Traumatic Hip Dislocation: Pediatric and Adult Evaluation and Management.

Traumatic hip dislocation of a native hip joint represents an orthopaedic emergency that should be treated promptly. Dislocations can be classified based on the associated injuries and the direction of dislocation. Expeditious evaluation, reduction, and management of associated injuries are required to optimize short and long-term function of the hip. There are several important differences between the blood supply and ossification of the pediatric hip that necessitate different strategies for the evaluation and management of traumatic hip dislocations in pediatric patients. Appropriate treatment is dictated by the direction and type of dislocation as well as associated injuries. In addition to closed reduction, arthroscopy, open reduction (potentially with fracture fixation and/or soft-tissue repair), osteotomy, and total hip arthroplasty all have roles in treatment. Consensus on optimal postreduction activity protocols after simple hip dislocation remain unestablished. Short and long-term outcomes are largely driven by the amount of time from injury to reduction and associated injuries.

Langerhans Cell Histiocytosis in the Pediatric Spine Requiring Stabilization: A Literature Review and Report of 3 Cases.

CASE: This report describes 3 cases of Langerhans cell histiocytosis (LCH) of the cervical and thoracic spine in patients aged 4 to 10 years. Each patient had painful lytic spinal lesions with vertebral body collapse and posterior involvement suggesting instability requiring corpectomy, grafting, and fusion. All 3 patients were doing well at their most recent follow-up without pain or recurrence. CONCLUSION: Although LCH of the pediatric spine is usually successfully treated non-operatively, we recommend corpectomy and fusion when there is instability of the spinal column and/or severe stenosis. Posterior element involvement occurred in all 3 cases and may lead to instability.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences.

PURPOSE: Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities. METHODS: Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected. RESULTS: The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity. CONCLUSIONS: In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers. CLINICAL RELEVANCE: As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Can the Femoro-Epiphyseal Acetabular Roof (FEAR) Index Be Used to Distinguish Dysplasia from Impingement?

BACKGROUND: Classifying hips with structural deformity on the spectrum from impingement to dysplasia is often subjective and frequently inexact. Currently used radiographic measures may inaccurately predict a hip's morphological stability in borderline hips. A recently described radiographic measure, the Femoro-Epiphyseal Acetabular Roof (FEAR) index, has demonstrated an ability to predict stability in the borderline hip. This measure is attractive to clinicians because procedures can be used on the basis of a hip's pathomechanics. This study was designed to further validate and characterize the FEAR index in a skeletally immature population, in hips with dysplasia/femoroacetabular impingement (FAI), and in asymptomatic hips. QUESTIONS/PURPOSES: (1) What are the characteristics of the FEAR index in children and how does the index change with skeletal maturation? (2) How does the FEAR index correlate with clinical diagnosis and surgical treatment in a large cohort of symptomatic hips and asymptomatic controls? (3) How does the FEAR index correlate with clinical diagnosis in the borderline hip (lateral center-edge angle [LCEA] 20°-25°) group? METHODS: A total of 220 participants with symptomatic investigational hips with a clinical diagnosis of dysplasia or FAI between January 2008 and January 2018 were retrospectively collected from the senior author's practice. Investigational hips were excluded if they had any femoral head abnormalities preventing LCEA measurement (for example, Perthes disease), Tönnis osteoarthritis grade greater than 1, prior hip surgery, or prior femoral osteotomy. In the 220 participants, 395 hips met inclusion criteria. Once exclusion criteria were applied, 15 hips were excluded due to prior hip surgery or prior femoral osteotomy, and 12 hips were excluded due to femoral head deformity. A single hip was then randomly selected from each participant, resulting in 206 investigational hips with a mean age of 13 ± 3 years. Between January 2017 and December 2017, 70 asymptomatic control participants were retrospectively collected from the senior author's institutional trauma database. Control hips were included if the AP pelvis film had the coccyx centered over the pubic symphysis and within 1 to 3 cm of the superior aspect of the symphysis. Control hips were excluded if there was any fracture to the pelvis or ipsilateral femur or the participant had prior hip/pelvis surgery. After exclusion criteria were applied, 16 hips were excluded due to fracture. One hip was then randomly selected from each participant, resulting in 65 control hips with a mean age of 16 ± 8 years. Standardized standing AP pelvis radiographs were used to measure the FEAR index, LCEA, and Tönnis angle in the investigational cohort. Standardized false-profile radiographs were used to measure the anterior center-edge angle (ACEA) in the investigational cohort. Two blinded investigators measured the FEAR index with an intraclass correlation coefficient of 0.92 [95% CI 0.84 to 0.96]. Question 1 was answered by comparing the above radiographic measures in age subgroups (childhood: younger than 10 years; adolescence: 10 to 14 years old; maturity: older than 14 years) of dysplastic, FAI, and control hips. Question 2 was answered by comparing the radiographic measures in all dysplastic, FAI, control hips, and a subgroup of operatively or nonoperatively managed dysplasia and FAI hips. Question 3 was answered by comparing the radiographic measures in borderline (LCEA 20°-25°) dysplastic, FAI, and control hips. RESULTS: The FEAR index was lower in older dysplastic of hips (younger than 10 years, 6° ± 9°; 10 to 14 years, 4° ± 10°; older than 14 years, 5° ± 9°; p < 0.001) and control hips (younger than 10 years, -6° ± 5°; 10 to 14 years, -15° ± 4°; older than 14 years, -16° ± 7°; p < 0.001). The diagnosis and age groups were independently correlated with the FEAR index (p < 0.001). The relationship between the FEAR index and diagnosis remained consistent in each age group (p = 0.11). The FEAR index was higher in all dysplastic hips (mean 5° ± 10°) than in asymptomatic controls (mean -13° ± 7°; p < 0.001) and FAI hips (mean -10° ± 11°; p < 0.001). Using -1.3° as a cutoff for FAI/control hips and dysplastic hips, 81% (112 of 139) of hips with values below this threshold were FAI/control, and 89% (117 of 132) of hips with values above -1.3° were dysplastic. The receiver operator characteristics area under the curve (ROC-AUC) was 0.91. Similarly, the FEAR index was higher in borderline dysplastic hips than in both asymptomatic borderline controls (p < 0.001) and borderline FAI hips (p < 0.001). Eighty-nine percent (33 of 37) of hips with values below this threshold were FAI/control, and 90% (37 of 41) of hips with values above -1.3° were dysplastic. The ROC-AUC for borderline hips was 0.86. CONCLUSION: The FEAR index was associated with the diagnosis of hip dysplasia and FAI in a patient cohort with a wide age range and with varying degrees of acetabular deformity. Specifically, a FEAR index greater than -1.3° is associated with a dysplastic hip and a FEAR index less than -1.3° is associated with a hip displaying FAI. Using this reliable, developmentally based radiographic measure may help hip preservation surgeons establish a correct diagnosis and more appropriately guide treatment. LEVEL OF EVIDENCE LEVEL: III, diagnostic study.

Operating Room Intervention Rates After Orthopaedic Resident-reduced Pediatric Both-Bone Forearm Fractures Relative to the Academic Calendar.

BACKGROUND: The purpose of this study was to evaluate the operating room (OR) intervention rates and quality of fracture reductions for pediatric diaphyseal both-bone forearm fractures performed by orthopaedic residents relative to the academic year. OR intervention was defined as any procedure performed in the OR, including closed reduction and casting, and was used to identify fractures that required secondary intervention after initial closed reduction performed by an orthopaedic resident in the emergency department. METHODS: A retrospective analysis identified pediatric patients presenting at our institution with both-bone forearm fractures from July 2010 to June 2016. Emergency-room sedation time, highest experience of orthopaedic resident documented to be present at the time of sedation (in postgraduate months), and frequencies of OR intervention were obtained by chart review. Fracture characteristics were determined by radiographic review. Immediate postreduction radiographs were used to measure cast indices, and adequacy of reduction was determined by postreduction angulation and translation. RESULTS: During the time period studied, 470 both-bone forearm reductions under sedation were performed by an orthopaedic resident at our institution. Of these, 41 fractures (41 patients) required 42 OR interventions (40 involved surgical fixation and 2 were repeat closed reductions). The academic year was divided into quartiles. The April to June quartile had the highest overall percentage of OR intervention (10.6%), followed by July to September (8.6%); however, there was no significant difference between quartiles in the percentages of reductions that needed OR intervention (P=0.553). There was also no correlation between the experience level of the resident performing the reduction (based on postgraduate months) and the frequency of OR intervention (P=0.244). The anteroposterior (AP) and lateral reduction grades did not vary based on quarters (P=0.584; 0.353). The ability to obtain adequate reduction and the rate of unacceptable cast index were also not significantly different between quarters (P=0.347 and 0.465). CONCLUSIONS: We found no significant difference in rates of OR intervention or the quality of reduction for pediatric both-bone diaphyseal forearm fractures treated by orthopaedic residents relative to the academic year. LEVEL OF EVIDENCE: Level III-comparative cohort study.

Does Compensatory Anterior Pelvic Tilt Decrease After Bilateral Periacetabular Osteotomy?

BACKGROUND: The kinetic link among the lumbar spine, pelvic tilt, and the hip has been hypothesized, but this relationship requires further study in acetabular dysplasia. Anecdotal reports suggest that patients may compensate for acetabular dysplasia with an involuntary increase in anterior pelvic tilt; it is not known if this relationship is affected by acetabular reorientation. QUESTIONS/PURPOSES: (1) Does compensatory pelvic tilt decrease on preoperatively obtained standing AP pelvis radiographs compared with those obtained at a minimum of 6 months after bilateral periacetabular osteotomy (PAO)? (2) Does a modified surrogate measurement of pelvic tilt, the pubic symphysis to sacroiliac (PS-SI) index, correlate with a physical synthetic bones model in which pelvic tilt can be directly measured? (3) Can the PS-SI index demonstrate high interrater reliability? METHODS: We assessed the surgical records of one surgeon, who participates in the longitudinally maintained Academic Network of Conservational Hip Outcomes Research (ANCHOR) registry, for patients who had undergone the second side of a staged bilateral PAO between 2007 and 2016; there were 113 such patients. Of those, 70 (62%) were lost to followup within 6 months of the second PAO or did not have adequate imaging studies, and another three (3%) were excluded for prespecified reasons, leaving 40 (35%) for evaluation in this retrospective study. Standing preoperative and most recent postoperative AP pelvis radiographs were used to measure the Tönnis angle, anterior wall index, posterior wall index, lateral center-edge angle, pubis symphysis-to-sacrococcygeal junction distance, and the PS-SI index. The most recent radiographs were obtained at a mean of 16 ± 6 months after the second PAO. We chose 6 months as the minimum because at this time point, the majority of patients have reached their maximum clinical improvement and are no longer limited by postoperative muscle dysfunction. Statistical analysis was performed using the intraclass correlation coefficient (ICC) for interrater reliability and paired t-tests for assessing change in measurements from pre- to postoperative. Additionally, a model was created using a physical synthetic bones model in which pelvic tilt could be directly measured. This model was secured through bilateral acetabuli on a mount and rotated through 5° increases in pelvic tilt. AP pelvis radiographs were obtained at each point, the PS-SI index was measured, and a regression analysis performed to evaluate for trend. RESULTS: Overall, 37 of 40 patients (93%) had a decrease in pelvic tilt, as measured by the PS-SI index. The mean amount of pelvic tilt as measured by the PS-SI index decreased after surgery when comparing the preoperative with latest radiographs on this parameter (97 ± 14 mm versus 89 ± 13 mm, mean difference 8 ± 9 mm; 95% confidence interval, -11 to -5; range 17 increase to 24 decrease, p < 0.001). A linear relationship between pelvic tilt and PS-SI index (PS-SI index = 5.0° + 3.6° tilt, R = 0.99) was identified in the synthetic bones validation model. Finally, the interrater reliability was found to be excellent for the PS-SI index preoperatively (ICC = 0.986) and postoperatively (ICC = 0.988). CONCLUSIONS: We found a modest reduction in anterior pelvic tilt after bilateral PAO. This finding suggests that acetabular reorientation affects pelvic position. In clinical practice, patients with acetabular dysplasia may compensate with dynamic and reversible changes in pelvic tilt. The PS-SI index is a reproducible tool to measure the height of the pelvic inlet as an assessment of pelvic tilt. In the future, clinical studies should evaluate the clinical implications of these radiographic findings, including the assessment of back pain, which although multifactorial may be influenced by pelvic tilt. LEVEL OF EVIDENCE: Level III, therapeutic study.

Characterization of doxycycline-loaded calcium phosphate cement: implications for treatment of aneurysmal bone cysts.

Percutaneous doxycycline for treatment for aneurysmal bone cysts (ABCs) has been shown to decrease recurrence rates, however, this requires multiple procedures, includes the risks soft tissue necrosis, and does not provide structural support. We propose utilizing curettage with doxycycline-loaded calcium phosphate cement. This study aimed to evaluate the elution profile of doxycycline from calcium phosphate cement. Calcium phosphate cement underwent an in vitro elution protocol evaluating doxycycline concentrations of 0, 5, 10, and 15 mg/mL. Eluted concentrations were quantified utilizing high performance liquid chromatography at predetermined time points over 96 h. Compressive strength was evaluated both pre- and post-elution and micro-computed tomography was utilized to assess changes in cement porosity. Cement with 15 mg/mL of doxycycline maintained a higher average concentration (mean, 95% confidence intervals) (14.5 µg/mL [9.2-19.9 µg/mL]) compared to both 5 mg/mL (5.8 µg/mL [3.1-8.6 µg/mL]; P < 0.001) and 10 mg/mL (8.4 ± µg/mL [6.0-10.9 µg/mL]; P < 0.001). Ultimate stress significantly decreased between pre- and post-elution samples for 10 mg/mL (P= 0.001) and 15 mg/mL (P = 0.004) groups. This study demonstrated a dose-dependent response in ultimate strength and compressive modulus with addition of doxycycline to calcium phosphate cement.

The Phosphinoboration of N-Heterocycles.

The addition of phosphinoboronate ester Ph2 PBpin (pin=1,2-O2 C2 Me4 ) (1) to a number of different N-heterocycles has been investigated. Reaction of 1 with pyridine resulted in highly selective formation of the corresponding 1,4-addition product, with addition of the electron-deficient Bpin group to the pyridine nitrogen atom and the phosphido group to the para carbon atom. Conversely, reactions of para-substituted pyridine derivatives occurred predominately to afford 1,2-addition products while quinoline reacted to afford the 1,2-adduct which ultimately isomerized to afford the corresponding 1,4-addition product. Preliminary computational studies have been undertaken to explore possible pathways for these transformations including transfer of the PPh2- anion from [B(PPh2 )2 pin]- to the 4-position of a borenium/boronium activated pyridine and concerted pathways for 1,2-addition via intramolecular nucleophilic attack of PPh2 at C2 of a Ph2 PBpin-coordinated pyridine via a four-centered transition state and intramolecular transfer of PPh2 to the 2-position of a boron-activated pyridine in a phosphido-bridged dimer involving a six-centered transition state.

A Comparison of the Outcomes for Cartilage Defects of the Knee Treated With Biologic Resurfacing Versus Focal Metallic Implants.

PURPOSE: To compare the results of focal metallic resurfacing with biologic procedures in patients more than 35 years of age with isolated, full thickness defects of the femoral condyle. METHODS: A total of 61 patients met the selection criteria resulting in 30 patients treated with biological procedures, including debridement, microfracture, osteochondral autograft transplantation, osteochondral allograft, and autologous chondrocyte implantation (BIO group), and 32 patients treated with focal metallic resurfacing (CAP group). The BIO and CAP groups were matched according to treatment location, defect grade and size, and age profile. Outcomes included Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short Form-12, and satisfaction. The primary combination endpoint was determined as a 20% improvement (minimum clinically important difference-20) on WOMAC pain and function at 2 years and no additional index lesion-related surgical intervention. Safety and effectiveness were also reported. RESULTS: Thirty patients in the BIO group (mean age of 44.6, range 35-64) had an average follow-up of 2.6 years and 32 patients in the CAP group (mean age 47.9, range 37-68) were followed for 2.0 years. Fifty-three percent in the BIO group and 75% in the CAP group achieved success per the endpoint definition. The mean total WOMAC score improved significantly for both groups (BIO: 57-78; P < .001) (CAP: 41-86; P < .001). The physical component score (Short Form-12 PCS) improved significantly in the CAP group only (30-36.4; P < .001). Good to excellent patient satisfaction was achieved by 80% in BIO and 91% in CAP. There were 4 secondary procedures on the index lesion in the BIO group and 2 in the CAP group. CONCLUSIONS: Careful patient selection can achieve high satisfaction rates with both biological and focal metal resurfacing procedures for the treatment of isolated focal chondral lesions of the femoral condyle in the knee. Focal metallic resurfacing results in similar clinical outcomes and provides excellent success rates at short-term follow-up. LEVEL OF EVIDENCE: Level III comparative study.

The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain.

PURPOSE: To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine. METHODS: A retrospective review of patients (ages 10-18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an "athlete" and "non-athlete" group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture. RESULTS: A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups. CONCLUSION: Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.

Cationic aluminum hydride complexes: reactions of carbene-alane adducts with trityl-borate.

Reaction of (Idipp)AlH3 with [Ph3C][B(C6F5)4] in toluene affords the dimeric aluminum dication [((Idipp)AlH(µ-H))2][B(C6F5)4]22. In contrast, the reaction of (IBn)AlH3 with [Ph3C][B(C6F5)4] in bromobenzene gives a redistribution product, the salt of a monomeric dication [(IBn)2AlH][B(C6F5)4]24.

The effect of rhBMP-2 in a novel, non-instrumented extremity nonunion model.

BACKGROUND: Pre-clinical models of bony nonunion typically employ critical-length defects. However, these models may not accurately reflect clinical practice since many nonunions are diagnosed without bone loss. We developed a non-displaced rat ulna fracture model in order to examine the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) with an absorbable collagen sponge (ACS) for nonunion treatment. METHODS: Transverse diaphyseal ulna fractures were created in 24 Sprague-Dawley rats. Eight animals (Group 1: Nonunion) received no further intervention. The remaining 16 animals were treated with 5 µg rhBMP-2/ACS at 8 weeks after the original intervention (Group 2: Nonunion + BMP) or at the time of initial injury (Group 3: Fresh fracture + BMP). RESULTS: In Group 1, 7 of 8 fractures demonstrated gross motion and a persistent radiographic gap (12.5% healing rate). In Groups 2 and 3, fractures healed at a rate of 75% (6 of 8 in each group) as determined by manual and radiographic evaluation. Biomechanical testing for torque load-to-failure and torsional stiffness demonstrated no significant difference between healed specimens treated with rhBMP-2. CONCLUSIONS: To our knowledge, this is the first description of a physiologic, non-stabilized, non-defect fracture nonunion model in a rodent. Furthermore, unlike previous nonunion models, the healing rates after treatment with rhBMP-2 are comparable to that of clinical data, suggesting that this model may provide an environment more representative of nonunions in humans.

The phosphinoboration reaction.

The synthesis of phosphinoboronate esters containing a single P-B bond is reported, together with preliminary reactivity studies towards a range of organic substrates. These compounds add readily to aldehydes, ketones, aldimines, and α,ß-unsaturated enones to give primarily the corresponding 1,2-addition products containing a new P-C bond. The first examples of transition-metal-catalyzed phosphinoborations of C-C multiple bonds in which P-C and B-C bonds are formed in a single step are also disclosed; allenes react by a highly regioselective 1,2-addition whereas terminal alkynes undergo a formal 1,1-addition.

Factors influencing arthrodesis rates in a rabbit posterolateral spine model with iliac crest autograft.

PURPOSE: The rabbit posterolateral intertransverse spine arthrodesis model has been widely used to evaluate spinal biologics. However, to date, the validity and reproducibility of performance of iliac crest bone graft, the most common and critical control group, has not been firmly established. We evaluated original research publications that utilized this model, identified which experimental conditions affected fusion rates, and developed an algorithm to predict fusion rates for future study designs. METHODS: A MEDLINE search was performed for publications through December, 2011 that utilized this model to evaluate fusion rates elicited by iliac crest autograft. All study parameters were recorded, and logistic regression analyses were performed to determine the effects of these variables on fusion rates as determined by either manual palpation or radiographs. RESULTS: Seventy studies with 959 rabbits in 102 groups met the inclusion criteria. Excluding studies that measured fusion at 4 or fewer weeks or intentionally tried to decrease the fusion rate, the overall fusion rate for autograft was 58.3 ± 16.3 % (mean ± SD) as determined by manual palpation and 66.4 ± 17.8 % by plain radiographs. Regression analysis demonstrated a difference between these outcome measures with a trend towards significance (p = 0.09). Longer time points and larger volumes of autograft resulted in significantly greater reported fusion rates (p < 0.0001 and p < 0.05, respectively). Neither strain, age, weight, nor vertebral level significantly affected fusion rates. CONCLUSIONS: Although experimental conditions varied across studies, time point evaluation and autograft volume significantly affected fusion rates. Despite some variability demonstrated across certain studies, we demonstrated that when the time point and volume of autograft were controlled for, the iliac crest control group of the rabbit posterolateral spinal arthrodesis model is both reliable and predictably affected by different experimental conditions.

Prospective long-term evaluation of meniscal allograft transplantation procedure: a minimum of 7-year follow-up.

This study reports the long-term effectiveness of meniscal allograft transplantation performed by a single senior operating surgeon. In this study 22 meniscus transplantations in 22 patients were evaluated at a minimum of 7-year follow-up (mean 8.5 +/- 1.3 years) using standardized scoring scales. Subgroup analysis was performed to stratify outcomes based on medial (59.1%) versus lateral (40.9%) meniscus transplantation, and transplantations performed in isolation (36.4%) versus those performed concomitantly (63.6%). Patients reported significant improvement in all scoring scales (p < 0.05). Average satisfaction was 8.8 out of 10. All the patients were completely or mostly satisfied with the results of their surgery. Overall subjective knee condition improved from 3.5 to 6.9 (p < 0.05). Patients undergoing medial compartment repair and combined transplantations reported greater improvement from baseline to followup than did their counterparts. An overall success rate of 88% was found for all patients at the final follow-up. Based on this data, meniscal allograft transplantation is a viable treatment option for meniscal-deficient patients in reducing pain, increasing range of motion, and improving patient function and satisfaction at a minimum of 7 years postsurgery.

Long-Term Evaluation of Autologous Chondrocyte Implantation: Minimum 7-Year Follow-Up.

PURPOSE: The purpose of this study was to report the clinical outcomes of autologous chondrocyte implantation (ACI) procedures performed by a single orthopedic surgeon at a minimum of 7 years follow-up. METHODS: A retrospective review of prospectively collected data was performed on 29 patients who underwent ACI of the knee between the years of 1998 and 2003. Prospective data were collected to assess changes in standardized outcome measures preoperatively and 2, 4, and 7 years postoperatively. All patients enrolled in the study were also recruited to undergo physical examination when possible. RESULTS: The final cohort consisted of 29 patients with a mean final follow-up time of 8.40 years (range = 7.14-10.88 years). Comparing preoperative scores to 7-year postoperative values, the mean International Knee Documentation Committee (IKDC) score improved from 39.80 to 59.24 (P < 0.001), mean Tegner-Lysholm score increased from 48.07 to 74.17 (P < 0.001), SF-12 physical score improved from 40.38 to 48.66 (P < 0.001), and SF-12 mental score improved from 44.14 to 48.98 (P < 0.05). Significant improvement occurred in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain (56.03 to 80.36), symptoms (54.19 to 74.75), activities of daily living (72.01 to 85.90), sports (23.34 to 55.34), and quality of life (24.56 to 56.03) (P < 0.001). In addition, 7-year postoperative scores were at or near levels seen at 2 years (mean = 2.16; range = 0.94-4.03 years) and 4 years (mean = 4.43; range = 2.16-5.88 years) postoperatively, reflecting durable improvement. Subjectively, on a scale of 1 to 10 (10 being completely satisfied), the mean postoperative satisfaction rate was 8.14. Additionally, 88.9% of the patients would elect to have this surgery again if the same problem was to occur in the contralateral joint. CONCLUSIONS: The results of ACI in patients who present with symptomatic, full-thickness chondral defects remain durable at a minimum of 7-year follow-up with persistent, high levels of patient satisfaction. LEVEL OF EVIDENCE: Case series; Level of evidence, IV.

Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review.

BACKGROUND: Joint injections and aspirations are used to reduce joint pain and decrease inflammation. The efficacy of these injections is diminished when they are placed inadvertently in the wrong location or compartment. The purpose of this study was to determine whether the use of varying sites or imaging techniques affects the rate of accurate needle placement in aspiration and injection in the shoulder, elbow, and knee. HYPOTHESES: (1) Accuracy rates of different joint injection sites will demonstrate variability. (2) Injection accuracy rates will be improved when performed with concomitant imaging. STUDY DESIGN: Systematic review of the literature. METHODS: Studies reporting injection accuracy based on image verification were identified through a systematic search of the English literature. Accuracy rates were compared for currently accepted injection sites in the shoulder, elbow, and knee. In addition, accuracy rates with and without imaging of these joints were compared. RESULTS: In the glenohumeral joint, there is a statistically higher accuracy rate with the posterior approach when compared with the anterior approach (85% vs 45%). Injection site selection did not affect accuracy for the subacromial space, acromioclavicular joint, elbow, or knee. The use of imaging improved injection accuracy in the glenohumeral joint (95% vs 79%), subacromial space (100% vs 63%), acromioclavicular joint (100% vs 45%), and knee (99% vs 79%). CONCLUSION: Injection accuracy rates are significantly higher for the posterior approach compared with the anterior approach for the glenohumeral joint. Similarly, the accuracy rates are also higher when imaging is used in conjunction with injection of the glenohumeral joint, subacromial space, acromioclavicular joint, and knee.