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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.]. [ABSTRACT FROM AUTHOR]

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 twoyear 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. [ABSTRACT FROM AUTHOR]