydrogel administration significantly improved the retention of matrix elements. Finally, NITEGE staining and gene expression analysis showed the ability of the HA gel to decrease chondrocyte catabolic activity. These results highlight the importance of reinforcing damaged cartilage with a biomaterial system to both preserve tissue content and reduce catabolism associated with injury and inflammation.

Knee Injuries in the Elite American Football Player: A Descriptive Pictorial Imaging and Mechanism of Injury Review.

ABSTRACT: Musculoskeletal injuries are common in American football, with an incidence ranging from approximately 10 to 35 per 1000 playing hours. Injuries occur more commonly in games than in practice. Although several studies have analyzed specific injury types in football, this review aims to describe the most common knee injuries sustained by American football players and to review the existing literature pertaining to the radiologic findings used in the diagnosis of these injuries.

Evaluation of the Effectiveness of Newer Helmet Designs with Emergent Shell and Padding Technologies Versus Older Helmet Models for Preserving White Matter Following a Season of High School Football.

We aimed to objectively compare the effects of wearing newer, higher-ranked football helmets (HRank) vs. wearing older, lower-ranked helmets (LRank) on pre- to post-season alterations to neuroimaging-derived metrics of athletes' white matter. Fifty-four high-school athletes wore an HRank helmet, and 62 athletes wore an LRank helmet during their competitive football season and completed pre- and post-season diffusion tensor imaging (DTI). Longitudinal within- and between-group DTI metrics [fractional anisotropy (FA) and mean/axial/radial diffusivity (MD, AD, RD)] were analyzed using tract-based spatial statistics. The LRank helmet group exhibited significant pre- to post-season reductions in MD, AD, and RD, the HRank helmet group displayed significant pre- to post-season increases in FA, and both groups showed significant pre- to post-season increases in AD (p's < .05 [corrected]). Between-group analyses revealed the pre- to post-season increase in AD was significantly less for athletes wearing HRank compared to LRank (p < .05 [corrected]). These data provide in vivo evidence that wearing an HRank helmet may be efficacious for preserving white matter from head impact exposure during high school football. Future prospective longitudinal investigations with complimentary imaging and behavioral outcomes are warranted to corroborate these initial in vivo findings.

Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction.

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

Rehabilitation of Soft Tissue Injuries of the Hip and Pelvis.

The athlete's hip is complex when it comes to the surrounding musculature-approximately 21 different muscles can cross the hip and pelvis region, all synchronously working to maintain pelvic stability and functional hip activities. Commonly injured muscle groups for high-level athletes include flexors, adductors, abductors, and/or proximal hamstring musculotendinous complex. These muscle groups work in harmony; however, each has an independent function and propensity for injury. Rehabilitation phases for each injury group can be broken down into 3 phases: acute management, strengthening, and return-to-sport or return-to-competition phase. Specific rehabilitation principles and modalities are described for each injury group.

Impact of Insurance and Practice Type on Access to Orthopaedic Sports Medicine.

BACKGROUND: The Patient Protection Affordable Care Act has expanded Medicaid eligibility in recent years. However, the provisions of the act have not translated to improved Medicaid payments for specialists such as orthopaedic surgeons. The number of health care practitioners who accept Medicaid is already decreasing, with low reimbursement rates being cited as the primary reason for the trend. HYPOTHESIS: Private practice orthopaedic groups will see patients with Medicaid or Medicare at lower rates than academic orthopaedic practices, and business days until appointment availability will be higher for patients with Medicaid and Medicare than those with private insurance. STUDY DESIGN: Cross-sectional study. METHODS: Researchers made calls to 2 regular-sized orthopaedic practices, 1 small orthopaedic practice, and 1 academic orthopaedic practice in each of the 50 states in the United States. Callers described a scenario of a recent injury resulting in a bucket-handle meniscal tear and an anterior cruciate ligament tear seen on magnetic resonance imaging at an outside emergency department. For a total of 194 practices, 3 separate telephone calls were made, each with a different insurance type. Data regarding insurance acceptance and business days until appointment were tabulated. Student t tests or analysis of variance for continuous data and χ2 or Fisher exact tests for categorical data were utilized. RESULTS: After completing 582 telephone calls, it was determined that 31.4% (n = 59) did not accept Medicaid, compared with 2.2% (n = 4) not accepting Medicare and 1% (n = 1) not accepting private insurance (P < .001). There was no significant association between type of practice and Medicaid refusal (P = 0.12). Mean business days until appointment for Medicaid, Medicare, and private insurance were 5.3, 4.1, and 2.9, respectively (P < .001). CONCLUSIONS: Access to care remains a significant burden for the Medicaid population, given a rate of Medicaid refusal of 32.2% across regular-sized orthopaedic practices. If Medicaid is accepted, time until appointment was significantly longer when compared with private insurance.

Increasing hip and knee flexion during a drop-jump task reduces tibiofemoral shear and compressive forces: implications for ACL injury prevention training.

Although most ACL injury prevention programmes encourage greater hip and knee flexion during landing, it remains unknown how this technique influences tibiofemoral joint forces. We examined whether a landing strategy utilising greater hip and knee flexion decreases tibiofemoral anterior shear and compression. Twelve healthy women (25.9 ± 3.5 years) performed a drop-jump task before and after a training session (10-15 min) that emphasised greater hip and knee flexion. Peak tibiofemoral anterior shear and compressive forces were calculated using an electromyography (EMG)-driven knee model that incorporated joint kinematics, EMG and participant-specific muscle volumes and patella tendon orientation measured using magnetic resonance imaging (MRI). Participants demonstrated a decrease in peak anterior tibial shear forces (11.1 ± 3.3 vs. 9.6 ± 2.7 N · kg-1; P = 0.008) and peak tibiofemoral compressive forces (68.4 ± 7.6 vs. 62.0 ± 5.5 N · kg-1; P = 0.015) post-training. The decreased peak anterior tibial shear was accompanied by a decrease in the quadriceps anterior shear force, while the decreased peak compressive force was accompanied by decreased ground reaction force and hamstring forces. Our data provide justification for injury prevention programmes that encourage greater hip and knee flexion during landing to reduce tibiofemoral joint loading.

Two fixation methods for acromioclavicular joint reduction during coracoclavicular ligament reconstruction: a biomechanical analysis.

One specimen from each of six pairs of cadaveric shoulders underwent a semitendinosus coracoclavicular ligament reconstruction with a hook plate used for acromioclavicular joint reduction, while on the other specimen a polydioxanone (PDS) suture braid was utilized. Cyclical loading followed by maximal load-to-failure testing was performed. Displacement during cyclical loading, loads to 50% and 100% displacement, stiffness, and maximal load to failure were determined for all specimens. Results showed that the locking hook plate allowed significantly less displacement of the coracoclavicular interval during cyclical loading (3.41 vs. 9.67 mm, p = .0081) and withstood significantly higher loads before both 50% (225.5 vs. 107.7 N, p = .0197) and 100% displacement (410.6 vs. 240.1 N, p = .0077). The locking hook plate was found to be significantly stiffer than the PDS suture braid (28.2 vs. 18.4 N/mm, p = .0029), but there was no difference in maximal load to failure between the two fixation methods (hook plate, 434.4 N; PDS, 476.7 N; p = .76).

Anatomic, Transepiphyseal Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: Our technique for physeal-sparing, anatomic anterior cruciate ligament (ACL) reconstruction reliably produces femoral tunnels that are of adequate length and that safely avoid the femoral physis without the addition of time-consuming surgical methods or substantial utilization of fluoroscopy. STEP 1 PREOPERATIVE PLANNING: Obtain radiographs and MRI of the knee as well as an anteroposterior radiograph of the hand (to obtain a bone age). STEP 2 PATIENT SETUP PORTAL PLACEMENT AND GRAFT HARVEST: The affected knee must be able to flex at least 90° with the end of the operative table lowered, in order to properly visualize the anatomy of the ACL femoral footprint. STEP 3 PREPARE ACL FOOTPRINT AND ESTABLISH FAR ANTEROMEDIAL PORTAL: Maintain soft-tissue remnants at both the femoral and the tibial footprint in order to individualize the anatomy. STEP 4 IDENTIFY EXTRA-ARTICULAR LANDMARKS AND PREPARE FEMORAL TUNNEL: Visualize and palpate your previously marked popliteal sulcus and lateral epicondyle; these landmarks are the crucial extra-articular points for establishing a safe femoral tunnel. STEP 5 PREPARE TIBIAL TUNNEL: The tibial tunnel can be safely drilled in a transphyseal manner in skeletally immature patients. STEP 6 FIX GRAFT: Use the Arthrex ACL TightRope RT for femoral fixation. STEP 7 POSTOPERATIVE CARE: As a skeletally immature athlete differs from a more mature athlete in several important ways, alter the postoperative protocol accordingly. RESULTS: Our clinical experience has corresponded to our MRI-based findings from our original study14, and we have not observed any physeal or chondral injuries leading to growth disturbances from our femoral tunnels. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Flexor tendon repair rehabilitation protocols: a systematic review.

PURPOSE: To systematically review various flexor tendon rehabilitation protocols and to contrast those using early passive versus early active range of motion. METHODS: We searched PubMed and Cochrane Library databases to identify articles involving flexor tendon injury, repair, and rehabilitation protocols. All zones of injury were included. Articles were classified based on the protocol used during early rehabilitation. We analyzed clinical outcomes, focusing on incidence of tendon rupture and postoperative functional range of motion. We also analyzed the chronological incidence of published tendon rupture with respect to the protocol used. RESULTS: We identified 170 articles, and 34 met our criteria, with evidence ranging from level I to level IV. Early passive motion, including both Duran and Kleinert type protocols, results included 57 ruptures (4%) and 149 fingers (9%) with decreased range of motion of 1598 tendon repairs. Early active motion results included 75 ruptures (5%) and 80 fingers (6%) with decreased range of motion of 1412 tendon repairs. Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols. When analyzing published articles chronologically, we found a statistically significant trend that overall (passive and active rehabilitation) rupture rates have decreased over time. CONCLUSIONS: Analyzing all flexor tendon zones and literature of all levels of evidence, our data show a higher risk of complication involving decreased postoperative digit range of motion in the passive protocols and a higher risk of rupture in early active motion protocols. However, modern improvements in surgical technique, materials, and rehabilitation may now allow for early active motion rehabilitation that can provide better postoperative motion while maintaining low rupture rates.

Anatomic landmarks utilized for physeal-sparing, anatomic anterior cruciate ligament reconstruction: an MRI-based study.

BACKGROUND: Anterior cruciate ligament (ACL) injury and reconstruction in the skeletally immature patient are becoming more common. The purpose of this study was to develop a reproducible anatomic ACL reconstruction technique, based on intra-articular and extra-articular landmarks, that reliably produces a femoral tunnel of adequate length and diameter while avoiding the distal femoral physis. METHODS: Magnetic resonance images (MRIs) of one hundred and eighty-eight children (age range, six to seventeen years) were evaluated. Two extra-articular landmarks, the femoral insertion of the popliteus tendon and the lateral femoral epicondyle, and one intra-articular landmark, the central portion of the femoral footprint of the ACL, were identified. Computer software was used to plot these landmarks in all three planes and to draw lines representing two potential femoral tunnels. The first line connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, and the second connected the center of the ACL femoral footprint with the lateral femoral epicondyle. The length of each tunnel, the shortest distance from the center of each tunnel to the distal femoral physis, and the height of the lateral femoral condyle from the physis to the chondral surface and to the base of the cartilage cap were calculated. A three-dimensional MRI reconstruction was used to confirm that placement of a femoral tunnel with use of the chosen landmarks would avoid the distal femoral physis. RESULTS: The mean distance from the center of the preferred ACL tunnel, which connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, to the distal femoral physis was 12 mm, independent of sex (p = 0.94) or age, and the shortest distance was 8 mm. The length of this proposed tunnel averaged 30.1 mm in the boys and 27.4 mm in the girls (p < 0.001), and it averaged 25.4 mm at an age of six years and 29.7 mm at an age of seventeen years. The mean distance from the center of the alternative tunnel, which connected the center of the ACL femoral footprint with the lateral epicondyle, to the distal femoral physis was 8.8 mm in the boys and 8.9 mm in the girls (p = 0.55). The mean length of this alternative tunnel was 34.3 mm in the boys and 31.6 mm in the girls (p < 0.001). CONCLUSIONS: Drilling from the center of the ACL femoral footprint to the insertion of the popliteus tendon would have resulted in a mean tunnel length of 27 to 30 mm, and it would have allowed the safe placement of a femoral tunnel at least 7 mm in diameter in a patient six to seventeen years old. The center of the ACL femoral footprint and the popliteus insertion are easily identifiable landmarks and will allow safe, reproducible, anatomic ACL reconstruction in the skeletally immature patient.

Lateral femoral cortical breach during anterior cruciate ligament reconstruction: a biomechanical analysis.

PURPOSE: The purpose of our study was to determine whether secondary fixation is needed when lateral femoral wall breach occurs and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of 3 different suspensory fixation devices. METHODS: Sixty fresh-frozen porcine femora were dissected to isolate the anterior cruciate ligament (ACL) footprint. Femoral ACL tunnels were then drilled at diameters of 7, 8, 9, and 10 mm. We conducted 5 separate cyclical and ultimate load testing trials, at each tunnel diameter, for 3 different cortical suspension devices. RESULTS: The mean load to failure decreased as the tunnel size enlarged for all 3 devices. In 7-mm tunnels, mean failure load ranged from 1,163.7 to 1,455.0 N across the 3 devices; in 8-mm tunnels, 1,154.7 to 1,643.2 N; in 9-mm tunnels, 820.8 to 1,125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N. Modes of failure also varied as the tunnel sizes enlarged. The ultimate load was not different among the 3 manufacturers (P = .08), but there was a difference in the ultimate load across the 4 tunnel diameters (P < .05), except when we compared the 7-mm tunnel with the 8-mm tunnel (P = .91). CONCLUSIONS: With 7- and 8-mm-diameter tunnels, failure loads with each of the suspensory devices tested exceeded the documented interference screw load to failure. CLINICAL RELEVANCE: Our findings suggest that, for soft-tissue ACL grafts, femoral tunnels of 8 mm or less can be drilled through the lateral femoral cortex while still using a suspensory device for graft fixation. With pediatric, double-bundle, and anatomic ACL reconstructions, smaller and shorter tunnels are routinely used. Thus, breaching the lateral cortex when using suspensory fixation may increase tunnel length while still achieving stable fixation.

A biomechanical analysis of point of failure during lateral-row tensioning in transosseous-equivalent rotator cuff repair.

PURPOSE: The purpose of this study was to determine the maximum load and point of failure of the construct during tensioning of the lateral row of a transosseous-equivalent (TOE) rotator cuff repair. METHODS: In 6 fresh-frozen human shoulders, a TOE rotator cuff repair was performed, with 1 suture from each medial anchor passed through the tendon and tied in a horizontal mattress pattern. One of 2 limbs from each of 2 medial anchors was pulled laterally over the tendon. After preparation of the lateral bone for anchor placement, the 2 limbs were passed through the polyether ether ketone (PEEK) eyelet of a knotless anchor and tied to a tensiometer. The lateral anchor was placed into the prepared bone tunnel but not fully seated. Tensioning of the lateral-row repair was simulated by pulling the tensiometer to tighten the suture limbs as they passed through the eyelet of the knotless anchor. The mode of failure and maximum tension were recorded. The procedure was then repeated for the second lateral-row anchor. RESULTS: The mean load to failure during lateral-row placement in the TOE model was 80.8 ± 21.0 N (median, 83 N; range, 27.2 to 115.8 N). There was no statistically significant difference between load to failure during lateral-row tensioning for the anterior and posterior anchors (P = .84). Each of the 12 constructs failed at the eyelet of the lateral anchor. Retrieval analysis showed no failure of the medial anchors, no medial suture cutout through the rotator cuff tendon, and no signs of gapping at the repair site. CONCLUSIONS: Our results suggest that the medial-row repair does not appear vulnerable during tensioning of the lateral row of a TOE rotator cuff repair with the implants tested. However, surgeons should exercise caution when tensioning the lateral row, especially when lateral-row anchors with PEEK eyelets are implemented. CLINICAL RELEVANCE: For this repair construct, the findings suggest that although the medial row is not vulnerable during lateral-row tensioning of a TOE rotator cuff repair, lateral-row anchors with PEEK eyelets appear vulnerable to early failure.

Inter-observer and intra-observer reliability of the Risser sign in a metropolitan scoliosis screening program.

BACKGROUND: Risser staging is one of several criteria used in scoliosis screening programs. This study aimed to evaluate the reliability of a radiologist's Risser interpretations from a large metropolitan scoliosis-screening program when compared to interpretations of 2 pediatric orthopaedic surgeons and 2 orthopaedic residents. METHODS: During the 2008 to 2009 school year, 275 students were reviewed as part of a metropolitan scoliosis-screening program. 100 of the radiographs were randomly chosen and de-identified for inclusion. Two attending orthopaedic surgeons and 2 orthopaedic residents independently interpreted the films on 3 occasions and assigned each a Risser stage. Inter- and intra-rater analyses using Kappa statistics were performed to determine the reliability of the Risser stage interpretations between the orthopaedic surgeons and the radiologist as well as the reliability of the interpretations among the individual surgeons. RESULTS: Inter-rater kappa values for the attending surgeons and the radiologist averaged 0.526. Inter-rater kappa values for the resident surgeons and the radiologist averaged 0.490 and 0.101. There was significant agreement between the attending surgeons on all 3 occasions (κ = 0.764, 0.809, 0.837). The intra-rater reliability among the attending surgeons (κ = 0.988, 0.957) and the resident surgeons (κ = 0.813, 0.495) showed statistical significance (P < 0.0001). Only half of the films had perfect agreement between the radiologist and the surgeons and 28% of the films were interpreted with a difference of 2 or more Risser stages. The radiologist did not interpret any of the films as a Risser 4 or 5 but 21% of the films were interpreted as a 4 or 5 by the orthopaedic surgeons. CONCLUSIONS: The scoliosis-screening program utilizes a referral pathway based on the radiologist's Risser stage interpretation in conjunction with the Cobb angle. The radiologist and the orthopaedic surgeons demonstrated only moderate agreement in their interpretations of Risser stages, resulting in a possible 21% over-referral rate. This study questions the efficacy of using the Risser stage as part of a large metropolitan scoliosis screening program and warrants further investigation.

Bilateral exertional compartment syndrome of the forearm: evaluation and endoscopic treatment in an elite swimmer.

Exertional compartment syndromes are uncommon but can significantly impair athletic performance. This report describes an unusual case of bilateral forearm compartment syndromes in an elite-level swimmer that was able to be treated successfully using a novel endoscopic fasciotomy method.