No Association Between Growth Hormone Therapy and Upper Extremity Physeal Tension Injuries: A Matched Case-control Study.

BACKGROUND: Recent evidence has identified a strong association between growth hormone therapy and physeal injuries in the lower extremity; however, few studies have investigated this association in the upper extremity. QUESTIONS/PURPOSES: (1) Do pediatric patients with physeal tension injuries of the shoulder and elbow have higher odds of having exposure to recombinant growth hormone therapy than matched controls? (2) Are the odds of having exposure to recombinant growth hormone therapy in physeal tension injuries different when stratified by shoulder and elbow injuries? METHODS: Using a matched case-control study design, patients between 4 and 18 years of age treated at a large, urban, academic center from February 1, 2016, to November 6, 2023, were identified by ICD-10 codes using EPIC SlicerDicer, an electronic medical record-based data mining tool. Patients diagnosed with physeal tension injuries in the shoulder or elbow were included in the case group, and those with midshaft radius, metaphyseal radius, or both-bone forearm fractures were included in the control group. A total of 618 patients with physeal injuries and 1244 with non-physeal fractures were identified and screened for inclusion. After further chart review to confirm diagnoses, 46% (283) of patients with physeal injuries and 54% (670) of patients with non-physeal fractures were included. A further 6% (16) of patients with physeal injuries and 2% (15) of patients with non-physeal injuries were excluded due concomitant dislocations or missing data, resulting in 267 eligible patients with physeal injuries and 655 eligible patients with non-physeal fractures. Two patients with concurrent elbow and shoulder physeal injuries were additionally excluded from stratified analyses. Patients with physeal injuries and non-physeal fractures were 1:1 matched by age ± 0.5 years, sex, and BMI ± 2 kg/m2. In all, 522 patients were included in the analysis, including 261 patients with physeal injuries and 261 with non-physeal fractures. The mean ± SD ages for both patient groups was 13 ± 2 years (p = 0.44), 88% (229 of 261) of all participants were male, and the mean BMIs were 19.9 ± 3.0 kg/m2 and 19.4 ± 3.0 kg/m2 (p = 0.11), respectively. Growth hormone exposure was compared between patients with physeal injuries and non-physeal fractures using a conditional logistic regression model. RESULTS: Overall, 4% (10 of 261) of patients with physeal injuries had exposure to growth hormone therapy as compared with 2% (4 of 261) of patients with non-physeal fractures (OR 2.5 [95% confidence interval 0.8 to 8.0]). Subgroup analyses of shoulder and elbow injuries demonstrated no difference in growth hormone exposure between patients with physeal injuries and non-physeal fractures (OR 2 [95% CI 0.4 to 10.2] and OR 3 [95% CI 0.6 to 14.9], respectively). CONCLUSION: In light of these results, clinicians may not need to advise precaution against sports or other activities that put the upper extremity physes under stress when treating patients with growth hormone supplementation therapy. Future multicenter studies, however, are indicated to further investigate for the existence of any subtle association between growth hormone therapy and upper extremity physeal injuries relative to the large association previously noted in the lower extremity in pediatric and adolescent patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Methods of Assessing Skeletal Maturity When Planning Surgeries About the Knee.

Increased participation in youth sports has led to more knee injuries necessitating surgical intervention. Among the youngest athletes, such procedures typically involve physeal-respecting techniques for anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction for patellar instability, osteochondritis dissecans fixation, and implant-mediated guided growth procedures. In each case, the choice of appropriate intervention is critically dependent on a patient's skeletal maturity. Compared with chronologic age, skeletal age accounts for individual maturation and is the benchmark for determination of development in orthopaedics. This is historically assessed using the Greulich and Pyle method, in which bone age is determined through comparison of a patient's hand radiograph with the closest standard radiograph from an atlas of American children from the early 1900s. In the setting of knee pathology, obtaining additional imaging requires further radiation and time. Several bone age determination methods exist incorporating radiographic characteristics of the distal femur, proximal tibia, and/or proximal fibula. This study therefore sought to review available methods for determination of skeletal age when planning surgeries about the knee using readily available, routine knee imaging. The review focuses on both radiograph and MRI-based skeletal maturity staging systems that surgeons may use to guide appropriate treatment while describing the strengths and weaknesses of each method.

The Intra-articular Tendinous Graft Diameter of 10-mm Bone-Patellar Tendon-Bone Autografts in Adolescent Patients: An MRI Analysis of 100 Patients.

Background: Bone-patellar tendon-bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact. Purpose/Hypothesis: The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation. Results: The mean calculated tendinous graft diameter of a 10 mm-wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference (P≤ .001). There was no significant association between age and cross-sectional area or graft diameter. Conclusion: Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts.

Visualization of Median Nerve Entrapment After Reduction of an Elbow Fracture Dislocation Using 3-Dimensional Magnetic Resonance Imaging: A Case Report.

CASE: A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function. CONCLUSION: Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle.

Investigating the Bone Bruise Patterns in Pediatric Patients With Contact and Noncontact Acute Anterior Cruciate Ligament Tears: A Multicenter Study.

BACKGROUND: In adults with anterior cruciate ligament (ACL) tears, bone bruises on magnetic resonance imaging (MRI) scans provide insight into the underlying mechanism of injury. There is a paucity of literature that has investigated these relationships in children with ACL tears. PURPOSE: To examine and compare the number and location of bone bruises between contact and noncontact ACL tears in pediatric patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Boys ≤14 years and girls ≤12 years of age who underwent primary ACL reconstruction surgery between 2018 and 2022 were identified at 3 separate institutions. Eligibility criteria required detailed documentation of the mechanism of injury and MRI performed within 30 days of the initial ACL tear. Patients with congenital lower extremity abnormalities, concomitant fractures, injuries to the posterolateral corner and/or posterior cruciate ligament, previous ipsilateral knee injuries or surgeries, or closed physes evident on MRI scans were excluded. Patients were stratified into 2 groups based on a contact or noncontact mechanism of injury. Preoperative MRI scans were retrospectively reviewed for the presence of bone bruises in the coronal and sagittal planes using fat-suppressed T2-weighted images and a grid-based mapping technique of the tibiofemoral joint. RESULTS: A total of 109 patients were included, with 76 (69.7%) patients sustaining noncontact injuries and 33 (30.3%) patients sustaining contact injuries. There were no significant differences between the contact and noncontact groups in terms of age (11.8 ± 2.0 vs 12.4 ± 1.3 years; P = .12), male sex (90.9% vs 88.2%; P > .99), time from initial injury to MRI (10.3 ± 8.1 vs 10.4 ± 8.9 days; P = .84), the presence of a concomitant medial meniscus tear (18.2% vs 14.5%; P = .62) or lateral meniscus tear (69.7% vs 52.6%; P = .097), and sport-related injuries (82.9% vs 81.8%; P = .89). No significant differences were observed in the frequency of combined lateral tibiofemoral (lateral femoral condyle + lateral tibial plateau) bone bruises (87.9% contact vs 78.9% noncontact; P = .41) or combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau) bone bruises (54.5% contact vs 35.5% noncontact; P = .064). Patients with contact ACL tears were significantly more likely to have centrally located MFC bruising (odds ratio, 4.3; 95% CI, 1.6-11; P = .0038) and less likely to have bruising on the anterior aspect of the lateral tibial plateau (odds ratio, 0.27; 95% CI, 0.097-0.76; P = .013). CONCLUSION: Children with contact ACL tears were 4 times more likely to present with centrally located MFC bone bruises on preoperative MRI scans compared with children who sustained noncontact ACL tears. Future studies should investigate the relationship between these bone bruise patterns and the potential risk of articular cartilage damage in pediatric patients with contact ACL tears.

Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study.

Background: A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls. Purpose: (1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs. Results: The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P = .366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P = .675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P≥ .999) of having a TSF than others. Conclusion: PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study.

Normative Running Kinematics in Healthy Adolescent Runners: A 2-Dimensional Video Analysis.

Background: The literature on the running kinematics of youth distance runners is limited. Purpose: We sought to describe 2-dimensional (2D) video analysis of running kinematics in healthy adolescent distance runners, which has not been previously described. Methods: We conducted an observational study of healthy, competitive runners between the ages of 14 and 18 years, prospectively recruited through local running clubs and our hospital's outreach between August 2019 and July 2023. Participants ran on a treadmill at a self-selected speed with markers attached to the thorax, pelvis, and lower extremities. A high-definition video camera recorded the runners in the sagittal and frontal planes. Kinematic measurements were completed using Dartfish software and reported as means and standard deviations. Results: Of the 53 participants (51% boys, mean age: 16.0 ± 1.4 years) included in the 2D running analysis, 91% ran with a rearfoot strike pattern, with a mean foot inclination angle of 10.2° ± 6.2°. Knee flexion angle at initial contact was 13.2° ± 3.8°, tibia inclination angle was 8.5° ± 3.2°, and peak knee flexion was 44.5° ± 3.6°. Cadence was 168.7° ± 8.6°. Contralateral pelvic drop was 6.0° ± 2.2° and peak rearfoot eversion was 11.8° ± 3.6°. Conclusions: This study is the first to describe running kinematics as captured by 2D video in healthy adolescent runners and to identify kinematic variables that may differ from those of adult runners. Further research is required to determine if adult recommendations are applicable to adolescent populations.

Prevalence of Concomitant Injuries by Sport in Pediatric Patients With ACL Rupture.

Background: Although the risk of concomitant injury with anterior cruciate ligament (ACL) tears as a function of specific sports participation has been studied in adults, the topic has not been examined in pediatric and adolescent patients. Purpose/Hypothesis: The purpose of the study was to determine if certain sports were associated with a higher risk of concomitant injuries in the setting of an ACL tear. It was hypothesized that the risk of concomitant injuries with ACL tears will differ by type of sport participation in the pediatric population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients ≤18 years old from 2 tertiary children's hospitals who had undergone primary ACL reconstruction between 2006 and 2018 were included. Sport at the time of injury, demographic factors, and injury pattern (medial meniscal [MM] tears, lateral meniscal [LM] tears, posterior cruciate ligament [PCL] tears, medial collateral ligament [MCL] tears, lateral collateral ligament [LCL] tears, and any concomitant injury) were identified. Results: A total of 855 patients with a mean age of 15.5 ± 1.7 years (range, 7-22 years) met the inclusion criteria. Of the included patients, 353 (41.3%) had an isolated ACL tear. A concomitant MM tear was identified in 27.6% of patients, LM tear in 42.9%, PCL injury in 0.4%, MCL injury in 3.0%, and LCL injury in 0.5%. There was no difference in the likelihood of concomitant MM injuries by sex (29.3% for male patients vs 26% for female patients; P = .31) or by sex within basketball (29.3% for male patients vs 25.6% for female patients; P = .96) or soccer (32.3% vs 26.3%; P = .06). Boys had higher proportions of LM injuries overall (51.7% for male patients vs 34.6% for female patients; P < .001) but not within the basketball subgroup (50.5% vs 40.0%; P = .86) or the soccer subgroup (59.7% vs 40.0%; P = .19). No statistically significant associations were found between patient age and specific ACL concomitant injury patterns. When stratifying by body mass index, it was found overweight and obese individuals constituted a greater proportion of LM (49.6% vs 39.1%; P = .01) but not MM (29.4% vs 25.5%; P = .28) injuries when compared to normal-weight patients. Using basketball as the comparison group, soccer and football injuries were 18% more likely to result in any concomitant injury, including concomitant MM, LM, PCL, MCL, and LCL injuries. Conclusion: In the pediatric population, soccer and football players were more likely to present with a concomitant injury in addition to ACL injury relative to basketball players. This study aids in understanding sport-associated ACL injury patterns and can help physicians with patient counseling and injury prevention.

A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens.

Purpose: To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule. Methods: Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci). Results: In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root). Conclusions: In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age. Clinical Relevance: The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.

No difference in stability among various knee flexion angles during fixation of anterolateral ligament reconstruction or lateral extra-articular tenodesis: A systematic review and meta-analysis of biomechanical studies.

Purpose: The purpose of this study was to investigate the effect of anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) fixation at low versus high flexion angles during anterior cruciate ligament reconstruction (ACLR) on rotation or translational knee stability. Methods: The inclusion criteria for this study were (1) cadaveric study, (2) cadaveric specimens underwent ACLR, (3) cadaveric specimen underwent ALLR or LET and (4) specimen preparation technique described the knee flexion angle at the time of ALLR or LET tensioning and fixation. A priori, 'low flexion' was defined as 0-30° and 'high flexion' was defined as 60-90° at graft fixation. Main outcomes of interest included internal rotation and anterior translation. Results: Data from 92 cadaveric knees (from 9 studies) were extracted and included in the meta-analysis. The mean pooled value for internal rotation was 10.1° (95% confidence interval [CI], 5.7-14.5°) for the low flexion group and 11.5° (95% CI, 7.4-15.7°) for the high flexion group (n.s.). The mean pooled value for anterior translation was 4.3 mm (95% CI, 0.5-8.1 mm) for the low flexion group and 3.0 mm (95% CI, 1.1-5.0 mm) for the high flexion group (n.s.). Conclusion: This meta-analysis of existing biomechanical research found that the rotational and translational stability of the knee were not significantly different between scenarios in which ALLR or LET fixation was performed at low knee flexion angles (0-30°) versus high knee flexion angles (60-90°). Level of Evidence: Level IV.

Health State Utilities and Cost-Effectiveness Economic Evaluation for Treatment of a Symptomatic Accessory Navicular.

BACKGROUND: Treatment strategies for a symptomatic accessory navicular include both operative and nonoperative approaches. The primary aim of this study is to define health utility values for 7 health states experienced by those with a symptomatic accessory navicular who undergo operative and/or nonoperative treatment. Secondarily, the study incorporates the health utility values with treatment costs, probabilities of various outcomes, and duration of health states into a cost-effectiveness model comparing the nonoperative treatment protocol at our institution vs surgical excision. METHODS: Institutional review board approval was obtained to call parents of patients 10-20 years old at the time of interview who were evaluated for a symptomatic accessory navicular from February 1, 2016, to March 2, 2023, at a single institution by one of 4 pediatric orthopaedic surgeons. Participants were asked to rate 7 health states from 0 to 100, with 0 representing death (if 18 years or older) or the worst health imaginable (if under 18 years) and 100 representing perfect health. Using published values for the probabilities of various treatment outcomes, time spent in various health states, and Medicare costs from the perspective of the payor and society, a decision analysis was constructed. RESULTS: Health utility values for 7 health states were obtained. Operative treatment was preferred to nonoperative treatment in the base case model. Surgery was more expensive ($16 825) than nonoperative treatment ($7486). Using a willingness-to-pay threshold of <$50 000 per quality-adjusted life year (QALY), surgery was cost-effective compared to nonoperative treatment with an incremental cost-effectiveness ratio of $20 303/QALY. Sensitivity analysis revealed that the only variable that indicated a preference for nonoperative treatment is a 71% likelihood of nonoperative treatment resolving the condition. CONCLUSION: Unless a physician suspects at least a 71% chance of a symptomatic accessory navicular resolving without operative treatment, surgical excision is recommended from a cost-effectiveness perspective.

Effect of Medial Patellofemoral Complex Reconstruction Technique on Patellofemoral Contact Pressure, Contact Area, and Kinematics.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is considered by many to be the gold standard to treat lateral patellar instability; however, some investigators have reported good clinical results after isolated medial quadriceps tendon-femoral ligament (MQTFL) reconstruction or a combined MPFL/MQTFL reconstruction. A handful of studies have preliminarily investigated the biomechanical consequences of these various medial patellar stabilizing procedures. Despite this, no existing study has included multiple medial patellofemoral complex (MPFC) reconstructions and assessment of lateral patellar translation at distinct flexion angles. HYPOTHESIS: Combined MPFL/MQTFL reconstruction would restore patellofemoral contact areas, forces, and kinematics closest to the native state compared with isolated reconstruction of the MPFL or MQTFL alone. STUDY DESIGN: Controlled laboratory study. METHODS: Ten adult cadaveric knee specimens were prepared and analyzed under 5 different conditions: (1) intact state, (2) transected MPFC, (3) isolated MPFL reconstruction, (4) isolated MQTFL reconstruction, and (5) combined MPFL/MQTFL reconstruction. Patellar tilt, lateral patellar translation, patellofemoral contact forces, and patellofemoral contact areas were measured in each condition from 0° to 80° through simulated knee flexion using a custom servohydraulic load frame with pressure sensor technology and a motion capture system for kinematic data acquisition. RESULTS: The isolated MPFL, isolated MQTFL, and combined MPFL/MQTFL reconstruction conditions produced significantly less lateral patellar tilt compared with the transected MPFC state (P < .05). No statistically significant differences were found when each reconstruction technique was compared with the intact state in patellar tilt, lateral patellar translation, contact forces, and contact areas. CONCLUSION: All 3 reconstruction techniques (isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction) restored native knee kinematics, contact forces, and contact areas without overconstraint. CLINICAL RELEVANCE: Isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction all restore patellofemoral stability comparable with the intact MPFC state without the overconstraint that could be concerning for increasing risk of patellofemoral arthritis.

Transosseous Repair of Isolated Posterior Medial Meniscal Root Injuries in Children and Adolescents.

The meniscal roots are critically important for maintaining knee stability, functional load distribution, and proper knee kinematics. Although adult meniscal root injuries have been a topic of increasing research, medial meniscus injuries also occur in pediatric and adolescent patients, with up to 2% of meniscal injuries involving root attachments. The purpose of this Technical Note is to demonstrate the transosseous repair of isolated posterior medial meniscal root injuries in children and adolescents, including tear visualization on magnetic resonance imaging and during arthroscopy, operative technique, and postoperative management.

MRI Features That Contribute to Decision-Making for Treatment of Capitellar OCD Lesions: An Expert Consensus Using the Delphi Method.

Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined. Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol. Study Design: A consensus statement. Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%. Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%). Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes.

Osseous and Cartilaginous Trochlear Development in the Pediatric Knee: A Cadaveric Computed Tomography Study.

Background: The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose: To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design: Descriptive laboratory study. Methods: A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results: Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion: This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance: This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint.

Simultaneous MPFL reconstruction and guided growth result in low rates of recurrent patellofemoral instability.

PURPOSE: Implant-mediated guided growth (IMGG) is used to address coronal plane deformity in skeletally immature patients. Few studies have reported on IMGG and simultaneous medial patellofemoral ligament (MPFL) reconstruction for paediatric patients with concurrent genu valgum and patellofemoral instability (PFI). This study aimed to report on the outcomes of these simultaneous procedures. MATERIALS AND METHODS: This was a retrospective review of paediatric patients undergoing simultaneous MPFL reconstruction and IMGG between 2016 and 2023. Mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle (HKA) and mechanical axis deviation (MAD) were measured on full-length hip-to-ankle plain radiographs. Measurements were taken preoperatively, prior to implant removal and/or at final follow-up with minimum 1-year clinical follow-up. RESULTS: A total of 25 extremities in 22 patients (10 female) underwent simultaneous IMGG and MPFL reconstruction. The mean age at surgery was 12.6 ± 1.7 years. The mean duration of implant retention was 18.6 ± 11.3 months. Nineteen extremities (76%) underwent implant removal by final follow-up. Preoperative HKA corrected from a mean of 5.8 ± 2.3° to -0.8 ± 4.5° at implant removal or final follow-up (p < 0.001), with mLDFA and MAD similarly improving (both p < 0.001). HKA corrected a mean of 0.7 ± 0.9° per month, while mLDFA and MAD corrected a mean of 0.5 ± 0.6°/month and 2 ± 3 mm/month, respectively. At the time of implant removal or final follow-up, 88% of patients demonstrated alignment within 5° of neutral. Only one extremity experienced subsequent PFI (4%). For 14 patients who underwent implant removal with further imaging at a mean of 7.8 ± 4.9 months, only one patient (7%) had a valgus rebound to an HKA > 5°. CONCLUSION: Simultaneous MPFL reconstruction and IMGG provided successful correction of lower extremity malalignment with only one recurrence of PFI. This approach is a reliable surgical option for skeletally immature patients with genu valgum and PFI. LEVEL OF EVIDENCE: Level 4 case series.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction.

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis.

BACKGROUND: The posterior tibial slope (PTS) has been proposed to be a radiographic risk factor for anterior cruciate ligament (ACL) injury in adults. However, this has not been well established in pediatric patients. PURPOSE: This systematic review and meta-analysis was performed to investigate any association between PTS and ACL tears in the pediatric population. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: A systematic review was performed to identify studies that examined the relationship between PTS, medial tibial slope (MTS), and lateral tibial slope (LTS) and ACL tears in children and adolescents aged ≤18 years. Full-text observational studies comparing PTS, MTS, and/or LTS values between pediatric (≤18 years of age) patients with and without ACL injury were included in this analysis. Review articles and case series were excluded. The authors calculated the mean difference (MD) via a restricted maximum-likelihood estimator for tau square and a Hartung-Knapp adjustment for random-effects model. RESULTS: A total of 348 articles were identified in the initial database search, yielding 10 for final inclusion and analysis. There was no statistically significant association between PTS (MD, 1.13°; 95% CI, -0.55° to 2.80°; P = .10), MTS (MD, 0.36°; 95% CI, -0.37° to 1.10°; P = .27), or LTS (MD, 1.41°; 95% CI, -0.20° to 3.02°; P = .075) and risk for ACL injury in this population. CONCLUSION: The current study found that unlike what has been shown in adult populations, increased PTS may not be a significant risk factor for ACL tears in pediatric and adolescent patents. LTS was the only measured parameter that neared statistical significance, perhaps suggesting a potential role for this measurement in determining ACL risk if further research is done in this population.