Building large-scale registries from unstructured clinical notes using a low-resource natural language processing pipeline.

Building clinical registries is an important step in clinical research and improvement of patient care quality. Natural Language Processing (NLP) methods have shown promising results in extracting valuable information from unstructured clinical notes. However, the structure and nature of clinical notes are very different from regular text that state-of-the-art NLP models are trained and tested on, and they have their own set of challenges. In this study, we propose Sentence Extractor with Keywords (SE-K), an efficient and interpretable classification approach for extracting information from clinical notes and show that it outperforms more computationally expensive methods in text classification. Following the Institutional Review Board (IRB) approval, we used SE-K and two embedding based NLP approaches (Sentence Extractor with Embeddings (SE-E) and Bidirectional Encoder Representations from Transformers (BERT)) to develop comprehensive registry of anterior cruciate ligament surgeries from 20 years of unstructured clinical data at a multi-site tertiary-care regional children's hospital. The low-resource approach (SE-K) had better performance (average AUROC of 0.94 ± 0.04) than the embedding-based approaches (SE-E: 0.93 ± 0.04 and BERT: 0.87 ± 0.09) for out of sample validation, in addition to minimum performance drop between test and out-of-sample validation. Moreover, the SE-K approach was at least six times faster (on CPU) than SE-E (on CPU) and BERT (on GPU) and provides interpretability. Our proposed approach, SE-K, can be effectively used to extract relevant variables from clinic notes to build large-scale registries, with consistently better performance compared to the more resource-intensive approaches (e.g., BERT). Such approaches can facilitate information extraction from unstructured notes for registry building, quality improvement and adverse event monitoring.

Pediatric Orthopaedic Venous Thromboembolism: A Systematic Review Investigating Incidence, Risk Factors, and Outcome.

Background: There is growing evidence of increased venous thromboembolism (VTE) incidence in children with trauma or infection. The purpose of this study was to conduct a systematic review of existing literature related to VTE in the pediatric orthopaedic population, to estimate the overall incidence of VTE and identify risk factors associated with this condition. Methods: A systematic review of the available literature was performed to identify articles that described VTE in pediatric orthopaedic surgery or admission. Literature queries were performed to identify articles published from 1980 to 2021 that included patients ≤21 years of age. A stepwise search strategy of 5 electronic databases yielded 1,426 articles, which were filtered by 2 reviewers to identify 30 articles for full-text review. The primary aim was to determine the rate of VTE, and the secondary aim was to identify risk factors for VTE. The pooled incidence of VTE was estimated and reported in cases per 10,000. Studies were stratified by study size, by trauma versus elective surgery, and by orthopaedic subspecialty. Results: The 30 articles reported 3,113 VTE events in 2,467,764 pediatric patients (including those with non-orthopaedic conditions), for a pooled VTE incidence of 20 events (95% confidence interval [CI] = 10.8 to 37.2) per 10,000. Four of the studies were excluded for incomplete data or high heterogeneity. The remaining 26 studies had 850,268 orthopaedic patients with 1,108 cases of VTE, for a pooled VTE incidence of 16.6 events (95% CI = 9.1 to 30.5) per 10,000. Studies with <10,000 patients and those involving a diagnosis of trauma had the highest VTE incidence when stratification was performed. The most frequently analyzed risk factors in 15 available studies included age, sex, obesity/body mass index, type of surgery, and use of a central venous catheter. Conclusions: This systematic review indicated that the risk of VTE associated with pediatric orthopaedic surgery or admission remains low, at <17 events per 10,000 cases. However, orthopaedic surgeons should be aware of the most common risk factors associated with pediatric orthopaedic VTE and should pay special attention to traumatic etiologies, as these yielded the highest incidence. Levels of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Size of Posterior Tibial Slope and Medial Tibial Depth in Patients With an Isolated Meniscal Tear Requiring Surgery and Matched Uninjured Controls.

BACKGROUND: Meniscal injuries are extremely common. Several anatomic features of the knee, including the tibial plateau morphology, have been shown to influence knee biomechanics and the risk of ligamentous injuries. Little is known, however, how these morphological features influence the risk of isolated meniscal injuries in the anterior cruciate ligament (ACL)-intact knee. HYPOTHESIS: There are differences in the slopes and concavity of the tibial plateau between patients with isolated meniscal tears and matched uninjured controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In total, 89 patients with first-instance isolated medial (n = 37) or lateral (n = 52) meniscal injuries requiring surgical treatment (mean age, 16 ± 1 years; 35% female) were matched to 89 controls with uninjured knees and no previous injuries (mean age, 16 ± 2 years; 35% female) based on age and sex. Magnetic resonance imaging scans (preoperative for injured group) were used to measure the coronal slope of the tibial plateau, posterior slope of the medial and lateral tibial plateaus, and maximum depth of the medial tibial plateau. General linear models were used to evaluate the differences in tibial plateau morphology between the knees with and without meniscal injuries, with and without adjustment for age and sex. RESULTS: Compared with matched controls, patients with surgically treated isolated meniscal tears had a smaller lateral tibial slope (by 2.2° [medial meniscal injury] and 1.6° [lateral meniscal injury]; P < .02), a smaller medial tibial slope (by 2.3° [medial meniscal injury] and 2.4° [lateral meniscal injury]; P < .001) and a larger medial tibial depth (by 0.8 mm [medial meniscal injury] and 0.9 mm [lateral meniscal injury]; P < .001). There were no differences in coronal tibial slope between the injured and uninjured groups. There were no differences in quantified anatomic features between the isolated medial and lateral meniscal injury groups. The same trends were observed after adjusting for age and sex. CONCLUSION: This study suggests that patients with an isolated meniscal tear requiring surgery have a smaller posterior tibial slope and a larger medial tibial depth (more concave medial tibial plateau) than matched uninjured controls. This is contrary to what is known for ACL tears, in which a steeper posterior tibial slope and a shallower medial tibial depth have been associated with an increased risk of ACL tear.

The Impact of COVID-19 on Multidisciplinary Care Delivery to Children with Cerebral Palsy and Other Neuromuscular Complex Chronic Conditions.

The COVID-19 pandemic has caused unprecedented challenges in the care of children with cerebral palsy (CP) and other neuromuscular complex chronic conditions (NCCCs). The purpose of this study is to explore the direct impact of the COVID-19 pandemic on healthcare delivery. From May to August 2020, medical professionals caring for CP and NCCC patients across multiple countries and disciplines completed a self-administered cross-sectional survey comparing practices before and during the COVID-19 pandemic. Of the 79 healthcare workers from eight countries who participated-predominantly pediatric orthopedic surgeons (32%), pediatricians (30%), and pediatric physiatrists (23%)-most of them felt that caring for NCCC patients during the pandemic presented unique difficulties, and they reported a significant decrease in the in-person NCCC clinic volume (p < 0.001), multidisciplinary appointments (p < 0.001), surgical cases (p = 0.008), and botulinum toxin/phenol injections. Most providers affirmed that institutional guidelines for perioperative emergent/urgent and elective procedures, workplace settings, and technology were modified to accommodate the ongoing public health crisis. The usage of telemedicine significantly increased for NCCC patient visits (p < 0.001). During the COVID-19 pandemic, many children with NCCCs lost access to routine, multidisciplinary care. Telemedicine became an integral part of communication and management. In the setting of the COVID-19 pandemic and with the threat of future healthcare disruptions, these data lay the foundation for trending the evolution of healthcare delivery and accelerating best practice guidelines for children with CP and NCCCs.

MRI Analysis of Knee Bony Morphology Variations in Children and Adolescents With Lateral Discoid Meniscus Compared With Asymptomatic Healthy Controls.

BACKGROUND: Lateral discoid meniscus accounts for most meniscal tears in children 10 years of age and younger. The role of bony morphology in discoid meniscus has been previously studied in a limited capacity using radiographs. PURPOSE: To use magnetic resonance imaging to measure features of the femoral condyles and tibial plateaus in patients with discoid meniscus to assess potential determinants of symptoms and subsequent surgery and to compare with matched controls to investigate age-related changes in bony features. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: After institutional review board approval, detailed morphology of the femoral condyles and tibial plateau was measured in 177 patients (3-18 years of age; 56% female) with confirmed lateral discoid meniscus. Measurements from 269 participants (3-18 years of age; 55% female) with asymptomatic knees were used as controls. Two-way analysis of variance with Holm-Sídák post hoc was used to compare measurements between discoid menisci and matched controls. Independent t tests were used to compare aspects of bony morphology within the discoid meniscus cohort. RESULTS: Compared with controls, patients with a lateral discoid meniscus had a larger bicondylar width and notch width (7- to 10-year-old and 15- to 18-year-old age groups; P < .05), larger tibial plateau width (11- to 14-year-old and 15- to 18-year-old age groups; P < .001), and smaller lateral (P < .02) and coronal (P < .02) tibial slopes across all age groups. Among patients with a discoid meniscus, larger bicondylar width, larger tibial plateau width, larger notch width, and a flatter lateral femoral condyle were associated with pain (P < .005) and lateral meniscal tears (P < .02). Larger notch width and notch width index were also associated with subsequent surgery (P < .05). CONCLUSION: There are clinically significant abnormalities in bony morphology in patients with a discoid meniscus, including larger femoral condyles and tibial plateaus and a flatter tibial plateau. Additionally, femoral size, femoral curvature, and tibial plateau size may influence the likelihood of knee pain, meniscal tear, and need for surgery. These findings highlight the importance of bony morphology in discoid meniscus pathophysiology in children and adolescents. Such measurements may also aid radiographic detection of discoid meniscus and guide decisions regarding the timing of potential surgical intervention.

Variations in the Management of Closed Salter-Harris II Distal Tibia Fractures.

BACKGROUND: There are no formal practice guidelines for the surgical management of closed, Salter-Harris (SH) II distal tibia fractures. The purpose of this study was to survey the indications for operative and nonoperative management of this injury across pediatric tertiary care centers. METHODS: We surveyed pediatric orthopedic surgeons at 20 tertiary care level-1 pediatric trauma centers. Surgeons were provided with 16 clinical scenarios that varied based on patient age and sex, and highlighted the following surgical indications: translation <3 mm, translation ≥3 mm, sagittal plane angulation >5 degrees, and coronal plane angulation >5 degrees. Each case's scenario and radiographs after closed reduction were presented in a randomized manner. Consensus was defined as 80% agreement, and descriptive statistics were used to summarize the results. RESULTS: In total, 33 of 37 surgeons completed the survey (89% response rate). All surgeons took trauma call at a level-1 pediatric trauma center and had an average of 8.8 years (SD: 6.5 y) of experience. Consensus was reached in 4 of 16 scenarios. Specifically, nonoperative management was recommended for all scenarios showing <3 mm of translation after closed reduction. The majority of surgeons recommended operative management in scenarios showing coronal plane angulation after closed reduction, but none of these scenarios reached consensus. There was a near-equal split in operative and nonoperative management in 8 of 16 scenarios. These scenarios showed ≥3 mm translation after closed reduction and sagittal plane angulation after closed reduction. Surgeons with 6 to 10 years in practice were the most likely to recommend surgery, especially in the case of >5 degrees coronal plane angulation postreduction ( P <0.05). CONCLUSIONS: There is considerable variation regarding the indications for operative and nonoperative management of closed, SHII distal tibia fractures. Consensus was reached for nonoperative management in patients with <3 mm of translation after closed reduction; however, with greater deformity consensus regarding optimal treatment was unable to be achieved. The variation in the management of distal tibia SHII fractures is significant, suggesting that perhaps clinical equipoise exists between operative and nonoperative management. LEVEL OF EVIDENCE: V.

Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration.

BACKGROUND: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database.

BACKGROUND: There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database. METHODS: Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected. RESULTS: Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02). CONCLUSIONS: UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare. LEVEL OF EVIDENCE: Level IV, prognostic.

Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure.

BACKGROUND: Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE: To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS: A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION: Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.

Lyme Arthritis in the Pediatric Knee: Clinical and Magnetic Resonance Imaging Differentiators.

Lyme disease is the most prevalent tick-borne illness in the United States, especially endemic in the Northeast and Upper Midwest. Distinguishing Lyme arthritis (LA), the most common manifestation of the disease in children, from septic arthritis (SA) can be challenging because of overlap in clinical presentations. This study examined the role of magnetic resonance imaging (MRI) as an adjunct to clinical and laboratory features used to differentiate between LA and SA in children and adolescents. Methods: The medical records and MRI scans of children who presented between 2009 and 2019 with an acute knee effusion ultimately diagnosed as LA or SA were retrospectively reviewed. Data collection included clinical information on the modified Kocher criteria (weight-bearing, fever, blood serology including white blood-cell [WBC] count, C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]), MRI findings, and serology confirmation of LA or bacterial SA. A total of 87 cases of confirmed LA and 9 cases of SA were identified. Results: The 2 cohorts had substantial clinical overlap with regard to the ability to bear weight, fever, and joint aspirate WBC count. Differences between the 2 groups in several MRI characteristics, specifically vastus lateralis myositis, subcutaneous edema, and lymphadenopathy, were significant. A multivariate analysis demonstrated that weight-bearing, CRP of <3 mg/L, absence of subcutaneous edema, myositis of multiple muscles including the vastus lateralis, and lymphadenopathy were predictive of LA. Conclusions: LA should be strongly suspected in endemic areas of the United States when children present with a knee effusion. The addition of MRI criteria to clinical and laboratory findings significantly improved the predictive value for identifying LA. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Changes in the Cross-Sectional Profile of Treated Anterior Cruciate Ligament Within 2 Years After Surgery.

Background: The cross-sectional area (CSA) of the anterior cruciate ligament (ACL) and reconstructed graft has direct implications on its strength and knee function. Little is known regarding how the CSA changes along the ligament length and how those changes vary between treated and native ligaments over time. Hypothesis: It was hypothesized that (1) the CSA of reconstructed ACLs and restored ACLs via bridge-enhanced ACL restoration (BEAR) is heterogeneous along the length. (2) Differences in CSA between treated and native ACLs decrease over time. (3) CSA of the surgically treated ACLs is correlated significantly with body size (ie, height, weight, body mass index) and knee size (ie, bicondylar and notch width). Study Design: Cohort study; Level of evidence, 2. Methods: Magnetic resonance imaging scans of treated and contralateral knees of 98 patients (n = 33 ACL reconstruction, 65 BEAR) at 6, 12, and 24 months post-operation were used to measure the ligament CSA at 1% increments along the ACL length (tibial insertion, 0%; femoral insertion, 100%). Statistical parametric mapping was used to evaluate the differences in CSA between 6 and 24 months. Correlations between body and knee size and treated ligament CSA along its length were also assessed. Results: Hamstring autografts had larger CSAs than native ACLs at all time points (P < .001), with region of difference decreasing from proximal 95% of length (6 months) to proximal 77% of length (24 months). Restored ACLs had larger CSAs than native ACLs at 6 and 12 months, with larger than native CSA only along a small midsubstance region at 24 months (P < .001). Graft CSA was correlated significantly with weight (6 and 12 months), bicondylar width (all time points), and notch width (24 months). Restored ACL CSA was significantly correlated with bicondylar width (6 months) and notch width (6 and 12 months). Conclusion: Surgically treated ACLs remodel continuously within the first 2 years after surgery, leading to ligaments/grafts with heterogeneous CSAs along the length, similar to the native ACL. While reconstructed ACLs remained significantly larger, the restored ACL had a CSA profile comparable with that of the contralateral native ACL. In addition to size and morphology differences, there were fundamental differences in factors contributing to CSA profile between the ACL reconstruction and BEAR procedures. Registration: NCT02664545 (ClinicalTrials.gov identifier).

COVID-Delayed Elective Surgery Has a Negative Effect on Young Sports Medicine Patients.

Purpose: The purpose of this study was to evaluate the physical and psychological effects of COVID-related elective surgery delays on young sports medicine patients. Methods: We conducted a cross-sectional study of patients (10-25 years old) who had elective sports medicine surgery delayed due to the COVID crisis. Electronic surveys were sent to patients and included the 12-item Short Form Health Survey (SF-12), which yields a physical component score (SF12-PCS) and a mental component score (SF12-MCS), the PROMIS Psychological Stress Experience survey (PROMIS-PSE), and self-designed questions about patient concerns regarding the COVID crisis and delayed surgery. Results: Of the 194 eligible patients with delayed elective sports surgeries, 107 patients (55%) elected to participate (mean age 17.6 ± 3.09 years, 30% male). The mean surgical delay was 76 days (CI 57-98). Delayed surgery patients scored significantly lower than population norms on the SF12-PCS (mean 39.3, CI 37.0-41.7; P < .001). Males scored significantly higher than females on the SF12-MCS (52.8 vs 45.7; P = .002), but the overall SF12-MCS mean was not significantly different from the general population (47.4; P =.07). The mean PSE score was significantly higher than population norms (57.7, CI 56.1-59.3; P < .001), but they did not differ by age or gender. Patients who reported higher levels of concern about their surgical delay endorsed significantly lower scores on the SF-MCS (P = .006) and higher scores on the PROMIS-PSE (P < .001), indicating greater emotional symptoms. The biggest concern with COVID-related surgical delays was a concern about not being back in time for a sports season. Conclusions: Young sports medicine patients reported significant physical and emotional symptoms associated with COVID-related surgical delays. Patients were most concerned about delays resulting in missed sport seasons. Those who reported greater levels of concern with surgical delays reported more emotional symptoms and higher levels of psychological stress. Clinical Relevance: It is important to understand the impact of delayed elective surgical treatment on young patients due to COVID. This study will allow us to make more informed choices for patients during the pandemic.

Anxiety surrounding supracondylar humerus pin removal in children.

Purpose: The purpose of this study was to quantify the anxiety experienced by patients undergoing pin removal in clinic following closed reduction and percutaneous pinning for supracondylar humerus fractures. Methods: We prospectively enrolled 53 patients (3-8 years) treated for supracondylar humerus fracture with closed reduction and percutaneous pinning between July 2018 and February 2020. Demographic and injury data were recorded. Heart rate and the Face, Legs, Activity, Cry, and Consolability scale were measured immediately before pin removal and after pin removal, and crossover control values were obtained at the subsequent follow-up clinic visit. Results: All patients experienced anxiety immediately prior to pin removal (95% confidence interval, 94%-100%) with a median Face, Legs, Activity, Cry, and Consolability score of 7 (interquartile range, 6-8). In addition, 98% of subjects experienced an elevated heart rate (95% confidence interval, 88%-100%). Patients experienced a median 73% reduction in Face, Legs, Activity, Cry, and Consolability score and mean 21% reduction in heart rate from prior to pin removal to after pin removal (p < 0.001). All 45 patients who completed their follow-up visit had a control Face, Legs, Activity, Cry, and Consolability score of 0 and a mean control heart rate of 89.7 bpm. Twenty-five of these 45 subjects (56%) had an elevated control heart rate for their age and sex. Mean heart rate prior to pin removal was 36% higher than control heart rate. There were no sex differences detected in Face, Legs, Activity, Cry, and Consolability scores or heart rate. Conclusions: Pediatric patients experience high levels of anxiety when undergoing pin removal following closed reduction and percutaneous pinning for supracondylar humerus fractures. This is an area of clinical practice where intervention may be warranted to decrease patient anxiety. Level of evidence: II.

Reproducibility and postacquisition correction methods for quantitative magnetic resonance imaging of the anterior cruciate ligament (ACL).

Quantitative magnetic resonance imaging has been used to evaluate the structural integrity of knee joint structures. However, variations in acquisition parameters between scanners pose significant challenges. Understanding the effect of small differences in acquisition parameters for quantitative sequences is vital to the validity of cross-institutional studies, and for the harmonization of large, heterogeneous datasets to train machine learning models. The study objective was to assess the reproducibility of T2 * relaxometry and the constructive interference in steady-state sequence (CISS) across scanners, with minimal hardware-necessitated changes to acquisition parameters. It was hypothesized that there would be no significant differences between scanners in anterior cruciate ligament T2 * relaxation times and CISS signal intensities (SI). Secondarily, it was hypothesized that differences could be corrected by rescaling the SI distribution to harmonize between scanners. Seven volunteers were scanned on 3T Prisma and Tim Trio scanners (Siemens). Three correction methods were evaluated for T2 *: inverse echo time scaling, z-scoring, and Nyúl histogram matching. For CISS, scans were normalized to cortical bone, scaled by the background noise ratio, and log-transformed. Before correction, significant mean differences of 6.0 ± 3.2 ms (71.8%; p = 0.02) and 0.49 ± 0.15 units (40.7%; p = 0.02) for T2 * and CISS across scanners were observed, respectively. After rescaling, T2 * differences decreased to 2.6 ± 2.7 ms (23.9%; p = 0.03), 1.3 ± 2.5 ms (10.9%; p = 0.13), and 1.27 ± 3.0 ms (19.6%; p = 0.40) for inverse echo time, z-scoring, and Nyúl, respectively, while CISS decreased to 0.01 ± 0.11 units (4.0%; p = 0.87). These findings suggest that small acquisition parameter differences may lead to large changes in T2 * and SI values that must be reconciled to compare data across magnets.

Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial.

BACKGROUND: Previous clinical studies have shown that psychological factors have significant effects on an athlete's readiness to return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR). HYPOTHESIS: We hypothesized that patients who underwent bridge-enhanced ACL restoration (BEAR) would have higher levels of psychological readiness to return to sport compared with patients who underwent ACLR. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 100 patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were randomized to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33 hamstring and 2 bone--patellar tendon-bone]) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL--Return to Sport after Injury (ACL-RSI) scale, were assessed at 6, 12, and 24 months postoperatively. RESULTS: Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2; P = .008); scores were similar at 12 and 24 months. Baseline factors independently predictive of higher ACL-RSI scores at 6 months were having a BEAR procedure and participating in level 1 sports prior to injury, explaining 15% of the variability in the scores. Regression analysis of baseline and 6-month outcomes as predictors indicated that the International Knee Documentation Committee (IKDC) score at 6 months explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC excluded from the model indicated that decreased pain, increased hamstring and quadriceps strength in the surgical limb, and decreased side-to-side difference in anteroposterior knee laxity were significant predictors of a higher ACL-RSI score at 6 months, explaining 34% of the variability in scores. Higher ACL-RSI score at 6 months was associated with earlier clearance to return to sports. CONCLUSION: Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months postoperatively. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months and were also associated with lower pain levels, better muscle recovery, and less knee laxity at 6 months. REGISTRATION: NCT02664545 (ClinicalTrials.gov identifier).

Jumping on the Bandwagon: Comparing the Efficacy of Chlorhexidine Versus Povidone-Iodine Preoperative Skin Antiseptic in Preventing Surgical Site Infections Following Pediatric Orthopaedic Surgery.

BACKGROUND: Adult literature has demonstrated chlorhexidine (CH) superiority at preventing surgical-site infections when compared with povidone-iodine (P-I). The purpose of this study is to compare the rate of postoperative infections after preoperative skin cleansing with either CH or P-I in pediatric orthopaedic surgery in an effort to identify superiority. METHODS: We retrospectively identified all patients (18 y and below) that underwent orthopaedic surgery at our institution in 2015, when P-I was the preoperative skin antisepsis of choice, and in 2018, when a change in protocol resulted in more frequent use of CH. Open fractures, infections, neuromuscular, and tumor surgeries were excluded. Orthopaedic surgeries were classified according to their subspecialty (sports-related/upper extremity, hip and lower extremity, trauma-related, or spine procedure). A 1:1 propensity score matching was conducted within each procedure group on the basis of age, sex, and year using nearest-neighbor matching. Spine procedures could not be matched and were subsequently excluded from analyses. RESULTS: Propensity score matching matched 1416 CH cases with 1416 P-I controls. The infection rate for CH was 19 infections per 1000 cases (27/1416; 1.9%) compared with an infection rate of 11 infections per 1000 cases (16/1416; 1.1%) for P-I subjects. No difference was detected in infection rate across preoperative skin antisepsis groups (P=0.12). Moreover, it was found that CH and P-I resulted in significantly equivalent infection rates to within ±1.5% (P=0.004). When stratified by procedure type, CH used in sports/upper extremity procedures resulted in 29 more infections per 1000 cases compared with P-I use (16/450; 3/450; P=0.005). No difference was detected in infection rate across CH and P-I skin antisepsis groups in lower extremity procedures (9/792; 8/792; P=1.00) or in trauma-related procedures (3/174; 4/174; P=1.00). CONCLUSIONS: CH and P-I are both protective against postoperative infections after sports/upper extremity, lower extremity, and trauma-related pediatric orthopaedic procedures. P-I may provide improved protection over CH as a preoperative skin antisepsis in upper extremity and sports-related procedures. LEVEL OF EVIDENCE: Level III-comparative cohort.

Earlier Resolution of Symptoms and Return of Function After Bridge-Enhanced Anterior Cruciate Ligament Repair As Compared With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Bridge-enhanced anterior cruciate ligament repair (BEAR) has noninferior patient-reported outcomes when compared with autograft anterior cruciate ligament reconstruction (ACLR) at 2 years. However, the comparison of BEAR and autograft ACLR at earlier time points-including important outcomes such as resolution of knee pain and symptoms, recovery of strength, and return to sport-has not yet been reported. HYPOTHESIS: It was hypothesized that the BEAR group would have higher outcomes on the International Knee Documentation Committee and Knee injury and Osteoarthritis Outcome Score, as well as improved muscle strength, in the early postoperative period. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 100 patients aged 13 to 35 years with complete midsubstance anterior cruciate ligament injuries were randomized to receive a suture repair augmented with an extracellular matrix implant (n = 65) or an autograft ACLR (n = 35). Outcomes were assessed at time points up to 2 years postoperatively. Mixed-model repeated-measures analyses were used to compare BEAR and ACLR outcomes. Patients were unblinded after their 2-year visit. RESULTS: Repeated-measures testing revealed a significant effect of group on the International Knee Documentation Committee Subjective Score (P = .015), most pronounced at 6 months after surgery (BEAR = 86 points vs ACLR = 78 points; P = .001). There was a significant effect of group on the Knee injury and Osteoarthritis Outcome Score-Symptoms subscale scores (P = .010), largely attributed to the higher BEAR scores at the 1-year postoperative time point (88 vs 82; P = .009). The effect of group on hamstring strength was significant in the repeated-measures analysis (P < .001), as well as at all postoperative time points (P < .001 for all comparisons). At 1 year after surgery, approximately 88% of the patients in the BEAR group and 76% of the ACLR group had been cleared for return to sport (P = .261). CONCLUSION: Patients undergoing the BEAR procedure had earlier resolution of symptoms and increased satisfaction about their knee function, as well as improved resolution of hamstring muscle strength throughout the 2-year follow-up period. REGISTRATION: NCT02664545 (ClinicalTrials.gov identifier).

Regional Differences in Anterior Cruciate Ligament Signal Intensity After Surgical Treatment.

BACKGROUND: Magnetic resonance-based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing. HYPOTHESES: (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL). RESULTS: For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points (P < .01) but compared with the tibial region only at 6 months (P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points (P < .01) but versus the tibial region only at 6 and 12 months (P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs (P < .01). CONCLUSION: The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.

Pediatric Venous Thromboembolism: Different Rates of Incidence, Anatomic Locations, and Risk Factors Between Orthopaedic and Nonorthopaedic Related Patients.

BACKGROUND: The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and nonorthopaedic pediatric related patients to determine if important differences exist. METHODS: Computed tomography and ultrasound data were reviewed for children (below 19 y old) with a diagnosed VTE between January 1, 2009 and December 31, 2016. Demographic and clinical data, including VTE anatomic location and risk factors, were recorded. Two major cohorts were identified: orthopaedic-related (ORTH) and nonorthopaedic-related (NORTH) VTEs. Incidence rates were estimated and risk factors were compared using χ2 testing. RESULTS: There were 373 children diagnosed with a VTE (average age 10.3 y) of a total of 810,097 treated as in-patients for an incidence rate of 4.60 per 10,000 cases (95% confidence interval=4.15 to 5.10 per 10,000 cases). The rate of ORTH VTEs (28 of 188,669 orthopaedic patients, 1.48 per 10,000 cases) was significantly lower than that of NORTH VTEs (345 of 621,428 nonorthopaedic patients, 5.55 per 10,000 cases; P<0.001). For the ORTH cohort, there was a significant difference in the proportion of deep vein thrombosis in the lower extremity (91%) compared with the upper extremity (9%) (P<0.001), while a more even distribution of NORTH deep vein thrombosis in the upper (50%) and lower (41%) extremities was appreciated. The primary risk factors for ORTH VTEs included surgery (93%; P<0.001), change in ambulatory status (61%; P<0.001), and trauma (18%; P<0.001), while the primary risk factors for NORTH VTEs included intravenous peripheral inserted central catheter/central line (61%; P<0.001) and cancer (27%; P=0.001). CONCLUSIONS: Pediatric ORTH VTEs have a significantly lower incidence rate and different primary risk factors than those of NORTH VTEs. This information is useful for health care providers when making decisions regarding risk and prophylaxis in pediatric patients with orthopaedic and nonorthopaedic conditions. LEVEL OF EVIDENCE: Level III.

ACL Size, but Not Signal Intensity, Is Influenced by Sex, Body Size, and Knee Anatomy.

BACKGROUND: Little is known about sex-based differences in anterior cruciate ligament (ACL) tissue quality in vivo or the association of ACL size (ie, volume) and tissue quality (ie, normalized signal intensity on magnetic resonance imaging [MRI]) with knee anatomy. HYPOTHESIS: We hypothesized that (1) women have smaller ACLs and greater ACL normalized signal intensity compared with men, and (2) ACL size and normalized signal intensity are associated with age, activity levels, body mass index (BMI), bicondylar width, intercondylar notch width, and posterior slope of the lateral tibial plateau. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Knee MRI scans of 108 unique ACL-intact knees (19.7 ± 5.5 years, 62 women) were used to quantify the ACL signal intensity (normalized to cortical bone), ligament volume, mean cross-sectional area, and length. Independent t tests were used to compare the MRI-based ACL parameters between sexes. Univariate and multivariate linear regression analyses were used to investigate the associations between normalized signal intensity and size with age, activity levels, BMI, bicondylar width, notch width, and posterior slope of the lateral tibial plateau. RESULTS: Compared with men, women had significantly smaller mean ACL volume (men vs women: 2028 ± 472 vs 1591 ± 405 mm3), cross-sectional area (49.4 ± 9.6 vs 41.5 ± 8.6 mm2), and length (40.8 ± 2.8 vs 38.1 ± 3.1 mm) (P < .001 for all), even after adjusting for BMI and bicondylar width. There was no difference in MRI signal intensity between men and women (1.15 ± 0.24 vs 1.12 ± 0.24, respectively; P = .555). BMI, bicondylar width, and intercondylar notch width were independently associated with a larger ACL (R 2 > 0.16, P < .001). Younger age and steeper lateral tibial slope were independently associated with shorter ACL length (R 2 > 0.03, P < .04). The combination of BMI and bicondylar width was predictive of ACL volume and mean cross-sectional area (R 2 < 0.3). The combination of BMI, bicondylar width, and lateral tibial slope was predictive of ACL length (R 2 = 0.39). Neither quantified patient characteristics nor anatomic variables were associated with signal intensity. CONCLUSION: Men had larger ACLs compared with women even after adjusting for BMI and knee size (bicondylar width). No sex difference was observed in signal intensity, suggesting no difference in tissue quality. The association of the intercondylar notch width and lateral tibial slope with ACL size suggests that the influence of these anatomic features on ACL injury risk may be partially explained by their effect on ACL size. REGISTRATION: NCT02292004 and NCT02664545 (ClinicalTrials.gov identifier).