The effect of factors from different time points on psychological readiness following ACL reconstruction.

OBJECTIVE: The purpose of this study was to examine factors correlated with psychological readiness to return to activity after ACLR. DESIGN: cross sectional study. SETTING: controlled laboratory. PARTICIPANTS: 164 patients (82 M/82 F, 22.5 ± 8.9yr, 171.6 ± 11.0 cm, 77.4 ± 18.6 kg, 8.6 ± 3.4 months post-ACLR) participated in this study after a primary, isolated, and uncomplicated ACLR. MAIN OUTCOME MEASURES: ACL Return to Sport Index (ACL-RSI). RESULTS: ACL-RSI scores demonstrated a weak positive correlation with activity level at the time of injury and a fair positive correlation with activity level at the time of post-operative testing (p-values: 0.004, <0.001). ACL-RSI scores showed a statistically significant fair negative correlation with pain and a moderate negative correlation with kinesiophobia during rehabilitation (p-values: <0.001, <0.001). There was no statistical significance between ACL-RSI and the surgical variables (p-value range: 0.10-0.61). CONCLUSIONS: Outcomes from testing during postoperative rehabilitation were most correlated with psychological readiness to return to activity after ACLR. Increased pain and kinesiophobia were associated with a decreased psychological readiness. Increased activity level prior to injury and activity level at the time of testing during rehabilitation were both correlated with increased psychological readiness. Psychological readiness to return to activity may need to be customized based on potentially modifiable patient-specific factors during the post-operative rehabilitation.

Editorial Commentary: Two-Year Follow-Up Is Too Short to Determine the Effectiveness of Anterior Cruciate Ligament Primary Repair.

Although recent studies have shown good results of anterior cruciate ligament primary repair at 2-year follow-up, one must be careful in adopting this technique. Historically, the classic study from West Point showed repair fails at 5 years. Perhaps future results will be improved with scaffolds, augmentation, or biologics. Only time will tell. For now, what's the (West) Point?

How to Recognize, Correct, and Avoid Intraoperative Complications During Anterior Cruciate Ligament Reconstructions.

Technical complications are a leading cause of graft failure following anterior cruciate ligament reconstructions. Complications can occur during any phase of the procedure, from graft harvesting to tunnel preparation to graft fixation. Predicting potential causes of technical difficulty and developing strategies to avoid potential pitfalls can limit the number of intraoperative complications. If adverse events do occur intraoperatively, prompt recognition and treatment can lead to favorable outcomes. It is important to discuss strategies to understand potential complications and develop tactics to avoid and correct adverse events that can occur during anterior cruciate ligament reconstruction.

No Deficits in Functional Outcomes of the Contralateral Limb Are Seen When the Hamstring Is Harvested for Augmentation of Small Diameter Ipsilateral Hamstring Autograft.

Purpose: To evaluate clinical outcomes of the contralateral, nonoperative limb in patients undergoing contralateral hamstring (HS) autograft harvest compared with patients undergoing ipsilateral HS autograft harvest alone. Methods: This study included 96 patients who underwent isolated anterior cruciate ligament reconstruction (ACLR) using 4-stranded HS autograft (n = 85) or 4-stranded HS autograft augmented with contralateral HS (n = 13) due to inclusion of ipsilateral graft diameter <8 mm. Isokinetic flexion and extension strength and dynamic performance of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were evaluated at 6 months' postoperatively. Rates of contralateral native ACL tear at minimum 2 years also were compared. For all comparisons, P < .05 was considered statistically significant. Results: Normalized isokinetic knee flexion and extension strength of the contralateral limb did not differ between cohorts (P = .34; P = .21, respectively). LSI for knee extension peak torque and knee flexion peak torque did not differ between cohorts (P = .44; P = .67, respectively). No difference in LSI was seen for any dynamic performance testing (single leg hop, P = .97; triple leg hop, P = .14; 6-m timed hop, P = .99). No difference was observed in International Knee Documentation Committee (P = .99) or Knee Injury and Osteoarthritis Outcome Score subscale measures (P = .39-.86). No difference in rates of contralateral knee native ACL tears were seen between cohorts (HS autograft + contralateral HS augmentation, n = 2, 15.4%; HS autograft, n = 7, 8.4%; P = .26). Conclusions: In this study, at the time of return to sport, we found no differences in contralateral limb functional performance or limb symmetry measurements between patients undergoing contralateral HS autograft harvest for augmentation of smaller (<8 mm) diameter HS autografts harvested from the injured extremity. Level of Evidence: Level III, retrospective cohort study.

Knee extensor torque-velocity relationships following anterior cruciate ligament reconstruction.

BACKGROUND: The inherent nature of the torque-velocity relationship is the inverse nature between the velocity of muscle contraction and torque production and is an indication of muscle function. The purpose of this study was to characterize the torque-velocity relationship in the quadriceps following anterior cruciate ligament reconstruction compared to healthy limbs. METHODS: 681 participants were included, 493 of which were patients at least four months following anterior cruciate ligament reconstruction (23.2 ± 10.08 yr, 6.6 ± 5.37 months post-surgery) and 188 were healthy participants (21.6 ± 3.77 yr). A subset of 175 post-surgical participants completed a repeated visit (8.1 ± 1.71 months post-surgery). Participants completed isokinetic knee extension at 90°/s and 180°/s. A one-way ANOVA was used to compare torque velocity relationships by limb type (surgical, contralateral, healthy). Paired samples t-tests were conducted to analyze the torque-velocity relationship across limbs and across time. FINDINGS: There was a large effect for limb type on torque-velocity (F(2, 1173) = 146.08, p < 0.001, η2 = 0.20). Surgical limbs demonstrated significantly lower torque-velocity relationships compared to the contralateral limbs (ACLR: 0.26 Nm/kg, contralateral:0.55 Nm/kg, p < 0.001, d = 1.18). Healthy limbs had similar torque-velocity relationships bilaterally (dominant limb: 0.48 Nm/kg, non-dominant limb: 0.49 Nm/kg, p = 0.45). The torque velocity relationship for the involved limb significantly increased in magnitude over time (+0.11 Nm/kg, p < 0.001, d = -0.61) while the contralateral limb torque-velocity relationship remained stable over time (0.0 Nm/kg difference, p = 0.60). INTERPRETATION: Following surgery, the knee extensors appear to have altered torque-velocity relationships compared to contralateral and healthy limbs. This may indicate a specific target for assessment and rehabilitation following surgery.

Hip Strength Recovery After Anterior Cruciate Ligament Reconstruction.

Background: Return-to-play (RTP) assessment after anterior cruciate ligament reconstruction (ACLR) rarely includes hip strength. Hypothesis: It was hypothesized that (1) patients after ACLR will have weaker hip abduction (AB) and adduction (AD) strength compared with the contralateral limb, with larger deficits in women, (2) there will be a correlation between hip and thigh strength ratios and patient-reported outcomes (PROs), and (3) hip AB and AD strength will improve over time. Study Design: Descriptive laboratory study. Methods: Included were 140 patients (74 male, 66 female; mean age, 24.16 ± 10.82 years) who underwent RTP assessment at 6.1 ± 1.6 months after ACLR; 86 patients underwent a second assessment at 8.2 ± 2.2 months. Hip AB/AD and knee extension/flexion isometric strength were measured and normalized to body mass, and PRO scores were collected. Strength ratios (hip vs thigh), limb differences (injured vs uninjured), sex-based differences, and relationships between strength ratios and PROs were determined. Results: Hip AB strength was weaker on the ACLR limb (ACLR vs contralateral: 1.85 ± 0.49 vs 1.89 ± 0.48 N·m/kg; P < .001) and hip AD torque was stronger (ACLR vs contralateral: 1.80 ± 0.51 vs 1.76 ± 0.52 N·m/kg; P = .004), with no sex-by-limb interaction found. Lower hip-to-thigh strength ratios of the ACLR limb were correlated with higher PRO scores (r = -0.17 to -0.25). Over time, hip AB strength increased in the ACLR limb more than in the contralateral limb (P = .01); however, the ACLR limb remained weaker in hip AB at visit 2 (ACLR vs contralateral: 1.88 ± 0.46 vs 1.91 ± 0.45 N·m/kg; P = .04). In both limbs, hip AD strength was greater at visit 2 than visit 1 (ACLR: 1.82 ± 0.48 vs 1.70 ± 0.48 N·m/kg; contralateral: 1.76 ± 0.47 vs 1.67 ± 0.47 N·m/kg; P < .01 for both). Conclusion: The ACLR limb had weaker hip AB and stronger AD compared with the contralateral limb at initial assessment. Hip muscle strength recovery was not influenced by sex. Hip strength and symmetry improved over the course of rehabilitation. Although strength differences across limbs were minor, the clinical importance of these differences is still unknown. Clinical Relevance: The evidence provided highlights the need to integrate hip strength into RTP assessments to identify hip strength deficits that may increase reinjury or lead to poor long-term outcomes.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

The Posterior Trans-Septal Portal in Knee Arthroscopy Review of the Technique Evolution, Indications, and Technical Pearls.

Complete arthroscopic visualization of the posterior com-partment of the knee is limited when using the traditional anterior portals. The trans-septal portal technique, created in 1997, has allowed surgeons to view the complete posterior compartment of the knee in a less-invasive way compared to open surgery. Since the description of the posterior trans-septal portal, several authors have modified the technique. However, the paucity of literature describing the trans-septal portal technique hints that widespread arthroscopic adop-tion has not yet been achieved. While still in its infancy, the literature has cumulatively reported over 700 successful knee surgeries using the posterior trans-septal portal technique with no reports of neurovascular injury. However, creation of the trans-septal portal carries risks due to its close prox-imity to the popliteal and middle geniculate artery, giving surgeons little room for technical error when developing this portal. Knowledge of the posterior anatomy, the evolution of the trans-septal portal, and current recommendations and safety options for using the technique will benefit orthopedic surgeons looking to incorporate this technique into their surgical arsenal. Furthermore, utilization of the trans-septal portal technique offers a significant benefit to the surgical treatment of conditions that involve the need for posterior knee access or visualization.

Comparison of Patient-Reported Outcomes, Strength, and Functional Performance in Primary Versus Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Clinical outcomes after revision anterior cruciate ligament reconstruction (ACLR) are not well understood. HYPOTHESIS: Patients undergoing revision ACLR would demonstrate worse patient-reported outcomes and worse limb symmetry compared with a cohort undergoing primary ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: 672 participants (373 with primary ACLR, 111 with revision ACLR, and 188 uninjured) completed functional testing at a single academic medical center. Descriptive information, operative variables, and patient-reported outcomes (International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Tegner Activity Scale score) were assessed for each patient. Quadriceps and hamstring strength tests were conducted using a Biodex System 3 Dynamometer. Single-leg hop for distance, triple hop test, and the 6-m timed hop test were also assessed. Limb symmetry index (LSI) between the ACLR limb and contralateral limb was calculated for strength and hop testing. Normalized peak torque (N·m/kg) was calculated for strength testing. RESULTS: No differences were found in group characteristics, excluding body mass (P < .001), or in patient-reported outcomes. There were no interactions between revision status, graft type, and sex. Knee extension LSI was inferior (P < .001) in participants who had undergone primary (73.0% ± 15.0%) and revision (77.2% ± 19.1%) ACLR compared with healthy, uninjured participants (98.8% ± 10.4%). Knee flexion LSI was inferior (P = .04) in the primary group (97.4% ± 18.4%) compared with the revision group (101.9% ± 18.5%). Difference in knee flexion LSI between the uninjured and primary groups, as well as between the uninjured and revision groups, did not reach statistical significance. Hop LSI outcomes were significantly different across all groups (P < .001). Between-group differences in extension in the involved limb (P < .001) were noted, as the uninjured group exhibited stronger knee extension (2.16 ± 0.46 N·m/kg) than the primary group (1.67 ± 0.47 N·m/kg) and the revision group (1.78 ± 0.48 N·m/kg). As well, differences in flexion in the involved limb (P = .01) were found, as the revision group exhibited stronger knee flexion (1.06 ± 0.25 N·m/kg) than the primary group (0.97 ± 0.29 N·m/kg) and the uninjured group (0.98 ± 0.24 N·m/kg). CONCLUSION: At 7 months postoperatively, patients who had undergone revision ACLR did not demonstrate inferior patient-reported outcomes, limb symmetry, strength, or functional performance compared with patients who had undergone primary ACLR. Patients who had undergone revision ACLR exhibited greater strength and LSI than their counterparts with primary ACLR, but these parameters were still inferior to those of uninjured controls.

The "N+10 Rule" to Avoid Graft-Tunnel Mismatch in Bone-Patellar Tendon-Bone ACL Reconstruction Using Independent Femoral Tunnel Drilling.

Background: Graft-tunnel mismatch (GTM) is a common problem in anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-patellar tendon-bone (BPTB) grafts. Hypothesis: Application of the "N+10 rule" in endoscopic ACLR with BPTB grafts will result in acceptable tibial tunnel length (TTL), minimizing GTM. Study Design: Controlled laboratory study. Methods: Endoscopic BPTB ACLR was conducted on the paired knees of 10 cadaveric specimens using 2 independent femoral tunnel drilling techniques-accessory anteromedial portal and flexible reamer. The graft bone blocks were trimmed to 10 × 20 mm, and the intertendinous distance (represented by "N") between the bone blocks was measured. The N+10 rule was used to set the angle of the ACL tibial tunnel guide to the appropriate number of degrees for drilling. The amount of excursion or recession of the tibial bone plug in relation to the anterior tibial cortical aperture was measured in both flexion and extension. A GTM threshold of ±7.5 mm was set based on prior studies. Results: The mean BPTB ACL intertendinous distance was 47.5 ± 5.5 mm. The mean measured intra-articular distance was 27.2 ± 3 mm. Using the N+10 rule, the mean total (flexion plus extension) GTM was 4.3 ± 3.2 mm (GTM in flexion, 4.9 ± 3.6 mm; GTM in extension, 3.8 ± 3.5 mm). In 18 of 20 (90%) cadaveric knees, the mean total GTM fell within the ±7.5-mm threshold. When comparing the actual measured TTL to the calculated TTL, there was a mean difference of 5.4 ± 3.9 mm. When comparing femoral tunnel drilling techniques, the total GTM for the accessory anteromedial portal technique was 2.1 ± 3.7 mm, while the total GTM for the flexible reamer technique was 3.6 ± 5.4 mm (P = .5). Conclusion: The N+10 rule resulted in an acceptable mean GTM in both flexion and extension. The mean difference between the measured versus calculated TTL using the N+10 rule was also acceptable. Clinical Relevance: The N+10 rule is a simple and effective intraoperative strategy for achieving desired TTL regardless of patient-specific factors to avoid excessive GTM in endoscopic BPTB ACLR using independent femoral tunnel drilling.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Influence of interim functional assessments on patient outcomes at the time of return to activity following ACL-reconstruction.

OBJECTIVE: To compare patient outcomes at the time of the return to activity (RTA) progression between those with a prior interim assessment and those without. DESIGN: Retrospective, Cohort Study. SETTING: Controlled Laboratory. PARTICIPANTS: Patients following Anterior Cruciate Ligament Reconstruction (ACLR) were recruited through an ongoing RTA assessment program. Patients were stratified into two testing groups = "Single RTA test": only assessment between 6 and 9 months post-ACLR and "Repeat RTA test": prior assessment performed >2-months before their RTA assessment. Patients were matched based on time post-surgery, age, activity level, and graft type. MAIN OUTCOME MEASURE: Self-reported knee function and isokinetic knee flexor and extensor strength/symmetry were compared between groups. RESULTS: 392 patients were identified. Once matched, 138 patients (21.1 ± 7.0 years, 7.3 ±0 .9 mo post-ACLR) were analyzed. Repeat RTA test patients demonstrated higher measures of self-reported knee function (P = .04) and greater knee flexion strength (P = .006) and symmetry (P = .05). CONCLUSION: Patients with interim functional assessments reported greater self-reported knee function and higher hamstring strength at the time of RTA compared to patients that completed their only assessment within this time point. Early functional assessments may identify individualized deficits that can be addressed while patients are under supervision of rehabilitation specialists.

Lateral Extra-Articular Tenodesis Staple Risks Penetration of Anterior Cruciate Ligament Reconstruction Tunnel.

Purpose: To identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling. Methods: Twenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques. Results: The staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P = .65). Conclusions: A high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation. Level of Evidence: Level IV, controlled laboratory study. Clinical Relevance: The risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.

Coaching in Sports Medicine.

Similar to elite athletes, surgeons use their skills on a daily basis but coaching for skillset refinement is not common among surgeons. Surgeon coaching has been proposed a method by which surgeons can gain insight into their performance and optimize their practice. However, many barriers exist to surgeon coaching such as logistics, time, cost, and pride. Ultimately, the tangible improvement in surgeon performance, the elevation of surgeon well-being, the optimization of the practice, and better patient outcomes support a wider implementation of surgeon coaching for surgeons at all stages of their career.

Dataset of FD&C Certified Food Dyes in Foods Commonly Consumed by Children.

This is dataset describing the levels of Food, Drug, & Cosmetic (FD&C) dye in juice drinks, breakfast cereals, frozen desserts, ice cream cones, fruit flavored soft drinks, frostings & icings, fruit snacks/candy, decoration chips for baking, water enhancers, and flavored fruit drink powder. Data values are organized by absolute values, averages, SDs and % RSD. High performance liquid chromatography with a photometric diode array detector (HPLC-PDA) was used to measure dye levels and generate the data. These values can be used to calculate levels of dyes consumed within various populations, such as children, and compare them to accepted daily intake (ADIs) values established by the United States Food & Drug Administration (US FDA). The data are interpreted in "Survey of Certified Food Dye Levels in Food Samples Consumed by Children for Updated Exposure Levels" in the Journal of Food Additives and Contaminants: Part B.1.

Exposures to FD&C synthetic color additives from over-the-counter medications and vitamins in United States children and pregnant women.

BACKGROUND: Food and Drug Administration (FDA) Food Drug and Cosmetic (FD&C) synthetic color additives (SCAs) have been associated with attentional and behavioral problems in children. Efforts to quantify exposure have focused on foods, while the contribution of medications and supplements remains unknown. OBJECTIVE: To estimate exposures to SCAs in children (2-16 years) and pregnant women from intake of common over-the-counter (OTC) medications and vitamins. METHODS: We estimated single-day exposure (mg/kg/day) to FD&C SCAs based on measurements of 25 different products and recommended dosages on product labels. Exposures were compared to SCA exposure estimates from food we previously developed and acceptable daily intakes (ADIs) established by FDA and the World Health Organization. RESULTS: The highest exposure was found for FD&C Red No. 40 in a children's cold/cough/allergy syrup. A child aged 12-16 years consuming the maximum daily dosage would have an exposure of 0.221 mg/kg/day, which is twice this age group's typical exposure to this additive from food. No estimated exposures exceeded the ADIs. SIGNIFICANCE: Some children's OTC medications and vitamins may cause daily SCA exposures comparable to those from foods. OTC medications and vitamins should be considered in efforts to quantify population exposure to FD&C SCAs. IMPACT: Exposure to synthetic color additives (SCAs) from foods has been associated with behavioral problems in children. Exposures from over-the-counter (OTC) medications and vitamins remain unquantified despite widespread use. We estimated exposures in children and pregnant women for 25 different OTC medication and vitamin products sold in the United States. While exposures were below acceptable daily intakes (ADIs) established by the US Food and Drug Administration and the World Health Organization, some were comparable to typical daily exposures from foods. This work critically informs future SCA exposure assessments and provides valuable information for parents concerned about the health effects of SCAs.