Bioinductive Patch as an Augmentation for Rotator Cuff Repair, a Systematic Review and Meta-Analysis.

INTRODUCTION: Rotator cuff tears (RCTs) are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be pursued. A significant and common complication after rotator cuff repair (RCR) is retearing or non-healing. Numerous augmentations to traditional suture RCR have been studied. Of these, the Smith+Nephew Regeneten bioinductive collagen patch has had promising initial results; however, analytic data for its use is lacking, and there is no meta-analysis comparing the available data to historical RCR outcomes. METHODS: A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMED, Cochrane, and ClinicalTrials.gov. 13 studies met inclusion and exclusion criteria. Only clinical trials on full and partial-thickness tears were included. American Shoulder and Elbow Surgeon score (ASES), Constant-Murley score (CMS), the visual analog scale for pain (VAS), the minimal clinically important difference (MCID), tendon thickness, and complication rates were primary outcomes of interest. A meta-analysis was performed to determine the overall complication and retear rate from the included studies. RESULTS: ASES, CMS, and VAS improved significantly in all studies that reported them, and most patients achieved MCID. Patient-reported outcome measure (PROM) improvements were similar to historical improvements in standard RCR, and a similar proportion of patients achieved MCID after standard repair. Tendon thickness improved significantly and to a similar degree as standard RCR. Overall retear rate after full thickness RCR augmented with the bioinductive patch was 8.3%. For partial thickness RCR, total retear rate of 1.1% across all patients. The overall complication rate with the bioinductive patch was 15.5% across all full-thickness RCR studies and 16.2% in partial thickness RCR. We found overall retear rate to be lower after augmentation with the bioinductive patch compared to traditional repair; however, the overall complication rate was similar for full-thickness tears and higher for partial-thickness tears. Lastly, adverse reactions to the bioinductive patch were noted at 0.2%. CONCLUSIONS: The bioinductive collagen patch appears to be a safe augmentation for rotator cuff repair. Patients are likely to experience significant subjective improvement in PROMs and significant increases in tendon thickness. Retear rate has been a concern after RCR for decades, and the bioinductive patch may help mitigate this risk. There is a lack of case-control studies comparing the bioinductive patch to traditional suture RCR. Such data is needed to better determine the role of the bioinductive patch in the treatment of full and partial-thickness rotator cuff repairs.

Are Recreational Sports a Relic of the Past OR a Solution for the Future?

ABSTRACT: Children's participation in sport is a critical component to their physical and social development and as such, efforts should be made to provide all children with the opportunity to play. In recent years, there has been an observed shift in the focus of youth sports from that of participation for the health benefits of physical activity and fun to that of winning and competing. As a result, there has been a rise in club sports offerings and a subsequent reduction in recreational sports opportunities. This change presents unique challenges to children's access to sport and may not adequately support their overall physical, social, and emotional development. This commentary will discuss the benefits and barriers to increasing recreational sport opportunities using the Social Ecological Model as a framework. It also will propose solutions that can be implemented at the intrapersonal, interpersonal, organizational, community, and public policy levels to revive recreational sports.

Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database.

BACKGROUND: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. PURPOSE: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). RESULTS: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. CONCLUSION: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

Highly Active Middle School Athletes Demonstrate Poor Motor Skill Proficiency.

BACKGROUND: Fundamental movement skills (FMS) are critical components to lifelong participation in sports and physical activity. With the rise in early sports specialization, mastery of motor skills may be limited in youth athletes. The purpose of this study was to assess FMS proficiency in highly active middle school athletes and determine whether proficiency differed between specialization levels and sex. HYPOTHESIS: (1) Most athletes would fail to achieve proficiency in all domains of the Test of Gross Motor Development (TGMD-2), (2) highly specialized athletes would demonstrate lower proficiency in all domains of the TGMD-2, and (3) male athletes would demonstrate higher proficiency than female athletes. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 91 athletes were recruited (44 male, 12.6 ± 0.9 years). Activity level was quantified using the Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (Pedi-FABS), specialization level was determined using the Jayanthi Specialization Scale, and the TGMD-2 was used to assess FMS proficiency. Descriptive statistics were used to describe gross motor, locomotor, and object control percentile rank. A 1-way analysis of variance (ANOVA) was used to assess differences in percentile rank between low, moderate, and high specialization groups and independent samples t tests were used to compare sexes (α < 0.05). RESULTS: Mean Pedi-FABS score was 23.6 ± 4.9. In total, 24.2%, 38.5%, and 37.4% of athletes classified as low, moderate, and highly specialized, respectively. Mean percentile ranks were 56.2%, 64.7%, and 62.6% for locomotor, object control, and gross motor domains, respectively. No athlete achieved a percentile rank >99% in any domain of the TGMD-2, and there was no significant difference between specialization groups or sex. CONCLUSION: Despite high activity levels, no athlete demonstrated proficiency in any domain of the TGMD-2, and there was no difference in proficiency between specialization levels or by sex. CLINICAL RELEVANCE: Sport participation, regardless of level, does not ensure adequate mastery of FMS.

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

Objective: Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%. Design: Quality improvement initiative. Setting: Children's Mercy Kansas City (CMKC), a freestanding children's hospital. Patients: Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy label and received a perioperative antibiotic. Methods: No standardized process existed to identify and clarify PCN-allergic-labeled patients preoperatively. We developed a process for patient identification combined with a pharmacist phone interview for PCN allergy clarification. In plan-do-study-act (PDSA) part 1, we implemented a computer-generated patient list. In PDSA part 2, we combined automated identification with a phone interview. In PDSA part 3, we enhanced the patient list, making it timely and concise. In PDSA part 4, we included a PCN allergy clarification electronic survey to caregivers via the electronic medical record. Results: Cefazolin use in PCN-allergic surgical patients increased from 50% to 74% following interventions. Patients who had their PCN allergy label clarified were 4 times more likely to receive cefazolin compared to those whose allergy labels were not clarified (OR, 4.21; 95% CI, 1.68-11.61; P = 0.003). Moreover, 90% of patients received cefazolin when their PCN allergy was clarified and cefazolin was recommended. When a PCN allergy label was not clarified, only 59% of patients received cefazolin. Conclusions: Appropriate clarification and documentation of PCN allergy labels increases the use of cefazolin for surgical prophylaxis.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients.

BACKGROUND: The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options. PURPOSE: To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort. RESULTS: There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs. CONCLUSION: In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

A Corresponding Point Measurement System Provides Reliable Measurement of Displacement for Medial Epicondyle Fractures.

Little consensus exists on the best method for evaluation and management of pediatric medial epicondyle fractures because of an inability to reliably evaluate fracture displacement with standard imaging techniques. This study aimed to determine the performance of various radiographic views in evaluating displaced medial epicondyle fractures when using a standardized measurement methodology. Methods: Ten fellowship-trained pediatric orthopaedic surgeons assessed fracture displacement in 6 patients with displaced medial epicondyle fractures using radiographic views (anteroposterior, lateral, axial, internal oblique [IO], and external oblique [EO]) and computed tomographic (CT) views (axial, 3-dimensional [3D] horizontal, and 3D vertical). Raters used a corresponding point method for measuring displacement. For each image, raters measured the absolute displacement, categorized the percent of displacement relative to the size of the fragment and fracture bed, and indicated a treatment option. Interobserver reliability was calculated for each view. Bland-Altman plots were constructed to evaluate the bias between each radiograph and the mean of the CT methods. Results: For absolute displacement, anteroposterior and EO views showed almost perfect interobserver reliability, with an interclass correlation coefficient (ICC) of 0.944 for the anteroposterior view and an ICC of 0.975 for the EO view. The axial view showed substantial reliability (ICC = 0.775). For the displacement category, almost perfect reliability was shown for the anteroposterior view (ICC = 0.821), the axial view (ICC = 0.911), the EO view (ICC = 0.869), and the IO view (ICC = 0.871). Displacement measurements from the anteroposterior, axial, and EO views corresponded to the measurements from the CT views with a mean bias of <1 mm for each view. However, the upper and lower limits of agreement were >5 mm for all views, indicating a substantial discrepancy between radiographic and CT assessments. Treatment recommendations based on CT changed relative to the recommendation made using the anteroposterior view 29% of the time, the EO view 41% of the time, and the axial view 47% of the time. Conclusions: Using a corresponding point measurement system, surgeons can reliably measure and categorize fracture displacement using anteroposterior, EO, and axial radiographic views. CT-based measurements are also reliable. However, although the mean difference between the radiograph-based measurements and the CT-based measurements was only about 1 mm, the discrepancy between radiographic views and CT-based methods could be as large as 5 to 6 mm. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Physical Literacy in Elementary Physical Education: A Survey of Fundamental Movement Skill Practice Patterns.

PURPOSE: To describe fundamental movement skill (FMS) practice patterns in the elementary physical education (PE) curriculum. METHODS: A cross-sectional survey was sent to PE teachers of grades 1 through 6. Sixty-eight responses were included for analysis. RESULTS: Only 38.2% of teachers taught all 12 FMS components. Compared with PE teachers for grades 4 to 6, a significantly higher proportion of PE teachers for grades 1 to 3 taught all 12 FMS and used direct instruction methods. For children falling behind, only 8.8% reported referring to an exercise program and no PE teacher sought a health care referral. A video abstract can be found in Supplemental Digital Content 1 (available at: http://links.lww.com/PPT/A342).

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.

Reliability of the Cutting Alignment Scoring Tool (CAST) to Assess Trunk and Limb Alignment During a 45-Degree Side-Step Cut.

BACKGROUND: Three-dimensional (3D) motion analysis is considered the gold standard for evaluating human movement. However, its clinical utility is limited due to cost, operating expertise, and lengthy data processing time. Numerous qualitative scoring systems have been introduced to assess trunk and lower extremity biomechanics during functional tasks. However, the reliability of qualitative scoring systems to evaluate cutting movements is understudied. Purpose/Hypotheses: To assess the inter-rater and intra-rater reliability of the Cutting Alignment Scoring Tool (CAST) among sports medicine providers and to evaluate rater agreement of each component of the CAST. The hypotheses were: 1) there would be good-to-excellent inter-rater and intra-rater reliability among sports medicine providers, 2) there would be good to almost perfect agreement for cut width and trunk lean variables and moderate to good agreement for valgus variables of the CAST. STUDY DESIGN: Repeated Measures. METHODS: Ten videos of a 45-degree side-step cut performed by adolescent athletes were independently rated on two occasions by six raters (2 medical doctors, 2 physical therapists, and 2 athletic trainers). The variables assessed include trunk lean to the opposite direction of the cut, increased cut width, knee valgus at initial load acceptance (static), and knee valgus throughout the task (dynamic). Variables were scored as either present, which were given a score of "1", or not present, which were given a score of "0". Video sequence was randomized in each rating session, and a two-week wash out period was given. RESULTS: The cumulative inter-rater and intra-rater reliabilities were good (ICC: 0.808 and ICC: 0.753). Almost perfect kappa coefficients were recorded for cut width (k=0.949). Moderate kappa coefficients were found for trunk lean (k= 0.632) and fair kappa coefficients were noted for dynamic and static valgus (k=0.462 and k= 0.533 respectively). CONCLUSION: These findings suggest that the CAST is a reliable tool to evaluate trunk and LE alignment during a cutting task by sports medicine providers. LEVEL OF EVIDENCE: Level 2 Diagnosis.

Pediatric Orthopaedic Surgeons Dissatisfied in On-Call Practices Despite Improving Call Conditions. The 2015 POSNA Membership Survey Regarding Trauma Care.

BACKGROUND: To examine the current trends in trauma call coverage of pediatric orthopaedic surgeons in North America and to identify predictors of surgeon on-call satisfaction. METHODS: In 2015, ∼1200 active members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding emergency room on-call practices. In total, 410 members completed the survey with a response rate of 35%. Information collected included call frequency, practice setting and satisfaction with call. This information was analyzed and compared with the 2006 and 2010 trauma call surveys of Pediatric Orthopaedic Society of North America membership using 2 sample difference in proportion, χ tests for trend and the Fisher exact tests. Logistic regression analyses were used to identify predictors of call satisfaction among pediatric orthopaedic surgeons. RESULTS: In total, 47% of pediatric orthopaedic surgeons had access to a designated trauma operating room in 2015, up from 39% in 2010 and 24% in 2006. In total, 43% of pediatric orthopaedic surgeons currently receive a stipend for taking call, up from 35% in 2010 and 28% in 2006. Although 83% of pediatric orthopaedic surgeons believe that trauma call is an integral part of their practice, only 53% are satisfied with their call experience. Controlling for covariates, believing that call is integral to one's practice doubles odds of call satisfaction. Having resident or fellow support and being financially compensated for orthopaedic trauma call also increases one's odds of satisfaction. The odds of being satisfied with call decrease by 7% for each year of increase in age of the surgeon. CONCLUSIONS: Access to a designated trauma operating room and financial compensation for call coverage have steadily increased over the past decade. A sizable majority of respondents continue to believe that trauma care is an integral part of being a pediatric orthopedist. Despite this, 47% of respondents remain dissatisfied with their trauma call arrangements. The age and attitude of the individual surgeon and extent of hospital support predict satisfaction of surgeons providing trauma coverage. LEVEL OF EVIDENCE: Level V-economic and decision analysis.

Cadaveric Analysis of the Distal Tibiofibular Syndesmosis.

BACKGROUND: Unstable ankle fractures with syndesmotic injuries commonly occur and can result in significant morbidity. Although the need for an anatomic reduction is clear, there is still debate surrounding the optimal operative treatment. Recent literature shows an increasing interest in anatomic ligament repair or reconstruction in the acute and chronic syndesmosis injury. Despite this trend, there is insufficient literature detailing anatomy of the distal tibiofibular syndesmosis. In the literature that does exist, there is controversy regarding the ligamentous anatomy of the syndesmosis. None of the current literature describes an anatomic constant that may be used as an intraoperative reference for anatomic ligament reconstructions. METHODS: Ten sets of tibia and fibula free of all soft tissue were used to analyze osseous structures. Another 10 nonpaired, fresh-frozen specimens were used to study the distal tibiofibular syndesmosis. These were measured using a 3-dimensional tracking system. Measurement of each ligament width at origin and insertion, length, and distance from the tibial articular cartilage was performed. RESULTS: The superior and inferior insertions of the anterior inferior tibiofibular ligament measured 22.7 mm and 3.4 mm proximal to the distal articular cartilage of the tibia, respectively. The superior insertion of the posterior inferior tibiofibular ligament measured 15.2 mm proximal to the articular cartilage. The superior and inferior insertions of the interosseous ligament measured 31.8 mm and 9.2 mm proximal to the distal articular cartilage, respectively. The inferior transverse ligament was a prominent identifiable structure in 70% of specimens. CONCLUSIONS: The superior margin of the distal articular cartilage could serve as a consistent anatomic landmark for reconstruction. The inferior transverse ligament is an identifiable structure in 70% of the specimens studied. CLINICAL RELEVANCE: This article clarifies the anatomy and provides measurements from an anatomic constant that can guide reconstruction and intraoperative evaluation of the syndesmosis.

Factors predicting the outcome of primary clubfoot surgery.

BACKGROUND: We aimed to determine the rate of further surgery, the functional outcome and the factors associated with outcome after primary clubfoot surgery. METHOD: We conducted a retrospective study of a cohort of all children who were less than 2 years of age at the time of surgery for idiopathic clubfoot deformity at the Hospital for Sick Children, Toronto, Ont., a tertiary care pediatric hospital. Of the 91 families who could be contacted, 63 agreed to return. The children's charts were reviewed, and their feet were given a Functional Rating System (FRS) score. RESULTS: Of the original operated population (n = 126), 75% were male and 41% had bilateral clubfoot. The average age at the time of surgery was 8 months, and the mean follow-up was 80.6 months. Further surgery was performed in 19% of cases. The mean FRS outcome score was 79. On average, the FRS score increased by 1.9 points as age at the time of surgery increased by 1 month. Only the presurgical talocalcaneal index was associated with the need for further surgery. CONCLUSION: The need for further surgery was 19% overall. Children who had surgery closer to 12 months of age had better functional results. Therefore, surgery should probably be performed in the second, rather than the first, 6 months of life.

Overuse injuries in the pediatric and adolescent athlete.

A growing number of pediatric orthopedic patients fall into two dissimilar groups: the obese patient with problems related to obesity, and the young athlete injured during sports. While there is widespread recognition of pediatric orthopedic diseases related to obesity, the injuries resulting from "overuse" or over participation in sports are less understood and recognized. The majority of athletes involved in team sports in the Unites States are grade school and interscholastic athletes. The motivation for participation in sports varies greatly. Young athletes at risk for injury include the reluctant athlete who is not in the aerobic condition necessary to participate in sports, the eager athlete who initiates participation too vigorously, and the ambitious athlete who chronically "overtrains".