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Background: Significant controversy surrounds ideal tunnel position for medial patellofemoral ligament (MPFL) reconstruction (MPFLR) in the pediatric setting. The start point for femoral tunnel positioning (the Schöttle point) relative to the distal medial femoral physis is not well defined. Previous studies provide conflicting data regarding position of the MPFL origin and the Schöttle point relative to the distal femoral physis. Hypothesis: The Schöttle point would be consistently distal to the distal medial femoral physis. Study Design: Descriptive laboratory study. Methods: The institutional picture archiving and communication system was queried for computed tomography (CT) imaging studies of pediatric knees. Data were imported to an open-source image computing platform. True lateral digitally reconstructed radiographs and 3-dimensional (3D) renderings were generated, and the Schöttle point was registered in 3D space. Then, 3D distance measurements were obtained from the Schöttle point to the distal medial femoral physis. Results: A total of 49 pediatric knee CT scans were included. Mean age was 13.0 ± 2.3 years. Mean minimum distance from the medial physis to the Schöttle point was 9.9 ± 3.0 mm (range, 3.4-16.1 mm). In 49 of 49 cases (100%), the Schöttle point was distal to the physis. Using a 6-mm reaming diameter would result in 3 of 49 (6%) femurs having violation of the distal medial femoral physis. Moving the start point 3 mm distally would result in 0 of 49 (0%) sustaining physeal injury. Conclusion/Clinical Relevance: The Schöttle point is consistently distal to the distal medial femoral physis. The mean minimum distance from the Schöttle point to the physis on the medial cortex is 9.9 mm. The Schöttle point provides a safe and reliable radiographic landmark for pediatric MPFLR, although reaming diameter should be considered.

The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (HPs) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative HP utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery.A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative HP visits within 30 d of surgical procedure were determined. HP and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization.50,775 patients were included with 50.5% having a preoperative HP visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P 0.0001). Preoperative testing was associated with HP visits (57.2% vs 41.4%; P 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in HP visits, utilization remained with significant associations in patients with increased comorbidities.Preoperative HP visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative HP visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

To determine the incidence of screw impingement on dynamic exam during hip arthroscopy in patients undergoing treatment for femoroacetabular impingement after previous slipped capital femoral epiphysis fixation and to evaluate screw characteristics with hardware impingement.A retrospective review from 2008 to 2020 was performed of slipped capital femoral epiphysis (SCFE) patients that underwent arthroscopy for symptoms of hip impingement. Patients underwent a dynamic exam under direct arthroscopic visualization to assess for sources of impingement, including bony anatomy and fixation hardware. Slip angle was calculated on lateral radiographs prior to arthroscopy, and screw length was noted in the initial operative reports at treatment of SCFE and reported in millimeters. Normality of data was assessed using Shapiro-Wilk tests, with statistical analysis performed using independent sampleThirty-nine hips were included, with 13 (33.3%) having screw impingement on dynamic exam. Slip angle was found to be increased in the screw impingement group (42.4° vs 35.5°;Shorter screws (55 mm or less) are at greater risk of causing hardware hip impingement after in situ SCFE fixation. When considering hip arthroscopy for the treatment of femoroacetabular impingement in patients with a previous SCFE, hardware impingement and subsequent hardware removal should be considered in hips with shorter screws and in hips that show objective hardware impingement on dynamic exam.Level IV, therapeutic case series.

Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery.A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression.Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities.While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions.Level IV-prognostic study.