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Introduction/Purpose: One of the most common injuries in the United States is the ankle sprain, accounting for 10-15% of sport injuries. Without proper treatment, about one-third of patients reinjure the same ankle and can progress to chronic lateral ankle instability. An ankle can be clinically evaluated by performing an inversion stress test and measuring the degree of varus tilt. The purpose of this retrospective chart review was to examine if a correlation exists between the degree of varus tilt on a stress x-ray and whether the patients were treated conservatively or surgically. Additionally, this chart review aims to confirm the validity of the guidelines of an abnormal talar tilt value, which is said to be a value greater than 10 degrees. Methods: A total of 584 patients between January 1st, 2016 and June 27th, 2019 were clinically diagnosed with lateral ankle instability and had an inversion stress x-ray. All 584 patients were seen and diagnosed by the same foot and ankle orthopedic surgeon in Columbus, Ohio. Of the 584 patients, 40 had bilateral lateral ankle instability and bilateral stress xrays, given a total of 624 ankles originally included in this chart review. Once the patient's charts were reviewed, 32 ankles were excluded because their ankle surgery did not involve correction of the lateral ankle instability. A total of 592 ankles (293 left and 299 right) were included in this review. The degree of varus tilt on all 592 ankles were determined by measuring the angle between the tibial plafond and the top of the talus. The angles were compared to the patients with surgical and conservative treatment. Results: The chart review showed that as the degree of varus tilt increases, the more likely the patient is to fail conservative treatment and need surgical correction. The types of conservative treatment that the patients failed were a combination of a brace, boot, physical therapy, orthotics, shoe changes, injection, and casting. The patients who had a varus tilt below 2.5 degrees were treated conservatively 60% of the time, where patients that had a varus tilt over 20.1 degrees were treated surgically 75% of the time. The review also showed a significant number of patients who were treated surgically with a varus tilt value less than 10 degrees (209 of 472 ankles), warranting further evaluation into what is considered an abnormal talar tilt. Conclusion: It is clear that patients with a higher degree of varus tilt have more ankle instability and are more likely to fail conservative treatment and require surgical correction. Additionally, this chart review showed that many patients needed surgical correction even with a low varus tilt value on stress x-ray. Further evaluation needs to be completed to determine what value is considered an abnormal varus tilt. One possible explanation of our findings is that the inversion stress test does not evaluate the subtalar joint, which can contribute to chronic lateral ankle instability. [ABSTRACT FROM AUTHOR]

Background: Lateral meniscal deficiency with valgus malalignment increases the rate of lateral compartment osteoarthritis. Lateral meniscal allograft transplantation (LMAT) with a concomitant varus-producing opening-wedge distal femoral osteotomy (DFO) is an option yet to be evaluated biomechanically. Purpose/Hypothesis: The purpose of this study was to clarify the biomechanical effects of the realignment procedure in the setting of LMAT. We hypothesized that (1) given the dependence of the lateral compartment on the lateral meniscus, a DFO and increasing degrees of varus would be insufficient to restore lateral compartment pressures to normal from a lateral meniscus-deficient state, and that (2) LMAT would restore lateral compartment pressures to the intact state while DFO would decrease lateral compartment pressures for any given state of the meniscus. Study Design: Controlled laboratory study. Methods: Ten cadaveric knees underwent opening-wedge varus-producing DFO secured by an external fixator. Anatomic alignment was standardized to 6° of mechanical valgus, and each joint was tested in full extension. Submeniscal placement of thin film pressure sensors allowed for the recording of contact pressure, peak contact pressure, and contact area. The specimens were loaded on a biaxial dynamic testing machine with loading angles between 9° valgus and 6° varus of mechanical alignment. Conditions tested included intact meniscus, meniscal deficiency, and meniscal transplantation. Results: Isolated varus-producing DFO to 6° in the meniscus-deficient state failed to restore joint pressures and contact areas to the intact state, with significant changes in mean contact pressure (175%), mean peak contact pressure (135%), and contact area (–41%) (all P <.05 vs intact), while LMAT restored all outcome measures (all P >.05 compared with intact). After LMAT, every additional 1° of DFO correction contributed to a decrease in the mean contact pressure, peak pressure, and contact area of 5.6% (–0.0479 N/mm2), 5.9% (–0.154 N/mm2), and 1.4% (–6.99 mm2) for the lateral compartment and 7.3% (+0.034 N/mm2), 12.6% (+0.160 N/mm2), and 4.3% (+20.53 mm2) for the medial compartment, respectively. Conclusion: Isolated DFO was inadequate to restore load distribution in meniscus-deficient knees, while concomitant LMAT restored near normal forces and improved the lateral compartment biomechanical profile. Clinical Relevance: Our findings support the concomitant use of LMAT and varus-producing DFO in the setting of lateral meniscal deficiency with valgus malalignment. This study provides tools for the orthopaedic surgeon to individualize the correction for each patient. [ABSTRACT FROM AUTHOR]

The majority of hip arthroplasties in the United States utilize cementless acetabular and femoral components. Despite their similarities, stem geometry can still differ. The purpose of this study is to compare the clinical results of two wedge-type stem designs. A retrospective study of patients who underwent primary THA utilizing a direct anterior approach between January 2016 and January 2017. Two cohorts were established based on femoral stem design implanted. Descriptive patient characteristics and surgical and clinical data was extracted which included surgical time, length of stay (LOS), presence of pain (categorized as groin, hip, or thigh pain) at the latest follow-up, and revisions. Immediate postoperative radiographs were compared with the latest follow-up radiographs to assess limb length discrepancies, stem alignment, and stem subsidence. A total of 544 patients were included. 297 patients received the Group A stem (morphometric) and 247 patients received the Group B stem (flat-tapered). A significantly higher proportion of Group B stems subsided ≥3 mm and were in varus alignment than the Group A design. Additionally, a significantly greater number of patients who received the Group B stem reported postoperative hip and thigh pain. The logistic regression found that the Group B stem was 2.32 times more likely to subside ≥3 mm than the Group A stem. Our study suggests modestly improved radiographic and clinical outcomes and fewer instances of thigh pain, subsidence, and varus alignment in the patients who received the Group Ahip stem. Further studies are warranted to assess long-term significance. [ABSTRACT FROM AUTHOR]

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon's experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a crosssectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. [ABSTRACT FROM AUTHOR]

Purpose: Various implant materials have been used in medial, opening-wedge high tibial osteotomy (HTO) including traditional metal and modern polyetheretherketone (PEEK) implants. The purpose of this study was to compare metal and PEEK implants and determine safety, varus deformity correction, as well as short- to mid-term hardware removal and arthroplasty rates.Methods: HTO performed with metal and PEEK implants were reviewed between 2000 and 2015 at two institutions with a minimum of 2 years follow-up. Postoperative complications, radiographic measures, and osteotomy union were compared between groups using Kruskal-Wallis and Fisher's exact testing. Survival free of hardware removal and arthroplasty was compared between groups using Kaplan-Meier testing. Risk factors for HTO conversion to arthroplasty were examined using Cox proportional hazards regression.Results: Ninety-five HTOs were performed in 90 patients (59 M, 31 F) using 50 metal and 45 PEEK implants. Mean follow-up was 4.2 years (range 2.0-16.5). Two metal and two PEEK HTO patients experienced nonunions, resulting in revision HTO at a mean of 1.0 years postoperatively (range 0.4-1.4 years). Both implant groups demonstrated similar, significant improvements in coronal deformity, with mean angulation improving from 6.0° and 5.4° varus preoperatively to 1.1° and 1.0° valgus postoperatively for the metal (p < 0.01) and PEEK groups (p < 0.01), respectively. 2- and 5-year hardware removal-free survival was 94% and 94% for PEEK, which was significantly superior to 80% and 73% observed for metal (p = 0.02). 2- and 5-year arthroplasty-free survival was similar for the metal (98% and 94%) and PEEK groups (100% and 78%) (n.s.). HTO performed for focal cartilage defects was observed to demonstrate decreased arthroplasty risk (HR 0.36, p = 0.03) when compared to HTO performed for osteoarthritis.Conclusions: Both metal and PEEK implants were found to be effective in obtaining and maintaining coronal varus deformity correction, with 88% overall arthroplasty-free survival at 5 years. Metal fixation demonstrated a higher rate of hardware removal while HTO performed for medial compartment osteoarthritis predicted conversation to arthroplasty.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Baseball pitchers employ various contralateral trunk tilt (CTT) positions when pitching depending on if they have an overhand, three-quarter, or sidearm delivery. There are no known studies that have examined how pitching biomechanics are significantly different in professional pitchers with varying amounts of CTT, which may provide insight into shoulder and elbow injury risk among pitchers with different CTT. Purpose: To assess differences in shoulder and elbow forces and torques and baseball pitching biomechanics in professional pitchers with maximum 30° to 40° CTT (MaxCTT), moderate 15° to 25° CTT (ModCTT), and minimum 0° to 10° CTT (MinCTT). Study Design: Controlled laboratory study. Methods: In total, 215 pitchers were examined, including 46 pitchers with MaxCTT, 126 pitchers with ModCTT, and 43 pitchers with MinCTT. All pitchers were tested using a 240-Hz, 10-camera motion analysis system, and 37 kinematic and kinetic parameters were calculated. Differences in kinematic and kinetic variables among the 3 CTT groups were assessed with a 1-way analysis of variance (P <.01). Results: Maximum shoulder anterior force and maximum elbow proximal force were significantly greater in ModCTT (403 ± 79 N) than MaxCTT (369 ± 75 N) and MinCTT (364 ± 70 N), while maximum elbow flexion torque and shoulder proximal force, respectively, were significantly greater in ModCTT (69 ± 11 N·m and 1176 ± 152 N, respectively) than MaxCTT (62 ± 12 N·m and 1085 ± 119 N, respectively). During arm cocking, maximum pelvis angular velocity was greater in MinCTT than MaxCTT and ModCTT, and maximum upper trunk angular velocity was greater in MaxCTT and ModCTT than MinCTT. At ball release, trunk forward tilt was greater in MaxCTT and ModCTT than MinCTT and greater in MaxCTT than ModCTT, while arm slot angle was less in MaxCTT and ModCTT than MinCTT and less in MaxCTT than ModCTT. Conclusion: The greatest shoulder and elbow peak forces occurred in ModCTT, which occurs in pitchers who throw with a three-quarter arm slot. More research is needed to assess if pitchers with ModCTT are at a higher risk of shoulder and elbow injury compared with pitchers with MaxCTT (overhand arm slot) and MinCTT (sidearm arm slot), although in the pitching literature, excessive elbow and shoulder forces and torques have been shown to correlate with elbow and shoulder injuries. Clinical Relevance: The results from the current study will help clinicians better understand if differences in kinematic and kinetic measures differ with pitching, or if differences in force, torque, and arm position occur at different arm slots. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis is common and debilitating, in part because it often affects more than one large weightbearing joint. The likelihood of undergoing more than one total joint arthroplasty has not been studied in a heterogeneous, multicenter population in the United States.Questions/purposes: We used prospectively collected data of patients with osteoarthritis from the multicenter Osteoarthritis Initiative (OAI) project to ask (1) What is the likelihood of a subsequent THA or TKA after primary TKA or THA? (2) What risk factors are associated with undergoing contralateral TKA after primary TKA?Methods: Longitudinally maintained data from the OAI were used to identify 332 patients who underwent primary TKA and 132 patients who underwent primary THA for osteoarthritis who did not have a previous TKA or THA in this retrospective study. OAI was a longitudinal cohort study of knee osteoarthritis conducted at five centers in the United States (Columbus, OH, USA; Pittsburgh, PA, USA; Baltimore, MD, USA; Pawtucket, RI, USA; and San Francisco, CA, USA). In this study, the mean follow-up time was 4.0 ± 2.3 years, with 24% (112 of 464) followed for less than 2 years. The primary outcome was the cumulative incidence of subsequent arthroplasty calculated using the Kaplan-Meier method. Age, BMI, gender, and contralateral Kellgren-Lawrence grade, medial joint space width, and hip-knee-ankle angles were modeled as risk factors of contralateral TKA using Cox proportional hazards.Results: Using the Kaplan-Meier method, at 8 years the cumulative incidence of contralateral TKA after the index TKA was 40% (95% CI 31 to 49) and the cumulative incidence of any THA after index TKA was 13% (95% CI 5 to 21). The cumulative incidence of contralateral THA after the index THA was 8% (95% CI 2 to 14), and the cumulative incidence of any TKA after index THA was 32% (95% CI 15 to 48). Risk factors for undergoing contralateral TKA were younger age (HR 0.95 for each year of increasing age [95% CI 0.92 to 0.98]; p = 0.001) and loss of medial joint space width with a varus deformity (HR 1.26 for each 1 mm loss of joint space width at 1.6 varus [1.06 to 1.51]; p = 0.005).Conclusion: Patients who underwent TKA or THA for osteoarthritis had a high rate of subsequent joint arthroplasties in this study conducted at multiple centers in the United States. The rate of subsequent joint arthroplasty determined in this study can be used to counsel patients in similar settings and institutions, and may serve as a benchmark to assess future osteoarthritis disease-modifying interventions.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Context: Early identification of incoming military personnel at elevated odds for bone stress injury (BSI) is important for the health and readiness of the US military. Design: Prospective cohort study. Methods: Knee kinematic data of the incoming US Military Academy cadets were collected while performing a jump-landing task (The Landing Error Scoring System) using a markerless motion capture system and depth camera. Data on incidence of lower-extremity injury, including BSI, were collected throughout the study period. Results: A total of 1905 participants (452 females, 23.7%) were examined for knee valgus and BSI status. A total of 50 BSI occurred during the study period (incidence proportion = 2.6%). The unadjusted odds ratio for BSI at initial contact was 1.03 (95% confidence interval [CI], 0.94–1.14; P =.49). Adjusted for sex, the odds ratio for BSI at initial contact was 0.97 (95% CI, 0.87–1.06; P =.47). At the instant of maximum knee-flexion angle, the unadjusted odds ratio was 1.06 (95% CI, 1.02–1.10; P =.01), and the odds ratio was 1.02 (95% CI, 0.98–1.07; P =.29) after adjusting for sex. This suggests that there was not a significant enough association for an increase in the odds of BSI based on either degree of knee valgus. Conclusions: Our results did not demonstrate an association between knee valgus angle data during a jump-landing task and future increased odds of BSI in a military training population. Further analysis is warranted, but the results suggests the association between kinematics and BSI cannot be effectively screened by knee valgus angle data in isolation. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) injury in youth can lead to expensive treatment, lengthy rehabilitation, and long-term impairment. Injuries to the ACL are more common in adolescents who participate in organized sports. Purpose: To examine whether there is an association between age, physical activity patterns, pubertal timing (Tanner stage), or body mass index (obesity/overweight status) and the risk of developing an ACL injury in youth. Study Design: Cohort study; Level of evidence, 2. Methods: Data from the Growing Up Today Study (GUTS), a prospective cohort study of youth throughout the United States, were used in this study. From 1996 to 2003, questionnaires were sent to GUTS participants every 12 to 18 months to assess a variety of self-reported factors; in a related 2004 questionnaire, ACL tears and other diagnoses among the participants were reported. Cox proportional hazard models were run to determine the sex-specific association of activity patterns and pubertal timing with risk of developing an ACL tear. Results: A total of 4519 boys and 5622 girls (age: 9-15 years) were included, with 2.4% and 2.0% sustaining an ACL injury, respectively. Age was found to be a significant risk factor for ACL injury in both sexes (male: hazard ratio [HR] = 1.30 [95% CI, 1.14-1.48]; female: HR = 1.23 [95% CI, 1.10-1.38]). Mean hours per week engaged in vigorous activity was also predictive of a higher risk of ACL injury (male: HR = 1.04 [95% CI, 1.01-1.08]; female: HR = 1.10 [95% CI, 1.07-1.14]). The sports that were the most predictive of injury were running, basketball, soccer, and cheerleading/gymnastics in girls and running, football, and karate/martial arts in boys. Additionally, in boys, overweight/obese status was found to be a significant predictor of ACL injury (HR = 2.61 [95% CI, 1.60-4.26]). Furthermore, among 9- to 13-year-old girls, advanced Tanner stage was a strong predictor of injury risk (HR = 2.43 [95% CI, 1.10-5.36]). Conclusion: Age, time engaged in vigorous activity, overweight/obese status, and advanced Tanner stage were associated with an increased risk of ACL injury in young adults and adolescents. Further research with follow-up data will help complement this study and continue to highlight the risk factors associated with ACL reconstruction in adolescents and young adults. [ABSTRACT FROM AUTHOR]

Background: The diagnosis of anterior cruciate ligament (ACL) tear relies on clinical evaluation and magnetic resonance imaging (MRI). Direct and indirect signs of ACL tear have been described with MRI evaluation. Posterior cruciate ligament (PCL) buckling has been described as an indirect radiographic sign of an ACL tear. Purpose: The aim of the present study was to assess the variations in PCL buckling angles in patients with ACL tears and in patients with isolated lesions in the posterior horn of the medial meniscus. In addition, the influence of different patterns of medial meniscus tears in ACL-deficient knees was investigated. Finally, the influences of risk factors such as tibial slope, delay from injury to surgery, absence of medial meniscus tear, degree of Lachman and pivot shift testing were also assessed. Study design: This was a cohort study. Methods: A total of 154 patients (78 in the group with ACL tear and 76 in the control group) were assessed with MRI and lateral weight-bearing X-ray to assess PCL buckling angle and tibial slope by two independent observers. The presence of a medial meniscus bucket handle or ramp lesion of the medial meniscus was assessed and recorded at the time of surgery. Results: PCL buckling angle measurement was highly reliable, with an ICC of 0.866 and 0.894, respectively, in the study group and the control group for interobserver reliability. The intrarater reliability was found to be high in PCL buckling angle for the study group [ICC = 0.955] and the control group [ICC = 0.943]. The mean angle in patients with ACL tear was 110.7 ± 15.2° and 115.3 ± 16.2° (for the two examiners) and 111.4 ± 12° and 114 ± 14.5° (for the two examiners) in patients with an intact, healthy ACL. An association emerged between bucket handle tears of the medial meniscus (p = 0.010) and a decreased PCL buckling angle and between ramp lesions of the medial meniscus and increased PCL buckling angle both (p = 0.024). Conclusions: Good inter- and intraobserver reliability for the measurement of the PCL buckling angle was observed. Increased PCL buckling angle values were observed in patients with concomitant ACL and bucket handle tears of the medial meniscus, while decreased angle values were observed in those who had ACL tear and ramp lesion of the medial meniscus. No statistically significant difference in the PCL buckling angle emerged between patients with ACL tears and those who had a healthy, intact ACL. [ABSTRACT FROM AUTHOR]

Presents a case of simultaneous bilateral anterior cruciate ligament (ACL) tears in collegiate gymnast in the U.S. Pathomechanics of ACL tears; Implications of varus instability and anterior shifting of the tibia during Lachman's test; Discussions on associate injuries with ACL tear.

Modular necks in total hip replacement (THR) can be a source of metal ion release. There are no data to date on the level of cobalt and chromium ions in the serum of patients with a cobalt-chrome stem and a titanium modular neck.~Background~Background~Serum ion levels were measured in healthy volunteers with a well-functioning ceramic-on-ceramic THR.~Methods~Methods~Average cobalt in serum was 1.21 µg/l for unilateral THR and 2.2 µg/l for bilateral THR. No patient had cobalt levels higher than 2.4 µg/l. No patient had measurable chromium levels. There were no differences in cobalt levels for hips with short necks versus hips with long necks.~Results~Results~The hybrid THR Profemur® Xm - Procotyl® L with a titanium modular neck on a cobalt-chrome stem design shows no signs of abnormal toxic ion levels (cobalt or chromium) in a randomly selected group of well-functioning hip patients.~Conclusions~Conclusions [ABSTRACT FROM AUTHOR]

Background: Medial meniscus posterior root (MMPR) tears are recognized as a substantial cause of disability and morbidity. However, meniscus root repair, regardless of technique, is not without potential complications. Purpose: To evaluate the reported incidence of complications and adverse events after isolated MMPR repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using Embase, PubMed, and Scopus databases with the following search terms combined with Boolean operators: "meniscus,""root," and "repair." Inclusion criteria consisted of level 1 to 4 human clinical studies in English or English-language translation reporting complications and adverse events after isolated posterior medial meniscus root repairs. The overall incidence of specific complications was estimated from the pooled sample of the included studies. Results: Eleven studies with a total pooled sample of 442 patients were identified. The mean patient age was 58.1 years, while the mean final follow-up time was 37.2 months (range, 12-84.8 months). The overall incidence of complications was 9.7% (n = 43/442), with the most commonly reported complication being progressive degenerative changes within the knee (10.4%; n = 25/240; n = 5 studies). A total of 1.25% (n = 3/240) of patients who experienced degenerative changes required conversion to total knee arthroplasty. Repair failures were reported in 3.1% (n = 10/327; n = 8 studies) of patients. Conclusion: Repairing MMPR tears is critical in preventing accelerated progression of knee osteoarthritis in patients without significant knee osteoarthritis preoperatively. While this repair is still recommended and necessary in appropriate patients, this review found that the incidence of complications after isolated posterior medial meniscus root repair was 9.7%, primarily involving the presence of progressive degeneration, while repair failure was reported in 3% of patients. [ABSTRACT FROM AUTHOR]

Objective: This review provides guidance and ideas for researchers through a comprehensive and comparative analysis of the present state, trends, and hotspots in the pediatric fracture literature over the past 6 years. Methods: We used Citespace 6.1.R6 software to explore the country/region distribution, institutions, journals, keyword analysis, and co-cited references of the literature from Web of Science core database. Results: There are 6472 pieces of pediatric fracture–related literature, including 2962 from 2017 to 2019 and 3510 from 2020 to 2022. The country with the most papers is the United States, and US institutions and journals also have a pivotal position in this field. Research hotspots for pediatric fractures in 2017–2019: The topic with the most attention is bone mineral density leading to related bone diseases. Treatment for pediatric fractures, including supracondylar humeral fractures, Monteggia fractures, forearm fractures, knee fractures, and ankle fractures in children, is another topic of greater interest. Brain injuries and dental injuries in children due to abuse and trauma are also concerning issues. Research hotspots for pediatric fractures in 2020–2022: comparison with 2017–2019 revealed a relative decrease regarding ankle-related epiphyseal injuries, but there is a higher focus on the epidemiology of fractures in children, risk factors, and reasons for childhood trauma. We have confirmed through literature co-citations that the literature of high interest is also in these aspects. Conclusion: Researchers and clinicians can quickly learn about topics of interest through authoritative journals and highly cited literature and rapidly master the current status and frontiers of the field through study, providing ideas for future work. [ABSTRACT FROM AUTHOR]

Background: Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies. Methods: The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. Results: Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria. Conclusion: This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered. [ABSTRACT FROM AUTHOR]

Background: High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure. Purpose: To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs. Study Design: Systematic review; Level of evidence, 4. Methods: The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded. Results: A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%). Conclusion: Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure. [ABSTRACT FROM AUTHOR]

Context: Although baseball is a relatively safe sport, numerous reports suggest a rapid rise in elbow injury rate among youth baseball pitchers.Evidence Acquisition: PUBMED WAS SEARCHED FOR EPIDEMIOLOGIC, BIOMECHANICAL, AND CLINICAL STUDIES OF ELBOW INJURIES IN BASEBALL (KEYWORDS: "youth OR adolescent" AND baseball AND pitching AND "ulnar collateral ligament OR elbow"; published January 2000 - April 2012). Studies with relevance to youth baseball pitchers were reviewed. Relevant references from these articles were also retrieved and reviewed. Original data, insight, and recommendations were added.Results: The majority of baseball elbow injuries are noncontact injuries to the dominant arm resulting from repetitive pitching. Five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. The risk factor with the strongest correlation to injury is amount of pitching. Specifically, increased pitches per game, innings pitched per season, and months pitched per year are all associated with increased risk of elbow injury. Pitching while fatigued and pitching for concurrent teams are also associated with increased risk. Pitchers who also play catcher have an increased injury risk, perhaps due to the quantity of throws playing catcher adds to the athlete's arm. Another risk factor is poor pitching biomechanics. Improper biomechanics may increase the torque and force produced about the elbow during each pitch. Although throwing breaking pitches at a young age has been suggested as a risk factor, existing clinical, epidemiologic, and biomechanical data do not support this claim.Conclusions: Some elbow injuries to youth baseball pitchers can be prevented with safety rules, recommendations, education, and common sense. Scientific and medical organizations have published safety rules and recommendations, with emphasis on prevention of overuse and pitching while fatigued. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): A. [ABSTRACT FROM AUTHOR]

The article discusses the study which is aimed to determine the surgical treatment of injury of the posterior cruciate ligament and posterolateral instability in the knee of a 5-year-old boy in the U.S. The boy has suffered from a direct contusion injury to his left knee. He was referred to the clinic three weeks after the accident for persistent pain, knee instability, and a gait abnormality. The examination has revealed that a moderate effusion of the knee accompanied by generalized tenderness, which was evident along the medial and lateral aspects of the joint.

Introduction: A negative correlation exists between functional outcomes and leg length discrepancy (LLD) following hip fracture repair. We have assessed the effects of LLD following hip fracture repair in elderly patients on 3-meter walking time, standing time, activities of daily living (ADL), and instrumental activities of daily living (IADL). Methods: One hundred sixty-nine patients enrolled in the STRIDE trial were identified with femoral neck, intertrochanteric, and subtrochanteric fractures that were treated with partial hip replacement, total hip replacement, cannulated screws, or intramedullary nail. Baseline patient characteristics recorded included age, sex, body mass index Charlson comorbidity index (CCI) score. ADL, IADL, grip strength, sit-to-stand time, 3-meter walking time and return to ambulation status were measured at 1 year after surgery. LLD was measured on final follow-up radiographs by either the sliding screw telescoping distance or the difference from a trans-ischial line to the lesser trochanters, and was analyzed as a continuous variable using regression analysis. Results: Eighty eight patients (52%) had LLD <5 mm, 55 (33%) between 5-10 mm and 26 subjects (15%) >10 mm. Age, sex, BMI, Charlson score, and ambulation status had no significant impact on LLD occurrence. Type of procedure and fracture type did not correlate with severity of LLD. Having a larger LLD was not found to have a significant impact on post-operative ADL (P =.60), IADL (P =.08), sit-to-stand time (P =.90), grip strength (P =.14) and return to former ambulation status (P =.60), but did have a statistically significant impact on 3-meter walking time (P =.006). Discussion: LLD after hip fracture was associated with reduced gait speed but did not affect many parameters associated with recovery. Continued efforts to restore leg length after hip fracture repair are likely to be beneficial. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to describe the frequency and risk factors for orthopedic surgery in patients with achondroplasia. CLARITY (The Achondroplasia Natural History Study) includes clinical data from achondroplasia patients receiving treatment at four skeletal dysplasia centers in the United States from 1957 to 2018. Data were entered and stored in a Research Electronic Data Capture (REDCap) database. Results: Information from one thousand three hundred and seventy-four patients with achondroplasia were included in this study. Four hundred and eight (29.7%) patients had at least one orthopedic surgery during their lifetime and 299 (21.8%) patients underwent multiple procedures. 12.7% (n = 175) of patients underwent spine surgery at a mean age at first surgery of 22.4 ± 15.3 years old. The median age was 16.7 years old (0.1–67.4). 21.2% (n = 291) of patients underwent lower extremity surgery at a mean age at first surgery of 9.9 ± 8.3 years old with a median age of 8.2 years (0.2–57.8). The most common spinal procedure was decompression (152 patients underwent 271 laminectomy procedures), while the most common lower extremity procedure was osteotomy (200 patients underwent 434 procedures). Fifty-eight (4.2%) patients had both a spine and lower extremity surgery. Specific risk factors increasing the likelihood of orthopedic surgery included: patients with hydrocephalus requiring shunt placement having higher odds of undergoing spine surgery (OR 1.97, 95% CI 1.14–3.26); patients having a cervicomedullary decompression also had higher odds of undergoing spine surgery (OR 1.85, 95% CI 1.30–2.63); and having lower extremity surgery increased the odds of spine surgery (OR 2.05, 95% CI 1.45–2.90). Conclusions: Orthopedic surgery was a common occurrence in achondroplasia with 29.7% of patients undergoing at least one orthopedic procedure. Spine surgery (12.7%) was less common and occurred at a later age than lower extremity surgery (21.2%). Cervicomedullary decompression and hydrocephalus with shunt placement were associated with an increased risk for spine surgery. The results from CLARITY, the largest natural history study of achondroplasia, should aid clinicians in counseling patients and families about orthopedic surgery. [ABSTRACT FROM AUTHOR]

Individuals who undergo anterior cruciate ligament reconstruction (ACLR) are at higher risk of posttraumatic osteoarthritis. Altered joint tissue loading caused by aberrant gait biomechanics leads to deleterious changes in joint health linked to the onset of posttraumatic osteoarthritis. Knee braces have been used to modify joint tissue loading in individuals with joint injury, yet the effects of walking with a brace after ACLR on biomechanical, biochemical, and structural cartilage outcomes are unknown. To compare biomechanical, biochemical, and structural outcomes between braced and nonbraced walking in individuals with ACLR. Crossover study. Research laboratory. A total of 34 individuals with unilateral ACLR (18 females, 16 males; time since ACLR = 50.1 ± 36.8 months). Gait biomechanics were assessed during braced and unbraced conditions on separate days. Vertical ground reaction force, knee-flexion angle, and internal knee-extension moment waveforms were evaluated throughout the stance phase and compared between conditions. Percentage changes in serum cartilage oligomeric matrix protein (%ΔCOMP) and femoral cartilage cross-sectional area (%ΔCSA) measured via ultrasound were calculated after a 3000-step walking protocol. Braced walking increased the knee-flexion angle (largest difference = 3.56°; Cohen d effect size = 1.72) and knee-extension moment (largest difference = −0.48% body weight × height; Cohen d effect size = −1.14) compared with nonbraced walking but did not influence vertical ground reaction force. Whereas no difference (P =.20) in %ΔCOMP existed between the braced and nonbraced conditions in the entire cohort (n = 30 with complete blood data), a larger increase (P =.04) in %ΔCOMP was seen during nonbraced than braced walking in individuals who demonstrated increased COMP during nonbraced walking. No difference (P =.86) in %ΔCSA was present between the braced and nonbraced conditions. Braced walking may improve sagittal-plane gait biomechanics and %ΔCOMP in a subset of individuals who demonstrate a typical increased COMP response to load (ie, increase in COMP) after nonbraced walking. [ABSTRACT FROM AUTHOR]

Background: Mechanoreceptors in the posterior cruciate ligament (PCL) can produce proprioception, which is an important reason why patients choose cruciate-retaining total knee arthroplasty (TKA). The number of mechanoreceptors in the PCL of patients with knee osteoarthritis (OA) is unknown. Purpose: To provide a theoretical basis for estimating the number of mechanoreceptors in the PCL by evaluating the relationship between this number and patient age or OA severity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An overall 28 PCLs from patients with knee OA were collected at the time of TKA and grouped according to patient age (group A, 60-69 years [n = 8]; group B, 70-79 years [n = 12]; group C, ≥80 years [n = 8]) and OA based on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (group I, ≤80 [n = 8]; group II, 81-120 [n = 10]; group III, >120 [n = 10]). Hematoxylin and eosin and S-100 immunohistochemical staining were performed on the slices near the tibial attachment of the PCL, and the number of mechanoreceptors in each slice was counted. Multifactor analysis of variance was used to evaluate the relationship between the number of mechanoreceptors and patient age or WOMAC score. Results: The number of mechanoreceptors (mean ± SD) in groups A, B, and C was 24.00 ± 15.19, 30.92 ± 11.41, and 23.38 ± 11.39, respectively, with no significant between-group differences. The number of mechanoreceptors in groups I, II, and III was 43.50 ± 4.99, 25.00 ± 5.27, and 15.20 ± 5.61, with significant differences between groups I and II, groups I and III, and groups II and III (P <.001 for all). Conclusion: In patients with knee OA, age had no significant effect on mechanoreceptor count, but the number of mechanoreceptors in the PCL decreased significantly with higher (worse) WOMAC score. These findings suggest that in patients of any age with high WOMAC scores, there may be little value as it relates to knee proprioception in performing a PCL-retaining TKA. [ABSTRACT FROM AUTHOR]

With the annual incidence of hip fractures and hip fracture fixation rising, the need for conversion total hip arthroplasty has also risen. About half of the 280,000 hip fractures that occur annually in the United States are extracapsular. Commonly extracapsular hip fractures are treated with either cephalomedullary nails (CMNs) or sliding hip screws (SHS). More recently, there has been a shift toward increased CMN use due to increased training with this fixation method as well as perioperative and biomechanical benefits. Given this shift, orthopedic surgeons need to understand the factors that lead to CMN failure. Failed CMN treatment leaves both patients and surgeons with few management options including revision fixation with or without osteotomy, conversion total hip arthroplasty, and conversion hemiarthroplasty. Surgeons must consider the patient and injury characteristics before deciding the best treatment plan. Conversion total hip arthroplasty is indicated in younger patients without femoral head and/or acetabular articular injury, degenerative joint disease, or avascular necrosis. Conversion total arthroplasty is a technically demanding and resource-intensive surgery associated with lower success rates and outcomes than primary total hip arthroplasty. Orthopedic surgeons should have thorough understanding of preoperative workup needed prior to surgery, implant selection associated with best outcomes, most common surgical approaches used, intraoperative considerations, and complications associated with conversion total hip arthroplasty. A comprehensive understanding of these concepts gives patients the best chance of having a successful outcome. [ABSTRACT FROM AUTHOR]

Background: The docking technique is widely used to perform ulnar collateral ligament (UCL) reconstructions because of its high failure torque and reliable clinical outcomes. A double–cortical button technique was recently described, with advantages including the ability to tension the graft at the ulnar and humeral attachments and the creation of single bone tunnels. Purpose/Hypothesis: To compare the biomechanics between the docking and double-button UCL reconstruction techniques using cadaveric specimens. We hypothesized that there would be no difference in postoperative stiffness or maximum strength between the techniques. Study Design: Controlled laboratory study. Methods: Eight matched pairs of cadaveric elbow joints underwent controlled humeral valgus torsion cycles in a test frame. Toe region stiffness, elastic region stiffness, and maximum torque were measured during a 4-step protocol: intact, injured, reconstructed (10 and 1000 cycles), and ramp to failure. Graft strains were calculated using 3-dimensional motion capture. Results: After 10 cycles, intact ligaments from the docking and double-button groups exhibited mean ± SD elastic torsional stiffness of 1.60 ± 0.49 and 1.64 ± 0.35 N·m/deg (P =.827), while docking (1.10 ± 0.39 N·m/deg) and double-button (1.05 ± 0.29 N·m/deg) reconstructions were lower (P =.754). There were no significant differences in maximum torque between the docking (3.45 ± 1.35 N·m) and double-button (3.25 ± 1.31 N·m) groups (P =.777). Similarly, differences in maximum graft strains were not significant between the docking (8.1% ± 7.2%) and double-button (5.5% ± 3.1%) groups (P =.645). The groups demonstrated similar decreases in these measures after cyclic loading. Ramp-to-failure testing showed no significant differences in ultimate torque between the docking (8.93 ± 3.9 N·m) and double-button (9.56 ± 3.5 N·m) groups (P =.739). Conclusion: The biomechanical behavior of the double-button technique was not significantly different from that of the docking technique. Both reconstruction techniques restored joint stability, but neither fully recapitulated preinjury joint stiffness. Clinical Relevance: With its procedural advantages, results preliminarily support the use of the double-button reconstruction technique for UCL reconstruction as a reliable single-tunnel technique for primary or revision cases. [ABSTRACT FROM AUTHOR]

Background: Knee osteoarthritis(KOA) is the most prevalent type of OA and a leading cause of disability in the United States. Falls are a major public health concern in older adults. Our aim was to examine how the severity of radiographic KOA impacts recurrent falls in a cohort of middle and older aged individuals enrolled in the Osteoarthritis Initiative (OAI).Methods: 3,972 participants, mean age of 63 years, 58% female were included. Participants were divided into 5 mutually exclusive groups based on their worst Kellgren-Lawrence grade of radiographic KOA from annual x-rays from baseline to 36-months. Generalized estimating equations for repeated logistic regression were used to model the association between KOA severity and the likelihood of recurrent falls (≥ 2 falls/year) over 5 years follow-up (>36-96 months).Results: Older adults (≥age 65) with KOA were at higher odds of recurrent falls in comparison to individuals without KOA in multivariate models (possible OA OR= 2.22, 95% CI= 1.09-4.52; mild OA OR=2.48, 95% CI= 1.34-4.62; unilateral moderate-severe OA OR= 2.84, 95% CI= 1.47- 5.50; bilateral moderate-severe OA OR= 2.52, 95% CI= 1.13-5.62). Middle aged adults(age 45-64) with KOA did not have increased odds of recurrent falls in comparison to those without KOA except for possible KOA (OR= 1.86, 95% CI=1.01-2.78) (KOA severity*age interaction = 0.025).Conclusions: Older adults with radiographic evidence of KOA have an increased likelihood of experiencing recurrent falls in comparison to those without KOA independent of established risk factors. Our results suggest fall prevention efforts should include older adults with all stages of KOA. [ABSTRACT FROM AUTHOR]

Introduction: A negative correlation exists between functional outcomes and leg length discrepancy (LLD) following hip fracture repair. We have assessed the effects of LLD following hip fracture repair in elderly patients on 3-meter walking time, standing time, activities of daily living (ADL), and instrumental activities of daily living (IADL). Methods: One hundred sixty-nine patients enrolled in the STRIDE trial were identified with femoral neck, intertrochanteric, and subtrochanteric fractures that were treated with partial hip replacement, total hip replacement, cannulated screws, or intramedullary nail. Baseline patient characteristics recorded included age, sex, body mass index Charlson comorbidity index (CCI) score. ADL, IADL, grip strength, sit-to-stand time, 3-meter walking time and return to ambulation status were measured at 1 year after surgery. LLD was measured on final follow-up radiographs by either the sliding screw telescoping distance or the difference from a trans-ischial line to the lesser trochanters, and was analyzed as a continuous variable using regression analysis. Results: Eighty eight patients (52%) had LLD <5 mm, 55 (33%) between 5-10 mm and 26 subjects (15%) >10 mm. Age, sex, BMI, Charlson score, and ambulation status had no significant impact on LLD occurrence. Type of procedure and fracture type did not correlate with severity of LLD. Having a larger LLD was not found to have a significant impact on post-operative ADL (P = .60), IADL (P = .08), sit-to-stand time (P = .90), grip strength (P = .14) and return to former ambulation status (P = .60), but did have a statistically significant impact on 3- meter walking time (P = .006). Discussion: LLD after hip fracture was associated with reduced gait speed but did not affect many parameters associated with recovery. Continued efforts to restore leg length after hip fracture repair are likely to be beneficial. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures. Hypothesis: We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test. Results: In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P =.249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P =.235). Conclusion: Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery. [ABSTRACT FROM AUTHOR]

Objective: Knee replacement (KR) rates are increasing exponentially in the US and straining insurance budgets. This study was undertaken to investigate how many KRs would be prevented at different levels of pain improvement, a major target of osteoarthritis (OA) trials. Methods: We used data from the Osteoarthritis Initiative (OAI) to emulate a trial of knee pain interventions on KR risk changes. We modeled hypothetical 1‐, 2‐ or 3‐unit reductions of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale whenever a person reported a pain score of ≥5 (of 20) in an affected knee at any clinic visit. We used causal inference–based targeted learning to estimate treatment effects for hypothesized pain intervention strategies adjusted for time‐dependent confounding. Sensitivity analyses assessed interventions at WOMAC pain scores of ≥4 and ≥7. Results: Of the 9,592 knees studied (n = 4,796 participants; 58.5% female; baseline age 61.2 years), 40.7% experienced WOMAC pain scores of ≥5. The estimated knee‐level (reference) risk of a KR, adjusted for loss to follow‐up and death, was 6.3% (95% confidence interval 5.0, 7.7%) in the OAI. Reductions of WOMAC pain scores by 1, 2, or 3 units decreased the KR risk from 6.3% to 5.8%, 5.3%, and 4.9%, respectively. Larger reductions in KR risk were achieved when interventions were applied at a WOMAC pain score of ≥4. Conclusion: Modest pain reductions from OA interventions would substantially reduce the number of KRs, with greater reductions achieved when pain decreased more and when interventions were introduced at lower pain levels. [ABSTRACT FROM AUTHOR]

Objective: Insurance expansion under the Affordable Care Act will amplify a projected 6-fold increase in total knee replacement (TKR) utilization by 2030 but will not fully address TKR disparities. Promoting appropriate use of TKR would help reduce disparities and improve outcomes. There are currently no validated appropriateness criteria (AC) for TKR in the US. We evaluated the performance of 2 non-US AC in a cohort of US TKR patients. Methods: AC1 was developed in Spain using the modified Delphi method with 624 patient scenarios. AC2 was developed in Canada using the overall Western Ontario and McMaster Universities Osteoarthritis Index score of >39 as the cutoff point for surgery. These criteria were applied to a random sample of TKR patients enrolled in our institutional registry. Preoperative clinical, radiographic, and patient-reported survey data were used in classifying patients. The rate of appropriateness was compared for the 2 AC. Inappropriate cases were further investigated to determine other mitigating factors beyond the criteria influencing the decision to operate. Results: In total, 508 TKR procedures were evaluated. All patients had osteoarthritic radiographic changes. On the basis of AC1, 7.7% of cases were classified as inappropriate and 11.6% uncertain. On the basis of AC2, 31.5% were classified as inappropriate. Only 4.7% of the cases were classified as inappropriate by both ACs; however, there was poor agreement between the 2 AC (κ = -0.08). Beyond the criteria, failure of nonsurgical treatment and clinically significant valgus/varus deformities influenced the decision for surgery. Conclusion: There was poor agreement between 2 validated AC for TKR when tested in a US population. Culturally specific AC are needed to promote rational use of TKR. [ABSTRACT FROM AUTHOR]

Purpose: Blount disease is most common among obese Black children. The reason for Blount's racial predisposition is unclear. Given that obesity is a risk factor for Blount disease and the known associations between race, obesity, and socioeconomic status in the United States, we hypothesized that socioeconomic status and severity of obesity differ between Black and non-Black children with late-onset Blount disease. We additionally examined differences in treatment types between Black and non-Black children. Methods: One hundred twenty-five patients from two institutions were included. Age at presentation, age of onset, body mass index, race, sex, and treatment type were recorded. These variables were compared between Black and non-Black children. Insurance type and estimated household income were used as markers of socioeconomic status. Results: Of the 125 patients with late-onset Blount disease, body mass index percentiles were higher for Black patients (96th ± 12th percentile) than non-Black patients (89th ± 22nd percentile) (p = 0.04). Black patients also had lower estimated incomes (US$48,000 ± US$23,000 vs US$62,000 ± US$30,000) (p = 0.01) and much higher rates of Medicaid enrollment (69% vs 24%) (p < 0.01) than did non-Black patients. Regarding treatment types, osteotomy was more common among Black patients (60%) than non-Black patients (38%) (p = 0.033). Conclusion: The race-related associations we found between obesity and socioeconomic status suggest that nongenetic factors may contribute to observed racial differences in the prevalence of Blount disease. [ABSTRACT FROM AUTHOR]

Lower extremity bone stress injuries (BSIs) place a significant burden on the health and readiness of the US Armed Forces. To determine if preinjury baseline performance on an expanded and automated 22-item version of the Landing Error Scoring System (LESS-22) was associated with the incidence of BSIs in a military training population. Prospective cohort study. US Military Academy at West Point, NY. A total of 2235 incoming cadets (510 females [22.8%]). Multivariable Poisson regression models were used to produce adjusted incidence rate ratios (IRRs) to quantify the association between preinjury LESS scores and BSI incidence rate during follow-up and were adjusted for pertinent risk factors. Risk factors were included as covariates in the final model if the 95% CI for the crude IRR did not contain 1.00. A total of 54 BSIs occurred during the study period, resulting in an overall incidence rate of 0.07 BSI per 1000 person-days (95% CI = 0.05, 0.09). The mean number of exposure days was 345.4 ± 61.12 (range = 3–368 days). The final model was adjusted for sex and body mass index and yielded an adjusted IRR for a LESS-22 score of 1.06 (95% CI = 1.002, 1.13; P =.04), indicating that each additional LESS error documented at baseline was associated with a 6.0% increase in the incidence rate of BSI during the follow-up period. In addition, 6 individual LESS-22 items, including 2 newly added items, were significantly associated with the BSI incidence. We provided evidence that performance on the expanded and automated version of the LESS was associated with the BSI incidence in a military training population. The automated LESS-22 may be a scalable solution for screening military training populations for BSI risk. [ABSTRACT FROM AUTHOR]

Background: Patients with hallux valgus commonly present with concomitant flatfoot deformity. First-ray hypermobility, among other biomechanical factors, has been suggested as a potential link between these deformities. However, not all hallux valgus patients exhibit symptoms associated with flatfoot deformity, and the necessity of correcting the asymptomatic flatfoot at the time of hallux valgus correction is unclear. We aimed to investigate the relationship between asymptomatic flatfoot and patient-reported and radiographic outcomes after the Lapidus procedure. Methods: This study included 142 patients who underwent the Lapidus procedure for hallux valgus at a single institution. Sixty-one patients met radiographic criteria for flatfoot. No patients exhibited symptoms related to flatfoot deformity on review of clinical notes. Preoperative, minimum 1-year postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores between asymptomatic flatfoot and control groups were compared. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary angle, talonavicular coverage angle (TNCA), and calcaneal pitch (CP) were compared. Results: Preoperatively, the flatfoot group had higher BMI 22.6 vs 24.6 (P < .01) and IMA 15.32 vs 14.0 degrees (P < .05). Both groups demonstrated preoperative to postoperative improvement in PROMIS physical function (P < .01), pain interference (P < .001), pain intensity (P < .001), and global physical health (P < .001). There were no preoperative or postoperative differences in PROMIS scores between groups. Postoperatively, there were no differences in HVA or IMA between groups; however, the flatfoot group exhibited greater deformity in Meary angle, TNCA, and CP (all P < .001). Conclusion: There were no significant postoperative differences in patient-reported outcomes of the Lapidus procedure between patients with and without asymptomatic flatfoot, and both groups achieved similar radiographic correction of their hallux valgus deformity. The Lapidus procedure appears to be a reasonable surgical option for hallux valgus correction in patients with asymptomatic flatfoot deformity. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSIs) significantly influence outcomes and health care costs after orthopaedic surgery, but they have not been well characterized for osteochondral allograft (OCA) transplantation with or without meniscal allograft transplantation (MAT). Purpose: To characterize the incidence, cost, and risk factors associated with potential or confirmed SSIs after large single-surface, multisurface, or bipolar allograft transplantation in the knee. Study Design: Case-control study; Level of evidence, 3. Methods: Prospectively collected registry data were analyzed for patients who underwent primary or revision OCA transplantation with or without MAT in the knee. The Centers for Disease Control and Prevention (CDC) guidelines were used to define SSIs and calculate the SSI incidence. Both potential and confirmed SSIs were analyzed to determine related treatment methods, calculate associated health care costs, and characterize risk factors based on the OCA surgery type (single-surface, multisurface, bipolar, ±MAT), American Society of Anesthesiologists physical status classification system, surgery duration, length of stay, age, sex, body mass index (BMI), and current tobacco use. Results: A total of 224 patients were included in the analysis. There were 2 SSIs in 1 patient that met CDC criteria, such that the incidence for this patient population was 0.9%. An additional 7 patients (3.1%) were examined for potential infections not classified as SSIs. Patients with potential or confirmed SSIs had a significantly higher mean BMI compared to patients with no evidence of an SSI (P <.001). BMI >35 (odds ratio, 9.1) and tobacco use (odds ratio, 6.6) were associated with greater odds for a potential or confirmed SSI. The mean health care costs were $6101 for patients who required additional emergency room visits and/or irrigation and debridement within 90 days postoperatively for potential or confirmed SSIs, $19 for patients with potential superficial incisional SSIs, and $12,100 for patients who experienced a potential or confirmed deep incisional or organ/space SSI >90 days from surgery. Conclusion: Large OCA transplantation with and without MAT were associated with a low incidence of confirmed SSIs (0.9%), and patients with BMI >35 and current tobacco use had greater odds of an SSI. Potential and confirmed SSIs were associated with unscheduled appointments, additional surgical procedures, and higher costs. [ABSTRACT FROM AUTHOR]

Background: Compared to more prevalent arthritic conditions, ankle arthritis is complicated by an earlier age of onset. Recently published data demonstrates excellent survivorship and complication rates in short-/midterm follow-up of younger patients who received a primary total ankle arthroplasty (TAA). Additionally, older TAA patients display comparable reported outcomes relative to hip/knee arthroplasty. However, there remains a paucity of literature surrounding the reported outcomes of younger patients undergoing TAA. Thus, our aim was to assess the reported outcomes of individuals aged <50 years receiving a primary TAA. Methods: A retrospective cohort analysis of adult patients <50 years who received a primary total ankle replacement was conducted. Patient demographics, diagnosis, treatment, and outcome characteristics were recorded from a chart review of 41 patients with at least 1 year of postoperative clinical follow-up. Postoperative reported outcomes were obtained via telephone interviews. Primary outcomes that were measured included emotional and physical health, activity limitation, ambulation, and global health. Measures used included the 36-Item Short Form Health Survey (SF-36), Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health, and Sickness Impact Profile Ambulation. The functional outcomes in our study sample were compared with age-and gender-matched norms from a general US population, and 95% CIs were calculated for each functional outcome mean. Student t test was used for continuous variables, and X2 analysis was used for categorical variables. Results: Thirty-one of 41 eligible patients were reached for interview. The average age at surgery was 39.7 years. Clinical and radiographic follow-up was a mean of 51.6 months and 31.2 months following TAA, respectively. General health as measured with the SF-36 was not significantly different from age-/gender-matched norms. Eighty-seven percent of patients would choose to have a TAA again. Although 58% reported being limited in vigorous activities, 61% were able to ambulate frequently for long periods of time. On average, the patients did not report ongoing pain, and only 16% reported fatigue that hindered activities. Eighty-one percent reported returning to full employment and performing their duties without difficulty, and 84% reported they resumed all normal social activities. Primary implant survivorship was 93%. Conclusion: Despite a younger age and potentially increased demands, patients aged <50 years undergoing primary TAA are generally satisfied with their index procedure at a mean follow-up of nearly 5 years. Our findings of positive outcomes on their health and well-being may improve surgeon insight for TAA as an alternative treatment for younger individuals with end-stage ankle arthritis. [ABSTRACT FROM AUTHOR]

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms. [ABSTRACT FROM AUTHOR]

Background: While factors affecting the course of knee osteoarthritis are mostly unknown, lesions on bone scan and mechanical malalignment increase risk for radiographic deterioration. Bone marrow edema lesions on magnetic resonance imaging correspond to bone scan lesions. Objective: To determine whether edema lesions in the subarticular bone in patients with knee osteoarthritis identify knees at high risk for radiographic progression and whether these lesions are associated with limb malalignment. Design: Natural history study. Setting: A Veterans Administration hospital in Boston, Massachusetts. Patients: Persons 45 years of age and older with symptomatic knee osteoarthritis. Measurements: Baseline assessments included magnetic resonance imaging of the knee and fluoroscopically positioned radiography. During follow-up at 15 and 30 months, patients underwent repeated radiography; at 15 months, long-limb films were obtained to assess mechanical alignment. Progression was defined as an increase over follow-up in medial or lateral joint space narrowing, based on a semi-quantitative grading. Generalized estimating equations were used to evaluate the relation of medial bone marrow edema lesions to medial progression and lateral lesions to lateral progression, before and after adjustment for limb alignment. Results: Of 256 patients, 223 (87.1%) participated in at least one follow-up examination. Medial bone marrow lesions were seen mostly in patients with varus limbs, and lateral lesions were seen mostly in those with valgus limbs. Twenty-seven of 75 knees with medial lesions (36.0%) showed medial progression versus 12 of 148 knees without lesions (8.1%) (odds ratio for progression, 6.5 [95% CI, 3.0 to 14.0]). Approximately 69% of knees that progressed medially had medial lesions, and lateral lesions conferred a marked risk for lateral progression. These increased risks were attenuated by 37% to 53% after adjustment for limb alignment. [ABSTRACT FROM AUTHOR]

Lower limb amputation has been associated with secondary impairments such as knee osteoarthritis in the uninvolved limb. Greater knee loading in the frontal plane has been related to severity and rate of progression in knee osteoarthritis. Reduced push-off work from the involved limb can increase uninvolved limb knee loading. However, little is known about specific effects that prosthetic foot damping may have on uninvolved limb loading. We hypothesized that uninvolved limb peak knee internal abduction moment (IAM) and loading rates would be greater when using a high-damping foot compared with a low-damping foot, across walking speeds. Eight healthy, young subjects walked in a prosthesis simulator boot using the experimental feet. Greater uninvolved limb first peak IAM (+16% in fast speed, P = .002; +11% in slow speed, P = .001) and loading rates (+11% in fast speed, P = .003) were observed when using the high-damping foot compared with low-damping foot. Within each foot, uninvolved limb first peak IAM and loading rates had a trend to increase with increased walking speed. These findings suggest that damping properties of prosthetic feet are related to uninvolved limb peak knee IAM and loading rates. [ABSTRACT FROM AUTHOR]

Background: Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. Purpose: To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. Study Design: Systematic review; Level of evidence, 4. Methods: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. Results: After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). Conclusion: Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases. [ABSTRACT FROM AUTHOR]

Linemen are at high risk for knee eartilage injuries and osteoarthritis. High-intensity movements from squatting positions (eg, 3-point stance) may produce high joint loads, increasing the risk for cartilage damage. We hypothesized that knee moments and joint reaction forces during lineman-specific activities would be greater than during walking or jogging. Data were collected using standard motion analysis techniques. Fifteen NCAA linemen (mean ± SD: height = 1.86 ±0.07 m, mass = 12I.45 ± 12.78 kg) walked, jogged, and performed 3 unloaded lineman-specific blocking movements from a 3-point stance. External 3-dimensional knee moments and joint reaction forces were calculated using inverse dynamics equations. MANOVA with subsequent univariate ANOVA and post hoc Tukey comparisons were used to determine differences in peak kinetic variables and the llexion angles at which they occurred. All peak moments and joint reaction forces were significantly higher during jogging than during all blocking drills (all P < .001). Peak moments occurred at average knee llexion angles > 70° during blocking versus < 44° in walking or jogging. The magnitude of moments and joint reaction forces when initiating movement from a 3-point stance do not appear to increase risk for cartilage damage, but the high llexion angles at which they occur may increase risk on the posterior femoral condyles. [ABSTRACT FROM AUTHOR]

Background: Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured. Purpose: To determine if there is a patterned change in MLB pitchers' pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or –1 signifying a stronger monotonic trend. Results: A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = –0.657; P <.001), 2-seam fastballs (τb = –0.429; P =.029), and sliders (τb = –0.524; P =.008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P =.038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = –0.581; P =.003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P =.013). Conclusion: The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes. [ABSTRACT FROM AUTHOR]

For a searchable version of these abstracts, please visit www.acrabstracts.org. [ABSTRACT FROM AUTHOR]

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears. [ABSTRACT FROM AUTHOR]

Introduction: Evidence‐based guidelines suggest a conservative, nonsurgical approach as first‐line treatment for knee osteoarthritis. However, previous literature has documented underutilization of the fundamental components of condition management emphasized in the guidelines. The intervention aim is to apply organized conservative components of care for knee osteoarthritis in an evidence‐based management program through the translation of research into practice with a target to observe meaningful functional improvement in a distinct population. Methods: The program, modeled after the nonsurgical arm of a randomized, controlled trial, was designed as a single‐arm observational cohort study with a pre‐ and post‐program comparison for participants reporting presence of knee osteoarthritis who were attributed to a specific employer's health plan in the United States. The 12‐week intervention consisted of condition education, group exercise, and a dietary intervention. Results: Ninety‐six participants enrolled in the program, of which 72% completed the protocol. The median change in pre‐ to post‐program Knee Injury and Osteoarthritis Outcome Score values was 10.4 ± 0.8 (Z = 210.5, p < 0.001)—a clinically important change. Secondary outcomes were complementary to the primary outcome. Conclusions: Results of the program indicate that the clinically significant 3‐month findings in the report by Skou et al. (2015) regarding functional improvement can be replicated in an alternate setting. Organizing and offering fundamental components of condition management in a group format with provider oversight could be a feasible and logical component in the continuum of care for knee osteoarthritis, while complementing other secondary management strategies following diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to assess the clinical and patient-reported outcomes of a customised, individually made (CIM) bi-compartmental knee arthroplasty (BKA).Methods: A prospectively recruited cohort of 79 patients was implanted with a CIM-BKA (patello-femoral plus either medial or lateral tibio-femoral, iDuo G2 system, Conformis, Billerica MA) at eight centres in the US and Germany. Patients were assessed for the 2011 KSS, KOOS, and ROM pre-operatively and at 2 weeks, 6 weeks, 12 weeks, 1 year, and 2 years post-operatively.Results: The objective KSS score significantly improved from 69 at the pre-operative visit, to 94 at the 2-year post-operative time-point. Similar improvements were observed for the KSS function and satisfaction domains. Significant improvements from pre-operative levels were observed across all five domains of the KOOS. Two patients have undergone surgery to revise their CIM-BKA implant to total knees, resulting in a survivorship rate of 97.5% at an average follow-up of 2.6 years.Conclusions: CIM-BKA compares favourably to published scores as well as revision rates for previously available monolithic OTS-BKA implants. CIM-BKA implants provide surgeons with a viable and patient-specific monolithic implant solution as an option for patients presenting with bi-compartmental disease, who might, otherwise, be treated by performing uni-condylar + patello-femoral joint or bicruciate sparing TKA surgeries. Longer follow-up and higher numbers have to be awaited for further validation of these encouraging early results.Level Of Evidence: 3b (individual case-controlled study). [ABSTRACT FROM AUTHOR]

Background: To date, there have not been any epidemiologic studies that have evaluated the association between swimming over a lifetime and knee health.Objective: The study aimed to evaluate the relationship of a history of swimming with knee pain, radiographic knee OA (ROA), and symptomatic knee OA (SOA).Design: Cross-sectional retrospective study.Setting: Four academic centers in the United States.Participants: Respondents to the historical physical activity survey within the Osteoarthritis Initiative with knee radiographs and symptom assessments.Methods: In this retrospective study nested within the Osteoarthritis Initiative, researchers performed logistic regression with the predictor being swimming over a lifetime and over particular age ranges.Main Outcome Measurements: Person-based definitions of frequent knee pain, ROA, and SOA.Results: A total of 2637 participants were included, with a mean age of 64.3 years (SD 8.9), body mass index of 28.4 kg/m2 (SD 4.9), and 44.2% male. Over a lifetime, the adjusted prevalence measures for frequent knee pain, ROA, and SOA for any versus no history of swimming were 36.4% (33.4% - 39.5%) v. 39.9% (37.4% - 42.5%), 54.3% (51.0% - 57.6%) v. 61.1% (58.4% - 63.7%), and 21.9% (19.4% - 24.7%) v. 27.0% (24.7% - 29.4%) respectively.Conclusions: This is the first epidemiologic study to indicate that swimming is potentially beneficial toward knee health, particularly when performed earlier in life (before age 35). Future prospective studies are needed to confirm these findings and to better scrutinize the associations in older age groups. [ABSTRACT FROM AUTHOR]

Examines the lower-extremity muscle activation during the star excursion balance test (SEBT) in the United States. Subject of equilibrium on the stance leg with contralateral foot on the extended lines from the common axis; Measurement of activity of the vastus medialis obliquus; Indication of anterior tibialis activity with the lateral excursion.