Postoperative Strength Differences at Short-Term Follow-Up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft.

METHODS

This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts.

RESULTS

A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36).

CONCLUSIONS

There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation

PURPOSE

Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction.

METHODS

From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared.

RESULTS

Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis.

CONCLUSIONS

At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Flatfoot Reconstruction for Painful Pediatric Idiopathic Flexible Flatfoot: Prospective Study Demonstrates Improved Alignment, Function, and Patient-reported Outcomes

BACKGROUND

This prospective study was undertaken to report outcomes following reconstructive surgery for patients with painful pediatric idiopathic flexible flatfoot.

METHODS

Twenty-five patients with pediatric idiopathic flexible flatfoot were evaluated pre- and post flatfoot reconstruction with lateral column lengthening (LCL). All patients had lengthening of the Achilles or gastrocnemius, while 13 patients had medial side soft tissue (MSST) procedures, 7 underwent medial cuneiform plantarflexion osteotomy (MCPO), and 5 had medializing calcaneal osteotomy. Measures of static foot alignment-both radiographic parameters and clinical arch height indices-were compared, as were measures of dynamic foot alignment and loading, including arch height flexibility and pedobarography. Preoperative and postoperative patient-reported outcome (PRO) scores were compared between those treated with or without MSST procedures.

RESULTS

The median subject age was 13.8 years (range: 10.3 to 16.5) at the time of surgery. All radiographic parameters improved with surgery ( P <0.001). The mean sitting arch height index showed a modest increase after surgery ( P =0.023). Arch height flexibility was similar after surgery. The mean center-of-pressure excursion index increased from 14.1% to 24.0% ( P <0.001), and the mean first metatarsal head (MH) peak pressure dropped ( P <0.001), while the mean fifth MH peak pressure increased ( P =0.018). The ratio of peak pressure in the fifth MH to peak pressure in the second MH increased ( P =0.010). The ratio of peak pressure in the first MH to peak pressure in the second MH decreased when an MCPO was not used ( P <0.002), but it remained stable when an MCPO was included. Mean scores in all PRO domains improved ( P <0.001). Patients treated without MSST procedures showed no difference in PROMIS Pain Interference scores compared to those without MSST procedures.

CONCLUSIONS

Flatfoot reconstruction surgery using an LCL with plantarflexor lengthening results in improved PROs. LCL changes but does not normalize the distribution of MH pressure loading. The addition of an MCPO can prevent a significant reduction in load-sharing by the first MH.

Back to Basics: Pediatric Casting Techniques, Pearls, and Pitfalls

Cast application is a critical portion of pediatric orthopaedic surgery training and is being performed by a growing number of non-orthopaedic clinicians including primary care physicians and advanced practice providers (APPs). Given the tremendous remodeling potential of pediatric fractures, correct cast placement often serves as the definitive treatment in this age population as long as alignment is maintained. Proper cast application technique is typically taught through direct supervision from more senior clinicians, with little literature and few resources available for providers to review during the learning process. Given the myriad complications that can result from cast application or removal, including pressure sores and cast saw burns, a thorough review of proper cast technique is warranted. This review and technique guide attempts to illustrate appropriate upper and lower extremity fiberglass cast application (and waterproof casts), including pearls and pitfalls of cast placement. This basic guide may serve as a resource for all orthopaedic and non-orthopaedicproviders, including residents, APPs, and medical students in training. Level of Evidence: IV.

Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial

BACKGROUND

Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective.

METHODS

This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery.

RESULTS

Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00).

CONCLUSIONS

Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

A Systematic Review of Propensity Score Matching in the Orthopedic Literature

Background

Propensity score matching (PSM) is a statistical technique used to reduce bias in observational studies by controlling for measured confounders. Given its complexity and popularity, it is imperative that researchers comprehensively report their methodologies to ensure accurate interpretation and reproducibility.

Purpose

This systematic review sought to define how often PSM has been used in recent orthopedic research and to describe how such studies reported their methods. Secondary aims included analyzing study reproducibility, bibliometric factors associated with reproducibility, and associations between methodology and the reporting of statistically significant results.

Methods

PubMed and Embase databases were queried for studies containing "propensity score" and "match*" published in 20 orthopedic journals prior to 2020. All studies meeting inclusion criteria were used for trend analysis. Articles published between 2017 and 2019 were used for analysis of reporting quality and reproducibility.

Results

In all, 261 studies were included for trend analysis, and 162 studies underwent full-text review. The proportion of orthopedic studies using PSM significantly increased over time. Seventy-one (41%) articles did not provide justification for covariate selection. The majority of studies illustrated covariate balance through P values. We found that 19% of the studies were fully reproducible. Most studies failed to report the use of replacement (67.3%) or independent or paired statistical methods (34.0%). Studies reporting standardized mean differences to illustrate covariate balance were less likely to report statistically significant results.

Conclusion

Despite the increased use of PSM in orthopedic research, observational studies employing PSM have largely failed to adequately report their methodology.

The Incidence of Pediatric Tibial Spine Fractures Is Greater and Peaks Later in Male Patients

Purpose

Methods

Results

Conclusions

Clinical Relevance

Pediatric Tibial Spine Fractures: Exploring Case Burden by Age and Sex

Background

Pediatric tibial spine fractures (TSFs) are a well-known clinical entity, but the epidemiology of these injuries is not fully understood. Further, there are limited data on outcomes after TSF treatment, specifically the proportion of patients requiring subsequent anterior cruciate ligament (ACL) reconstruction.

Purpose

To describe the distribution of TSF case burden by age and sex and to determine the proportion of patients undergoing subsequent ACL reconstruction or developing ACL insufficiency.

Study Design

Descriptive epidemiology study.

Methods

The Truven Health MarketScan database was queried to identify patients aged 7 to 18 years with TSFs between 2016 and 2018. Diagnosis and initial treatment (surgical vs nonoperative) were recorded based on database coding. Case burden by age and sex was calculated. The database, which includes longitudinal data, was then queried for subsequent diagnoses of ACL insufficiency as well as subsequent ACL reconstruction procedures performed among the patients.

Results

We found 876 cases of TSF, 71.3% of which were treated nonoperatively. The male to female ratio for case burden was 2.2:1. Cases peaked at age 13 to 14 years for boys and age 11 to 12 years for girls. Of all cases identified, 3.7% also had either a diagnosis code for ACL laxity entered in a delayed fashion into the database or a later procedure code for ACL reconstruction (considered together to represent "subsequent ACL insufficiency"). Only 15 subsequent ACL reconstructions (1.7% of cases) were found, all of which were among boys and 9 of which were among boys aged 13 to 14 years.

Conclusion

This longitudinal study is the largest epidemiological analysis of pediatric TSFs to date. We found low rates of subsequent ACL insufficiency and ACL reconstruction, with boys aged 13 to 14 years accounting for most of those cases. Rates of subsequent ACL reconstruction were lower than previously reported. Boys accounted for more than two times as many TSF cases as girls.

A Novel Shorthand Approach to Knee Bone Age Using MRI: A Validation and Reliability Study

Background:

Bone-age determination remains a difficult process. An atlas for bone age has been created from knee-ossification patterns on magnetic resonance imaging (MRI), thereby avoiding the need for radiographs and associated costs, radiation exposure, and clinical inefficiency. Shorthand methods for bone age can be less time-consuming and require less extensive training as compared with conventional methods.

Purpose:

To create and validate a novel shorthand algorithm for bone age based on knee MRIs that could correlate with conventional hand bone age and demonstrate reliability across medical trainees.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Included in this study were adolescent patients who underwent both knee MRI and hand bone age radiographs within 90 days between 2009 and 2018. A stepwise algorithm for predicting bone age using knee MRI was developed separately for male and female patients, and 7 raters at varying levels of training used the algorithm to determine the bone age for each MRI. The shorthand algorithm was validated using Spearman rho (r_S) to correlate each rater’s predicted MRI bone age with the recorded Greulich and Pyle (G&P) hand bone age. Interrater and intrarater reliability were also calculated using intraclass correlation coefficients (ICCs).

Results:

A total of 38 patients (44.7% female) underwent imaging at a mean age of 12.8 years (range, 9.3-15.7 years). Shorthand knee MRI bone age scores were strongly correlated with G&P hand bone age (r_S = 0.83; P < .001). The shorthand algorithm was a valid predictor of G&P hand bone age regardless of level of training, as medical students (r_S = 0.75), residents (r_S = 0.81), and attending physicians (r_S = 0.84) performed similarly. The interrater reliability of our shorthand algorithm was 0.81 (95% CI, 0.73-0.88), indicating good to excellent interobserver agreement. Respondents also demonstrated consistency, with 6 of 7 raters demonstrating excellent intrarater reliability (median ICC, 0.86 [range, 0.68-0.96]).

Conclusion:

This shorthand algorithm is a consistent, reliable, and valid way to determine skeletal maturity using knee MRI in patients aged 9 to 16 years and can be utilized across different levels of orthopaedic and radiographic expertise. This method is readily applicable in a clinical setting and may reduce the need for routine hand bone age radiographs.

Do Pediatric Patients With Anterior Cruciate Ligament Tears Have a Higher Rate of Familial Anterior Cruciate Ligament Injury?

Background:

Several studies have examined the anterior cruciate ligament (ACL) injury history among relatives of patients undergoing ACL reconstruction (ACLR), but they have primarily analyzed adults with variable results.

Hypothesis:

We hypothesized that he rate of familial ACL injuries among pediatric patients with ACL tears would be greater than that among pediatric patients with uninjured knees.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Pediatric patients (≤18 years of age) who underwent ACLR between January 2009 and May 2016 were contacted to complete a questionnaire on subsequent complications and family history of ACL tears. A control cohort was recruited from children with uninjured knees seen in the concussion clinic of our institution. Binary logistic regression was used to determine the factors predictive of having a familial ACL tear history or complications.

Results:

Overall, 450 pediatric patients with primary ACL tears were included. Age at the time of surgery was 14.9 ± 2.2 years with a follow-up of 4.3 ± 2.1 years. When compared with 267 control patients, those with an ACL tear reported a higher rate of first-degree relatives with an ACL injury history (25.1% vs 12.0%; P < .001). In multivariate analysis, children with ACL injury had nearly 3 times (odds ratio [OR], 2.7) higher odds of having a first-degree relative with an ACL tear (95% CI, 1.7-4.2; P < .001). Patients were stratified by the number of first-degree relatives with ACL tears: no relatives, 1 relative, or ≥2 relatives. Children with ≥2 first-degree relatives were more likely to sustain a postoperative graft failure (OR, 5.1; 95% CI 1.7-15.2; P = .003) or a complication requiring surgical intervention (OR, 7.5; 95% CI, 2.6-22.0; P < .001).

Conclusion:

A family history of ACL injury is more likely in pediatric patients with ACL tears than in uninjured children. Further, patients undergoing primary ACLR as well as a strong family history of ACL tears are more likely to sustain a postoperative graft rupture or complication requiring surgery.

Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections

BACKGROUND

The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health-care institutions. The identification of infected individuals is vital to prevent the spread of illness to staff and other patients as well as to identify those who may be at risk for disease-related complications. This is particularly relevant with the resumption of elective orthopaedic surgery around the world. We report the results of a universal testing protocol for COVID-19 in patients undergoing orthopaedic surgery during the coronavirus pandemic and to describe the postoperative course of asymptomatic patients who were positive for COVID-19.

METHODS

A retrospective review of adult operative cases between March 25, 2020, and April 24, 2020, at an orthopaedic specialty hospital in New York City was performed. Initially, a screening questionnaire consisting of relevant signs and symptoms (e.g., fever, cough, shortness of breath) or exposure dictated the need for nasopharyngeal swab real-time quantitative polymerase chain reaction (RT-PCR) testing for all admitted patients. An institutional policy change occurred on April 5, 2020, that indicated nasopharyngeal swab RT-PCR testing for all orthopaedic admissions. Screening and testing data for COVID-19 as well as relevant imaging, laboratory values, and postoperative complications were reviewed for all patients.

RESULTS

From April 5, 2020, to April 24, 2020, 99 patients underwent routine nasopharyngeal swab testing for COVID-19 prior to their planned orthopaedic surgical procedure. Of the 12.1% of patients who tested positive for COVID-19, 58.3% were asymptomatic. Three asymptomatic patients developed postoperative hypoxia, with 2 requiring intubation. The negative predictive value of using the signs and symptoms of disease to predict a negative test result was 91.4% (95% confidence interval [CI], 81.0% to 97.1%). Including a positive chest radiographic finding as a screening criterion did not improve the negative predictive value of screening (92.5% [95% CI, 81.8% to 97.9%]).

CONCLUSIONS

A protocol for universal testing of all orthopaedic surgery admissions at 1 hospital in New York City during a 3-week period revealed a high rate of COVID-19 infections. Importantly, the majority of these patients were asymptomatic. Using chest radiography did not significantly improve the negative predictive value of screening. These results have important implications as hospitals anticipate the resumption of elective surgical procedures.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An In-Depth Analysis of Graft Rupture and Contralateral Anterior Cruciate Ligament Rupture Rates After Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

Reported rates of graft rupture and contralateral anterior cruciate ligament (ACL) rupture after ACL reconstruction (ACLR) are higher among pediatric patients than adults. Previous series may have underestimated postoperative event risk because of small sample sizes and high proportions of dropouts.

PURPOSE

To calculate rates of graft rupture and contralateral ACL rupture after ACLR in a large pediatric series.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

ACLRs performed in our tertiary care children's hospital system over a period of >7 years were identified through billing review. Cases were sorted based on operative technique, with all-epiphyseal ACLRs considered separately. Transphyseal ACLRs were divided into 2 groups based on patient age, with a cutoff of 16 years. Clinic follow-up data as well as prospectively collected survey data were used to note graft rupture and contralateral ACL rupture events. Rates of graft rupture and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis.

RESULTS

The final data set included 996 patients. A total of 161 patients underwent all-epiphyseal ACLR. Of the remaining transphyseal surgeries, 504 patients were <16 years of age at the time of surgery and 331 were ≥16 years. The 4-year cumulative rate of graft rupture via Kaplan-Meier survival analysis was 19.7% among all patients. The rate was 18.2% among all-epiphyseal ACLRs, 21.6% among transphyseal ACLRs in patients <16 years, and 16.4% among transphyseal ACLRs in patients ≥16 years (P = .855). Survival analysis estimated the 4-year cumulative rate of contralateral ACL rupture at 12.0% among all patients: 6.63% among all-epiphyseal ACLRs, 15.7% among transphyseal ACLRs in patients <16 years, and 8.05% among transphyseal ACLRs in patients ≥16 years (P = .093).

CONCLUSION

This is the largest series of pediatric ACLRs yet reported, and it shows that the risks of another ACL injury after first-time ACLR are higher than previously reported. The risk of contralateral ACL rupture was lower than that for graft rupture. Our methods, including prospective follow-up surveys and survival analysis to generate cumulative rate estimates, provide a best-practice example for future case series calculations. Our results provide insight into the postoperative course of pediatric patients undergoing ACLR and are crucial for preoperative patient and family counseling. Understanding these risks may also influence return-to-play decisions.

Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria

BACKGROUND

Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated.

PURPOSE

To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation.

STUDY DESIGN

Economic and decision analysis.

METHODS

A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation.

RESULTS

The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%.

CONCLUSION

The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up-as well as advanced testing goals upon which RTP is contingent-to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis.

CLINICAL RELEVANCE

This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.

Which Children Are at Risk for Contralateral Anterior Cruciate Ligament Injury After Ipsilateral Reconstruction?

BACKGROUND

Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction.

METHODS

After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival.

RESULTS

A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01).

CONCLUSIONS

After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years.

LEVEL OF EVIDENCE

Level III-prognostic study.

Pediatric ACL Reconstruction and Return to the Operating Room: Revision Is Less Than Half of the Story

BACKGROUND

Although there are several causes of unplanned return to the operating room (RTOR) following pediatric anterior cruciate ligament (ACL) reconstruction (ACLR), prior outcomes studies focus primarily on the risk of graft failure. We sought to comprehensively describe indications for RTOR in pediatric primary ACLR patients, estimate associated rates of RTOR, and assess the impact of concomitant meniscal procedures on these rates.

METHODS

This retrospective cohort study considered patients who underwent primary ACLR at an urban, pediatric tertiary care hospital between 2013 and 2015. Cohorts were defined based on the presence or absence of a concomitant surgical meniscal procedure with the index ACLR. The primary outcome was RTOR for an indication pertaining to ACLR or a potential predilection for knee injury. Cases of RTOR were cataloged and classified according to indication. Survival analyses were performed using the Kaplan-Meier estimation and competing-risks regression. Comparisons of any-cause RTOR rates were done using log-rank tests.

RESULTS

After exclusion criteria were applied, 419 subjects were analyzed. RTOR indications were organized into 5 categories. The overall rate for any RTOR by 3 years after surgery was 16.5%. Graft failure and contralateral ACL tear were the most common indications for RTOR, with predicted rates of 10.3% and 7.1%, respectively. ACL graft failure accounted for less than half of RTOR cases cataloged. Patients who had a concomitant meniscus procedure had lower rates of RTOR.

CONCLUSIONS

Approximately 1 in 6 pediatric ACLR patients underwent ≥1 repeat surgery within 3 postoperative years for indications ranging from wound breakdown to contralateral ACL rupture. While previous studies revealed high rates of complication after pediatric ACLR due primarily to graft failure, we found that re-tear is responsible for less than half of the 3-year RTOR risk. As almost half of re-tears in our sample occurred before clearance to return to full activities, we suspect that the high rate of complication is largely attributable to pediatric patients' high activity levels and difficulties adhering to postoperative restrictions. Early treatment of meniscus pathology may reduce rates of RTOR.

LEVEL OF EVIDENCE

Level III-therapeutic.

Extended Antibiotic Prophylaxis May Be Linked to Lower Peri-prosthetic Joint Infection Rates in High-Risk Patients: An Evidence-Based Review

In 2018, Inabathula et al. published the results of a historical control study examining 90-day peri-prosthetic joint infection (PJI) rates at a single center before and after the institution of an extended post-operative oral antibiotic protocol for high-risk total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. In the study, "Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate" (J Bone Joint Surg Am. 2018;100[24]:2103-2109), the authors considered any one of several patient-related criteria-including diabetes, a body mass index of 35 kg/m² or higher, or active smoking-as sufficient to designate a patient "high risk" for PJI. Before the extended antibiotic therapy protocol was instituted, PJI rates for primary THA and TKA in the high-risk subgroup were 4.3% and 2.1%, respectively. After it was instituted, the respective rates dropped to 1.1% and 0.4%, comparable to those seen in the non-high-risk patients treated using standard peri-operative prophylaxis. After adjusting for patient factors, regression analysis showed that high-risk patients receiving only peri-operative antibiotics were more likely to develop PJI than high-risk patients receiving the extended antibiotic protocol. Although these results suggest possible benefits of extended antibiotic prophylaxis in arthroplasty, methodologic limitations and inadequate discussion of potential drawbacks of widespread adoption of such protocols limit the impact of the findings. Future research is warranted to more narrowly define risk factors for PJI and to demonstrate the safety and efficacy of extended antibiotics in reducing the long-term burden of PJI.

Releasing the tether: Weight normalization following corrective spinal fusion in cerebral palsy

PURPOSE

Feeding difficulties are common among patients with cerebral palsy (CP) and neuromuscular (NM) scoliosis. We theorize that posterior spinal fusion (PSF) reduces intra-abdominal pressure, resulting in improved feeding and subsequent weight gain. We hypothesized that, among nonambulatory patients with CP and NM scoliosis, we would observe significant gain in weight following PSF.

METHODS

Fifty subjects with nonambulatory CP who underwent PSF for NM scoliosis were included. Age and weight were recorded for the preoperative year; on the day of surgery; and at 6-month, 1-year, and 2-year follow-up. Weights were converted to weight percentiles using CP-specific growth charts. The weight percentile distributions were compared between time points using descriptive statistics as well as regression analysis.

RESULTS

The average change in weight from the day of surgery to 2-year follow-up was +3.4 percentiles. Patients who started out under the 50th percentile gained an average of 17.3 percentiles in the first year after PSF ( p = 0.009). Regression analysis showed that patients with baseline weight <50th percentile tended to gain in weight percentile over the first postoperative year ( β = 1.990, p = 0.001). No trend was present among this group prior to surgery ( p = 0.692) or during the second postoperative year ( p = 0.945). No trends were noted prior to or after surgery for patients with baseline weights ≥50th percentile. No significant association was observed between curve severity (measured by preoperative Cobb angle) and weight change.

CONCLUSIONS

This series is the first to document significant weight gain after PSF for NM scoliosis, supporting the theory that spinal correction improves digestive function.

LEVEL OF EVIDENCE

Prognostic level II.

The Association of Clavicle Fracture With Brachial Plexus Birth Palsy

PURPOSE

Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP.

MATERIALS AND METHODS

The 1997 to 2012 Kids' Inpatient Database (KID) was analyzed for this study. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups.

RESULTS

The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5-121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1).

CONCLUSIONS

This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Operative Reduction for Developmental Dysplasia of the Hip: Epidemiology Over 16 Years

BACKGROUND

The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations.

METHODS

The Healthcare Utilization Project Kids' Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates.

RESULTS

An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018).

CONCLUSIONS

The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH.

LEVEL OF EVIDENCE

Level III.

Use of Continuous Passive Motion Reduces Rates of Arthrofibrosis After Anterior Cruciate Ligament Reconstruction in a Pediatric Population

Joint immobilization after anterior cruciate ligament (ACL) reconstruction may lead to intra-articular adhesions and range of motion deficits. Some practitioners thus advocate for the use of postoperative continuous passive motion (CPM) machine protocols. However, previous studies have failed to show CPM to be effective in increasing postoperative range of motion. Continuous passive motion has, however, been shown to reduce rates of arthrofibrosis requiring manipulation under anesthesia (MUA) in adult populations. To date, there has been no study of the efficacy of CPM after ACL reconstruction in a pediatric population. This was a retrospective cohort study of pediatric patients (age <20 years) who underwent primary ACL reconstruction at an urban tertiary care children's hospital. Clinically significant arthrofibrosis was defined as reduced knee flexion requiring MUA within 6 months of surgery. The final dataset included 163 patients. There was no significant difference between cohorts in range of motion at the 1-week, 1-month, 3-month, and 6-month time points (P=.137, .695, .897, and .339, respectively). The 2 cohorts also did not differ significantly in pain scores at these time points (P=.684, .623, .507, and 1.000, respectively). At 3 and 6 months, neither quadriceps nor hamstrings strength differed significantly between cohorts. Four patients (7.4%) in the no-CPM cohort required MUA for arthrofibrosis within 6 months of surgery, while no patients in the CPM cohort required MUA (P=.023). This suggests that CPM use reduces arthrofibrosis requiring MUA in pediatric patients after ACL reconstruction. Future work may better define the clinical utility and cost-effectiveness of CPM in rehabilitation after these surgeries. [Orthopedics. 2019; 42(1):e81-e85.].

How Does Obesity Impact Pediatric Anterior Cruciate Ligament Reconstruction?

PURPOSE

To assess the relationship of elevated body mass index (BMI) on postoperative outcomes, including graft rupture, contralateral anterior cruciate ligament (ACL) tear, new meniscus injuries, isokinetic strength testing, and range of motion (ROM) in a large group of pediatric patients. We also sought to calculate the risk of graft rupture in overweight patients with small femoral or tibial tunnels. The secondary objective was to evaluate the association between BMI and concurrent meniscus tears and the need for meniscectomy at the time of primary ACL reconstruction.

METHODS

We retrospectively reviewed all pediatric patients undergoing primary ACL reconstruction at our institution. BMI percentile for age was used to categorize children as having normal BMI or being overweight or obese per Centers for Disease Control and Prevention guidelines. Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral ACL tear, and meniscus injuries), ROM, and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, logistic regression to control for confounders.

RESULTS

Of the 1,056 patients included, 535 (50.7%) were male and 521 were (49.3%) female, with a mean age of 15.1 ± 2.4 years. The average BMI was 23.1 ± 4.7. There were 675 (63.9%) children with normal BMI, 228 (21.6%) who were overweight, and 153 (14.5%) who were obese. In multivariate analysis, children with elevated BMI had a higher rate of concurrent meniscus tears compared with those with normal BMI (76.3% vs 70.2%; P = .02) and 1.6 times higher odds of requiring a meniscectomy (95% confidence interval, 1.2-2.2; P < .01). The 723 patients included in the analysis of postoperative complications had a mean follow-up duration of 26.2 ± 3.3 months Postoperatively, BMI did not impact the rate of graft rupture, contralateral ACL injury, or new meniscus tears. There was no increased risk of graft failure in overweight children with smaller graft size (≤8 mm). There was no clinically relevant difference in postoperative ROM or isokinetic strength testing.

CONCLUSIONS

After ACL rupture, overweight and obese children sustained more overall meniscus tears and more irreparable meniscus tears than those with normal BMI. Graft size did not impact the risk of early graft failure in overweight patients. With an appropriate rehabilitation protocol, there was no increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in early follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Prophylactic Tibial Stem Fixation in the Obese: Comparative Early Results in Primary Total Knee Arthroplasty

Purpose

Obesity is a risk factor for aseptic loosening after total knee arthroplasty (TKA). Prophylactic use of tibial stems may enhance tibial fixation in obese patients. The aim of this study was to determine whether a tibial stem extension decreases rates of early failure in obese patients.

Materials and Methods

This study included 178 consecutive primary TKAs (143 patients) with a body mass index ≥35 kg/m². Fifty TKAs were performed with the use of a 30 mm tibial stem extension, and 128 TKAs were performed with a standard tibial component. Patients with two-year clinical follow-up were included. The primary outcome was revision for aseptic loosening. Secondary outcomes were all-cause revision and radiolucent lines (RLLs) on radiographs.

Results

Average follow-up was 34 months (range, 24 to 46 months). No failures for aseptic loosening occurred. The occurrence of secondary procedures was not significantly different between groups. Quantification of RLLs revealed no difference between groups.

Conclusions

At early follow-up, no difference was measured in revision rates, need for subsequent procedures, or RLLs between groups.

Uncemented Tantalum Monoblock Tibial Fixation for Total Knee Arthroplasty in Patients Less Than 60 Years of Age: Mean 10-Year Follow-up

BACKGROUND

Although tibial component loosening has been considered a concern after total knee arthroplasty without cement, such implants have been used in younger patients because of the potential for ingrowth and preservation of bone stock. However, mid-term and long-term studies of modern uncemented implants are lacking. We previously reported promising prospective 5-year outcomes after using an uncemented porous tantalum tibial component in patients who underwent surgery before the age of 60 years. The purpose of this study was to determine clinical and radiographic implant survivorship at 10 years in this large series of young patients.

METHODS

The original cohort included 79 patients (96 knees) who were <60 years old at the time of surgery. All procedures were performed with an uncemented, posterior-stabilized femoral component and a porous tantalum monoblock tibial component by 1 high-volume arthroplasty surgeon at a single institution. Patients were followed prospectively. The Knee Society Score (KSS), radiographic findings, and any complications or revisions were recorded.

RESULTS

At the latest follow-up, 76% (60) of the 79 patients (74% [71] of the 96 knees) were available for evaluation or had undergone revision (n = 6); 7 patients had died with the implants in place, and 12 patients were lost to follow-up. The average follow-up for the available implants was 10 years (range, 8 to 12 years). There were no progressive radiolucencies on radiographic review. The mean functional KSS was 68 points (range, 0 to 100 points). All revisions were for reasons unrelated to tibial fixation: femoral component loosening (1), stiffness (1), pain and swelling (2), and instability (2). The all-cause revision rate was 6% (6 of 96 knees).

CONCLUSIONS

Uncemented porous tantalum monoblock tibial components provided reliable fixation, excellent radiographic findings, and satisfactory functional outcomes at a mean of 10 years postoperatively. We identified no cases of tibial component loosening. These promising clinical and radiographic results support the use of uncemented tibial components. Such implants may produce well-integrated, durable long-term constructs in young patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Challenges in the Management of Anterior Cruciate Ligament Ruptures in Skeletally Immature Patients

Although initially considered rare, anterior cruciate ligament (ACL) ruptures in pediatric patients recently have increased substantially as a result of greater awareness of the injury and increased participation in youth sports. Although pediatric patients with an ACL injury and a clinically stable joint may handle the injury well and return to sports activity without requiring surgical reconstruction, young, active patients with an ACL rupture and an unstable joint may be good candidates for ACL reconstruction to prevent ongoing instability and additional joint damage. ACL reconstruction techniques have been developed to prevent physeal injury in skeletally immature patients. The surgical treatment of skeletally immature patients with an ACL rupture may differ from that of adults with an ACL rupture and presents unique challenges with regard to reconstruction technique selection, graft preparation, rehabilitation, and return to sports activity. Orthopaedic surgeons should understand various physeal-sparing ACL reconstruction techniques and the general challenges associated with the surgical management of ACL ruptures in pediatric patients.

Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.^1-4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.

Online Patient Ratings of Hand Surgeons

PURPOSE

To evaluate factors associated with positive online patient ratings and written comments regarding hand surgeons.

METHODS

We randomly selected 250 hand surgeons from the American Society for Surgery of the Hand member directory. Surgeon demographic and rating data were collected from 3 physician review Web sites (www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com). Written comments were categorized as being related to professional competence, communication, cost, overall recommendation, staff, and office practice. Online presence was defined by 5 criteria: professional Web site, Facebook page, Twitter page, and personal profiles on www.Healthgrades.com and/or www.Vitals.com.

RESULTS

A total of 245 hand surgeons (98%) had at least one rating among the 3 Web sites. Mean number of ratings for each surgeon was 13.4, 8.3, and 1.9, respectively, and mean overall ratings were 4.0 out of 5, 3.3 out of 4, and 3.8 out of 5 stars on www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, respectively. Positive overall ratings were associated with a higher number of ratings, Castle Connolly status, and increased online presence. No consistent correlations were observed among online ratings and surgeon age, sex, years in practice, practice type (ie, private practice vs academics), and/or geographic region. Finally, positive written comments were more often related to factors dependent on perceived surgeon competence, whereas negative comments were related to factors independent of perceived competence.

CONCLUSIONS

Physician review Web sites featured prominently on Google, and 98% of hand surgeons were rated online. This study characterized hand surgeon online patient ratings as well as identified factors associated with positive ratings and comments. In addition, these findings highlight how patients assess care quality.

CLINICAL RELEVANCE

Understanding hand surgeon online ratings and identifying factors associated with positive ratings are important for both patients and surgeons because of the recent growth in physician-rating Web sites.

Abductor muscle necrosis due to iliopsoas bursal mass after total hip arthroplasty

BACKGROUND

While symptomatic iliopsoas bursal lesions have been reported after total hip arthroplasty (THA), mass effect of the collection causing abductor muscle damage has not been reported in the literature.

METHODS AND RESULTS

This report discusses the presentation, clinical findings, and operative management of a patient, status post metal-on-polyethylene THA, with a large psoas bursal collection with resulting abductor muscle injury and deep venous thrombosis from compression of the femoral vein. Despite the improved wear characteristics of modern-generation THA implants, physicians must be aware of the possibility of soft tissue irritation of the iliopsoas as a cause of soft tissue swelling, persistent pain, and potential adverse complications. It is also important to recognize the variety of effects and spectrum of severity for associated lesions, including muscle damage.

CONCLUSIONS

This report highlights the rare findings of abductor muscle necrosis, as well as acute thrombosis, related to iliopsoas bursitis. It also highlights a review of the available literature.