Animal models used in meniscal repair research from ex vivo to in vivo: A systematic review.

This systematic review, registered with Prospero, aims to identify an optimal animal model for meniscus repair research, moving from ex vivo experimentation to in vivo studies. Data sources included PubMed, Medline, all Evidence-Based Medicine Reviews, Web of Science, and Embase searched in March 2023. Studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data including animal model, type of experiment, type of tear, surgical techniques, and measured outcomes, were recorded, reviewed, and analyzed by four independent reviewers. The SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE) Rob tool was used for critical appraisal and risk of bias assessment. Out of 11,719 studies, 72 manuscripts were included for data extraction and analysis; 41 ex vivo extra-articular studies, 20 ex vivo intra-articular studies, and only 11 in vivo studies. Six animal models were employed: porcine, bovine, lapine, caprine, canine, and ovine. Longitudinal lesions were the most frequently studied tear pattern and sutures the most common repair technique. Studied outcomes focused mainly on biomechanical assessments and gross observations. This systematic review can guide researchers in their choice of animal model for meniscus repair research; it highlighted the strengths of the porcine, caprine, and bovine models for ex vivo cadaveric studies, while the porcine and caprine models were found to be more suited to in vivo studies due to their similarities with human anatomy. Research teams should familiarize themselves with the advantages and disadvantages of various animal models before initiating protocols to improve standardization in the field.

Flatfoot arch correction with generic 3D-printed orthoses at different body weight percentages.

BACKGROUND: Flatfoot can be associated with foot pathologies and treated conservatively with foot orthoses to correct arch collapse and alleviate painful symptoms. Recently, 3D printing has become more popular and is widely used for medical device manufacturing, such as orthoses. This study aims at quantifying the effect of generic 3D-printed foot orthoses on flatfoot arch correction under different static loading conditions. METHODS: Participants with normal and flatfeet were recruited for this cross-sectional study. Clinical evaluation included arch height, foot posture index, and Beighton flexibility score. Surface imaging was performed in different loading conditions: 1) 0% when sitting, 2) 50% when standing on both feet, and 3) 125% when standing on one foot with a weighted vest. For flatfoot participants, three configurations were tested: without an orthosis, with a soft generic 3D printed orthosis, and with a rigid 3D printed orthosis. Arch heights and medial arch angles were calculated and compared for the different loading conditions and with or without orthoses. The differences between groups, with and without orthoses, were analyzed with Kruskal-Wallis tests, and a p < 0.05 was considered significant. RESULTS: A total of 10 normal feet and 10 flatfeet were analyzed. The 3D printed orthosis significantly increased arch height in all loading conditions, compared to flatfeet without orthosis. Wearing an orthosis reduced the medial arch angle, although not significantly. Our technique was found to have good to excellent intra and interclass correlation coefficients. CONCLUSIONS: Generic 3D printed orthoses corrected arch collapse in static loading conditions, including 125% body weight to simulate functional tasks like walking. Our protocol was found to be reliable and easier to implement in a clinical setting compared to previously reported methods. LEVEL OF EVIDENCE: II.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Criteria.

BACKGROUND: Postoperative rehabilitation is an important component of recovery after anterior cruciate ligament (ACL) reconstruction (ACLR), facilitating successful return to sport (RTS) by reducing risk factors for repeat injury. PURPOSE: This systematic review aimed to determine the best protocol for RTS after ACLR in children. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: PubMed, Embase, PEDro, SPORTDiscus, and Web of Science databases were searched from October 3, 2014, to November 3, 2022. The inclusion criteria were the pediatric population (<18 years old) after ACLR with clear RTS criteria and/or mean/median time to RTS. Multiligament knee injuries were excluded from this study. The methodologic quality of the included articles was assessed using the methodological index for non-randomized studies (MINORS). The highest possible score was 24 points for comparative studies (ie, a study comparing 2 protocols or more). Noncomparative studies or studies with a single protocol could score a maximum of 16 points as assessed by the MINORS score. RESULTS: The search yielded 1816 titles, and 24 were retained based on the inclusion and exclusion criteria. Every study was published between 2015 and 2022. Among the 24 studies included, 13 were retrospective and 11 were prospective. The mean MINORS score for the noncomparative studies was 13 of 16 (n = 23) and 23 of 24 for the comparative study (n = 1). The studies were categorized into unspecified clearance (n = 10), milestone based (n = 13), and combined time and milestone (n = 1). A total of 1978 patients (57% female) were included in the review. The mean age at ACLR was 14.7 years. The most common endpoint used was graft rupture (0% to 35%). In the unspecified group, the quickest RTS was 5.8 months and the longest was 9.6 months. Statistically significant risk factors for ACL reinjury included younger age and earlier RTS. The latter was a significant contributor to graft failure for combined time-based and milestone-based RTS. In the milestone-based group, the most common criteria were ≥90% limb symmetry measured using hamstring strength, quadriceps strength, and/or hop tests. The mean RTS time was 6.8 to 13.5 months. CONCLUSION: RTS should be delayed, when possible, especially in the younger population. A combination of quantitative tests and qualitative tests is also recommended. However, optimal RTS criteria have yet to be determined. Future prospective studies should focus on comparing the different times and milestones currently available.

Retroarticular drilling for osteochondritis dissecans of the talus: A systematic review.

BACKGROUND: Opinions differ on the optimal treatment for stable talar osteochondritis dissecans (OCD) with intact cartilage. Some recommend conservative management, while others prefer surgical care, which includes debridement and micro-fractures, transarticular drilling through a direct or medial malleolus approach and retroarticular drilling. The rationale behind retroarticular drilling is to induce bone marrow healing without touching the intact cartilage. The goal of this systematic review is to summarize the clinical outcomes of retroarticular drilling as a standalone procedure for stable talar OCD with intact cartilage. PATIENTS AND METHODS: A systematic review of the literature prospectively registered in the PROSPERO register was performed along the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, EMBASE and Evidence-Based Medicine databases were searched from inception to December 2021 for retroarticular drilling for stable talar OCD with an intact cartilage. Two independent evaluators screened the search results, selected the articles to be included in the analysis and assessed the methodological quality of all included articles with the Newcastle-Ottawa Scale (NOS). RESULTS: Twelve studies, on 99 patients were included in the final analysis. Methodological quality was poor for all the included studies. High heterogeneity prevented any pooling or meta-analysis, but favorable clinical results were reported according to excellent post-intervention scores on the American Orthopedic Foot and Anke Score (AOFAS), ranging from 88.9 to 100. There was also significant improvement in pain as measured by the Visual Analog Scale (VAS), ranging between 2.3 and 5.9. DISCUSSION: Favorable results seem to be achieved with retroarticular drilling without grafting for stable talar OCD with intact cartilage, but more powered comparative studies between surgical options and conservative management are needed to establish the gold standard treatment. LEVEL OF EVIDENCE: IV.

Ultrasound Assessment of Ankle Syndesmotic Injuries in a Pediatric Population.

OBJECTIVE: To determine sensitivity and specificity for anterior-inferior tibiofibular ligament (AiTFL) integrity and tibiofibular clear-space (TFCS) cut-off points for dynamic evaluation using ultrasound (US) in a pediatric population. DESIGN: Prospective cohort study. SETTING: Tertiary care university-affiliated pediatric hospital patients between the ages of 12 and 18 sustaining acute ankle trauma with syndesmotic injury. INTERVENTIONS: Participants were assigned to the syndesmotic injury protocol that included a standardized MRI and US. MAIN OUTCOME MEASURES: Anterior-inferior tibiofibular ligament integrity for static assessment and TFCS measurements for dynamic assessment on US. For dynamic assessment, the distance between the distal tibia and fibula was first measured in neutral position and then in external rotation for each ankle. The US results on AiTFL integrity were compared with MRI, considered as our gold standard. Optimal cut-off points of TFCS values were determined with receiver operating characteristics curve analysis. RESULTS: Twenty-six participants were included. Mean age was 14.8 years (SD = 1.3 years). Sensitivity and specificity for AiTFL integrity were 79% and 100%, respectively (4 false negatives on partial tears). For dynamic assessment, the cut-off points for the differences in tibiofibular distance between the 2 ankles in 1) neutral position (TFCS N I-U ) and 2) external rotation (TFCS ER I-U ) were 0.2 mm (sensitivity = 83% and specificity = 80%) and 0.1 mm (sensitivity = 83% and specificity = 80%), respectively. CONCLUSIONS: Static US could be used in a triage context as a diagnostic tool for AiTFL integrity in a pediatric population as it shows good sensitivity and excellent specificity.

Tough gel adhesive is an effective method for meniscal repair in a bovine cadaveric study.

PURPOSE: To test tough gel adhesives to repair meniscus tears under relevant loading conditions and determine if they have adequate biomechanical properties to repair meniscus tears in a bovine cadaveric study. METHODS: Cyclic compression tests on 24 dissected bovine knees were performed. The tough gel adhesive was used either as an adhesive patch or as a coating bonded onto commercially available surgical sutures. Forty-eight menisci were tested in this study; 24 complete radial tears and 24 bucket-handle tears. After preconditioning, the specimens underwent 100 cycles of compression, (800 N/0.5 Hz) on an Instron© machine and the size of the gaps measured. One third of the menisci were repaired with pristine sutures, one third with adhesive patches, and one third with sutures coated in adhesive gel. The size of the gaps was compared after 100 and 500 cycles of compression. RESULTS: The mean gap measured at the tear site without treatment was 6.46 mm (± 1.41 mm) for radial tears and 1.92 mm (± 0.65 mm) for bucket-handle tears. After treatment and 500 cycles of compression, the mean gap was 1.63 mm (± 1.41 mm) for pristine sutures, 1.50 mm (± 1.16 mm) for adhesive sutures and 2.06 mm (± 1.53 mm) for adhesive gel patches. There was no significant difference between treatments regardless of the type of tear. Also, the gaps for radial tears increased significantly with the number of compression cycles applied (p > 0.001). CONCLUSION: From a biomechanical standpoint, the tough adhesive gel patch is as effective as suturing. In addition, it would allow the repair of non-suturable tears and thus broaden the indications for meniscus repair. LEVEL OF EVIDENCE: Controlled laboratory study.

Development and validation of a French-language cross-cultural adaptation of the Pedi-IKDC Questionnaire.

BACKGROUND: The Pedi-IKDC is an English-language, knee-specific, paediatric questionnaire used by orthopaedic surgeons around the world as a valuable patient-reported outcome measure (PROM). The objective of this study was thus to extend the applicability of the Pedi-IKDC to French-speaking Canadian patients, for both clinical practice and research, by developing a French-language cross-cultural adaptation of the original version. HYPOTHESIS: The French adaptation of the Pedi-IKDC is valid and reliable for evaluating French-speaking children with knee conditions. PATIENTS AND METHODS: The Pedi-IKDC was translated to French by a panel of orthopaedic surgeons then back-translated by a professional translator. The original English version and the back-translation were compared to assess their similarity and confirm the faithfulness of the French translation. The validity of the French version was then tested at a major paediatric hospital in French-speaking Canada, in 203 children, including 163 with knee pain and 40 without knee symptoms. Internal consistency, construct validity, and discriminant capacity of the French version were assessed. RESULTS: Internal consistency of the Pedi-IKDC adaptation was excellent (Cronbach's alpha, 0.934 in the knee-pain group). Construct validity was robust, with all nine hypotheses adapted from the original Pedi-IKDC article demonstrating strong (n=7) or moderate (n=2) correlations (p<0.001). The evaluation of discriminant capacity identified no statistically significant score differences according to most of the respondent characteristics (body mass index, age group, type of diagnosis, and type of treatment). However, scores differed significantly between females and males. DISCUSSION: The French-language cross-cultural adaptation of the Pedi-IKDC obtained using a universally recognized method for translating PROMs demonstrated good performance, with psychometric properties similar to those of the original Pedi-IKDC and of its Danish, Italian, and Russian adaptations. LEVEL OF EVIDENCE: II.

Are outdoor playgrounds the real culprit for elbow fractures in children? A lesson learned from COVID-19 sanitary measures.

BACKGROUND: The association between elbow fractures and outdoor playgrounds has always been anecdotal. We sought to determine the impact of closing outdoor playgrounds and other play areas during the COVID-19 lockdown on elbow fractures in a pediatric population. METHODS: We conducted a retrospective cohort study of all elbow fractures from a single pediatric referral hospital between 2016 and 2020 for the months of April and May. The months chosen corresponded to the COVID-19 lockdown during which outdoor playgrounds were closed. Inclusion criteria were elbow fracture diagnosis based on radiography and age younger than 18 years. Fracture type, where the injury occurred and the mechanism of injury were recorded. RESULTS: A total of 370 fractures were reported, with an average of 83 (95% confidence interval [CI] 83-84) per year for 2016-19 and only 36 recorded in 2020. The average annual number of fractures before 2020 was 17 (95% CI 16-17) for schools, and 33 (95% CI 31-34) for outdoor playgrounds, including 22 (95% CI 21-24) falls from playground structures. No fracture was reported in schools in 2020, and only 3 were reported from outdoor playgrounds (including 1 associated with falling from playground structures). CONCLUSION: We found an association between elbow fractures in a pediatric population and outdoor playground accessibility, but also with indoor public locations. Our findings emphasize the importance of safety measures in those facilities.

Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.

Modification of the properties of a suture thread with a tough gel coating: A baseline ex-vivo study.

The mechanical properties of sutures are important for wound closure and meniscus repair. A tough gel coating technology has been developed to modify and functionalize sutures, but its effects on suture degradation remain unexplored. Our aim is to investigate how a tough gel coating mediates the properties of the suture. The Polyglactin910 (Vicryl) suture was chosen because it is widely used, strong, easy to handle, and degradable. This study compared six pristine Vicryl sutures and six coated Vicryl sutures at 0, 2, 4, and 6 weeks. All the sutures were soaked in phosphate-buffered saline (PBS), to mimic degradation in physiological conditions, and tensile strength was tested at each time point. The pH of the soaking mediums was measured weekly and compared at 4, 5, and 6 weeks. No significant difference (p = 0.059 and p = 0.576) was found between the absolute and normalized breaking force of coated and pristine Vicryl sutures at 0, 2, 4, and 6 weeks. After 4 weeks of immersion, the soaking medium became more acidic for both suture types. The decrease in pH was less significant for coated Vicryl sutures than for pristine ones (p < 0.001) at 4, 5, and 6 weeks of immersion. Although coating does not affect the strength of Vicryl sutures soaked in PBS, it can effectively act as a buffer to the acidic environment caused by suture degradation, which could help reduce inflammation. Hydrogel coating is a promising technology to modify suture characteristics.

What is the J-sign and why is it important?

PURPOSE OF REVIEW: Recurrent lateral patellofemoral instability is a complex condition that requires a thorough evaluation to optimize treatment. The J-sign test is classically part of the physical examination, but its significance and importance remain unclear. This review aims to describe how to perform the test and classify the observation as well as to analyze the most recent literature on its clinical applications. RECENT FINDINGS: The J-sign test has been described as positive (present) or negative (absent), and classified using the quadrant method and the Donnell classification. Suboptimal inter-rater reliability has been shown for both classifications, making comparison between clinicians and studies challenging. The J-sign is most predominantly associated with patella alta, trochlear dysplasia, lateral force vector, and rotational abnormalities. A growing number of studies have shown a correlation between a positive J-sign and lower clinical outcome scores and higher rate of surgical failure. SUMMARY: The J-sign is an important aspect of the physical examination in patients with recurrent lateral patellofemoral instability. Although there is no consensus on how to perform or classify the test, it can be used as a marker of severity of patellofemoral instability and is one of the tools available to guide the treatment plan.

The Radiographic Femoroepiphyseal Acetabular Roof Index Is a Reliable and Reproducible Diagnostic Tool in Patients Undergoing Hip-Preservation Surgery: A Systematic Review.

PURPOSE: To assess the utility of the femoroepiphyseal acetabular roof (FEAR) index as a diagnostic tool in hip-preservation surgery. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception until May 2022 for literature addressing the utility of the FEAR index in patients undergoing hip-preservation surgery, and the results are presented descriptively. RESULTS: Overall, there were a total of 11 studies comprising 1,458 patients included in this review. The intraobserver agreement for the FEAR index was reported by 3 of 11 studies (intraclass correlation coefficient range = 0.86-0.99), whereas the interobserver agreement was reported by 8 of 11 studies (intraclass correlation coefficient range = 0.776-1). Among the 5 studies that differentiated between hip instability and hip impingement, the mean FEAR index in 319 patients in the instability group ranged from 3.01 to 13.3°, whereas the mean FEAR index in 239 patients in the impingement group ranged from -10 to -0.77° and the mean FEAR index in 105 patients in the control group ranged from -13 to -7.7°. Three studies defined a specific cutoff value for the FEAR index, with 1 study defining a cutoff value of 5°, which correctly predicted treatment decision between periacetabular osteotomy versus osteochondroplasty 79% of the time with an AUC of 0.89, whereas another defined a cutoff of 2°, which correctly predicted treatment 90% of the time and the last study set a threshold of 3°, which provided an AUC of 0.86 for correctly predicting treatment decision. CONCLUSIONS: This review demonstrates that the FEAR index has a high agreement and consistent application, making it a useful diagnostic tool in hip-preservation surgery particularly in patients with borderline dysplastic hips. However, given the variability in FEAR index cutoff values across studies, there is no absolute consensus value that dictates treatment decision. LEVEL OF EVIDENCE: Level IV; Systematic Review of Level II-IV studies.

Cavus Foot in Soccer Players: Increased Prevalence in Experienced Players and Risk Factor for Injury.

BACKGROUND: Foot type, especially cavus foot, is associated with foot and ankle soccer injuries, such as ankle sprains, ankle instability, and foot and ankle lateral injuries. The aim of this study was to identify risk factors for foot and ankle injuries among soccer players. METHODS: Male and female soccer players, from beginners to semiprofessionals, aged between 10 and 40 years were enrolled in this cross-sectional study. Players filled in questionnaires about their training and injury history. Clinical measurements included foot length, Foot Posture Index-6, and arch height flexibility. Each variable was dichotomized: age (<18 years versus ≥18 years), level of play (AA and below versus AAA and above), foot type (cavus or not), and injury. Injury occurrence was analyzed using χ2 tests between each group of variables, and significance was set at P < .05. RESULTS: A total of 277 players, including 81 females, volunteered; 147 were younger than 18 years and 180 were AA level or below. Cavus foot prevalence was 30%. In the cavus foot group, 51.8% of players had reached at least an AAA level compared with 27.8% in the normal-arched group (P < .001 [χ2]). Injuries were associated with a cavus foot type (P < .01 [χ2]) and with sex, age, or highest level played (P < .001 [χ2]). CONCLUSIONS: This study identified a high prevalence of cavus foot among soccer players of all ages, with an increased prevalence among higher-level players. The injury risk factors were female sex, older age, playing at a higher level, and cavus feet.

Subchondroplasty in the treatment of bone Marrow lesion in early Knee Osteoarthritis: A systematic review of clinical and radiological outcomes.

BACKGROUND: Knee osteoarthritis (KOA) is increasingly prevalent in North American society. The significant societal burden it represents makes it essential to promote and target new treatments in earlier phases of the disease. Among others, subchondroplasty is a newly documented technique using calcium phosphate injection targeting the osteochondral lesions preceding KOA, also known as Bone Marrow Lesions (BMLs). This article aimed to review the existing literature on clinical and radiological outcomes of subchondroplasty in the treatment of BMLs in KOA. METHOD: A systematic review was performed using PubMed, Embase, Medline and Cochrane Database of Systematic Reviews. Studies on calcium phosphate injections into BMLs for KOA and its clinical and radiological outcomes were screened and reviewed by independent evaluators. RESULTS: After screening, ten articles were included, totaling 540 patients. Follow-up ranged from 6 months to 7 years. Overall, the procedure showed significant functional and quality of life improvement, as well as pain relief, as shown by Patients-Reported Outcomes Measures (PROMs). There were very few complications reported, the most important being leakage of calcium phosphate outside the targeted site. Conversion rate to total knee arthroplasty (TKA) ranged from 14 % to 30 % at 2 years post-procedure. Long term radiological outcomes have been poorly documented. CONCLUSIONS: Subchondroplasty is a promising avenue for the treatment of KOA. However, quality evidence is still required before any real conclusions and practical management guidelines can be drawn. Prospective, randomized studies with a control group and a rigorous assessment of long-term clinical and radiological outcomes are recommended.

Meniscus Repair in Pediatric Athletes.

Meniscus tears are common in the pediatric population, typically occur after noncontact injuries, and can be diagnosed clinically with MRI confirmation. Surgery should be offered to patients with loss of range of motion, persistent symptoms, or displaced/complex tears. Given poor long-term outcomes reported after meniscectomy, repair should be attempted when possible as pediatric menisci are well vascularized and have better outcomes after repair than their adult counterparts. The location of the tear is an important determining factor when deciding on the type of repair to use. Pediatric meniscus repair techniques will be discussed noting differences between pediatric and adult procedures. Further studies are needed to explore the role of biologics and define postoperative protocols.

Advanced practice physiotherapy in paediatrics: Implementation results.

Objectives: This study aimed to evaluate the implementation of an advanced practice physiotherapist (APP) clinic in our paediatric institution and assess APP and orthopaedic surgeon satisfaction. Methods: In this retrospective cohort study, all patient records from the APP clinic's second year (March 2017 to March 2018) at CHU Sainte-Justine were reviewed. These were compared with the records of patients seen by orthopaedic surgeons within the gait clinic the year before implementing the clinic. The following data were collected: demographic, professional issuing referral, reason for referral, consultation delay, clinical impression, investigation, and treatment plan. We also documented every subsequent follow-up to rule out any diagnostic change and identify surgical patients. Clinician satisfaction was assessed by the Minnesota Satisfaction and PROBES Questionnaires along with a short electronic survey. Results: Four hundred and eighteen patients were assessed by APPs and 202 by orthopaedic surgeons. APPs managed patients independently in 92.6% of cases. Nearly 86% of patients were discharged following the initial visit, and 7.4% were referred to a physiotherapist. Only 1% of APP patients eventually required surgery compared with nearly 6% in the orthopaedic group. The mean waiting time for consultation was greater in the APP group (513.7 versus 264 days). However, there was a significant reduction in mean waiting time over the last 3 months surveyed (106.5 days). Conclusions: The feedback from all clinicians involved was positive, with a greater mean score on the Minnesota Satisfaction and PROBES Questionnaire for APPs. The APP gait clinic appears to be an effective triage clinic. Level of evidence: III.

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis.

BACKGROUND: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality. PURPOSE: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). RESULTS: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location. CONCLUSION: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.

Limited evidence for graft selection in pediatric ACL reconstruction: a narrative review.

Anterior cruciate ligament reconstruction is the preferred treatment to anterior cruciate ligament injury. With the increase in anterior cruciate ligament injuries in both adults and skeletally immature patients comes the need for individualized anterior cruciate ligament reconstruction graft selection whether it is the type of graft (auto vs. allograft) or the harvesting site (hamstrings, iliotibial band, quadriceps, patella). Several factors need to be considered preoperatively in order to optimize the patients' recovery and restore anterior cruciate ligament strength and function. These include age and bone maturity, preoperative knee flexor/extensor strength, sport participation, patient's needs and anatomical characteristics. This paper aims at bringing evidence supporting the use of a personalized approach in graft selection for faster and more efficient return to sport and propose a theoretical framework to support the approach.

Outcome of retroarticular drilling for osteochondritis dissecans of the talus in a pediatric population.

BACKGROUND: Outcomes of bone marrow stimulation for osteochondritis dissecans (OCD) of the talus in pediatric patients is not optimal. The objective was to evaluate the retroarticular drilling technique for talar OCD. METHODS: A retrospective case-series study of pediatric cases treated for talar OCD with retroarticular drilling was done. Clinical and radiological outcome scores were recorded as follows: the percentage of patients who had a successful treatment, the percentage for every category of the Berndt and Harty treatment result grading and the percentage for every radiographical outcome score were computed. RESULTS: Nineteen patients (18 girls; mean age: 14.6 ± 2.1 years) were included. The mean follow-up was 14.8 (±11.7) months. 26.3% required revision surgery. The Berndt and Harty scores were: 57.9% good, 10.5% fair, 31.6% poor. Radiological outcomes were: 21% healed, 47.4% partially healed, 31.6% no healing. The radiological outcome score was better for younger patients (P = 0.01) and those with an open physis (P = 0.001). CONCLUSION: 26.3% of patients needed revision surgery after talar OCD retroarticular drilling and 21% were healed radiographically. Skeletal immaturity and a younger age were associated to a better radiological outcome.

Complication rates following all-epiphyseal ACL reconstructions in skeletally immature patients: A retrospective case series study.

ABSTRACT: The aim was to evaluate the safety of a physeal-sparing anterior cruciate ligament reconstruction technique (ACLR), performed with Orthopediatrics (Warsaw, IN) equipment, by assessing complications.Skeletally immature patients who underwent all-epiphyseal ACLR between 2015 and 2017 with postoperative follow-up were included in this retrospective study. Complications, demographic, clinical, surgical, and imaging data was retrieved from an urban tertiary pediatric hospital database. Physeal status, limb-length discrepancies (LLD), and angular deformities were assessed on preoperative and postoperative radiographs, growth disturbances were reported, and initial and follow-up diameters of tunnels were compared.Nineteen ACLRs were included from 18 patients, 4 females and 14 males, with bone age at surgery of 13.3 ± 1.0 years. At a mean follow-up of 19.2 ±â€Š10.1 months, there were no symptomatic growth disorders requiring intervention. There were: 2 (11.1%) unilateral early physeal closures, 2 (10.5%) new angular deformities (5°-10°), 4 (22.2%) LLD (1-2 cm), 1 (5.6%) contralateral ACLR, 1 (5.6%) femoral screw removal, 2 (10.5%) graft ruptures, and 1 meniscal tear (5.3%). Mean tunnel widening was 1.7 mm and 1.5 mm on the femoral and tibial side, respectively, and no massive osteolysis was recorded at the polyetheretherketone implant site.The complication rates were comparable to those in similar studies, with no growth-related complications at 19.2 months.