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Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores ( P0.001) and anxiety scores ( P =0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.Level I.

Early-onset scoliosis (EOS) can have harmful effects on pulmonary function. Serial elongation, derotation, and flexion (EDF) casting can cure EOS or delay surgical intervention. Most described casting techniques call for specialized tables, which are not available at many institutions. We describe an innovative technique for EDF casting utilizing a modified Jackson table (MJ) and compare results to a Risser frame (RF).All patients who underwent EDF casting at our institution between January 2015 and January 2019 were identified and retrospectively reviewed. Patients were stratified by type of table used and clinical and radiographic outcomes were compared. Standard descriptive statistics were calculated.We identified 25 patients who underwent 77 casting events, 11 on an MJ table and 14 on a RF. Mean follow-up was 32 months (range 11-61 months). 28% of patients had idiopathic scoliosis. There was no significant difference in age at initiation of casting (P = 0.3), initial Cobb angle (equivalence, P = 0.009), or rate of idiopathic scoliosis between the MJ and RF groups. There was no significant difference in initial coronal Cobb angle percent correction (equivalence, P = 0.045) or percent correction at 1-year follow-up (equivalence, P = 0.010) between the two groups. There was no difference in cast related complications. There was a significant difference in surgical time, with the MJ group 11 min shorter than the RF (P = 0.005).The MJ table is a safe and effective alternative for applying EDF casts under traction without the need for a specialized table.III.

Iliopsoas (IP) tendinitis from impingement upon the acetabular component after total hip arthroplasty (THA) has been treated with open and endoscopic IP tenotomy or acetabular component revision. This study describes the results of a consecutive series of patients treated with endoscopic IP tenotomy as a less invasive alternative. Twenty-eight patients with IP impingement after THA underwent endoscopic IP lengthening from 2012 to 2021 at a single-center academic institution. The follow-up of 24 of these patients was achieved with a mean follow-up of 7.6 months (range 1–28). Outcomes included the modified Harris Hip Score (mHHS), visual analog pain scale (VAS), satisfaction, component positioning and complications. Seventy-one percent of patients were satisfied or very satisfied after their operation. The median mHHS preoperatively was 57 (Interquartile range [IQR] 43–60) and postoperatively was 75 (IQR 66–92, P 8 mm, body mass index >30, and less than 2 years from their index THA. Two patients developed a deep infection 7 and 10 months postoperatively (neither related to the release), and one patient underwent open psoas release for persistent impingement. Endoscopic IP tenotomy is a safe and effective treatment for impingement after THA. Patients with cup prominence >8 mm, body mass index >30 and less than 2 years since their index THA may have more clinically meaningful improvements in pain and function.

Approximately half of treated clubfoot patients initially corrected with the Ponseti method experience relapse that requires additional treatment. The consequences of relapse on childhood activity levels have not been well studied. Ponseti noted lower functional ratings at 18-year follow-up in clubfoot patients who had undergone tibialis anterior tendon transfer for relapse.Clubfoot Activity and Recurrence Exercise study (CARES) is an observational, prospective cohort study that compares physical activity in 30 clubfoot patients without and with relapse. Eligible participants were 5 to 10 years old, diagnosed with idiopathic clubfoot at birth, and had not received any clubfoot treatment for at least 6 months before study. Recruitment for this study occurred in-person and through Facebook clubfoot groups. Consented participants wore Fitbits secured to their wrists for at least 14 days, and completed a demographic survey, Child Health Questionnaire (CHQ), and the clubfoot disease-specific instrument (CDSI). Participants' daily activity was monitored through Fitabase.Participants without and with clubfoot relapse had similar daily step counts, distance walked, and step intensities, except for moderately active step intensity, which was higher in the clubfoot relapse group. Total steps, total distance, distances (very active, moderately active), minutes (very active, fairly active), and lightly active intensity of steps were significantly higher for participants whose families earn more than $100,000 per year. Various physical activities and sports were reported by both groups in daily activity sheets. Neither demographics nor the CDSI or the CHQ scores significantly differed between the 2 groups. Step counts of children with clubfoot with or without relapse were similar to published levels for healthy children.Children with clubfoot initially treated with the Ponseti method who undergo treatment for relapse have comparable physical activity to those who have not relapsed. They also have comparable step counts to that of the general pediatric population. These reassuring findings can guide conversations with parents when addressing concerns regarding their children's physical activity after treatment for relapse of clubfoot deformity.Level II-therapeutic studies-investigating the results of treatment.

ImportanceThe US Centers for Disease Control and Prevention shortened the recommended isolation period for SARS-CoV-2 infection from 10 days to 5 days in December 2021. It is unknown whether an individual with the infection may still have a positive result to a rapid antigen test and potentially be contagious at the end of this shortened isolation period.ObjectiveTo estimate the proportion of individuals with SARS-CoV-2 infection whose rapid antigen test is still positive starting 7 days postdiagnosis.Design, Setting, and ParticipantsThis case series analyzed student athletes at a National Collegiate Athletic Association Division I university campus who tested positive for SARS-CoV-2 between January 3 and May 6, 2022. Individuals underwent rapid antigen testing starting 7 days postdiagnosis to determine whether they could end their isolation period.ExposuresRapid antigen testing 7 days after testing positive for SARS-CoV-2.Main Outcomes and MeasuresRapid antigen test results, symptom status, and SARS-CoV-2 variant identification via campus wastewater analysis.ResultsA total of 264 student athletes (140 [53%] female; mean [SD] age, 20.1 [1.2] years; range, 18-25 years) representing 268 infections (177 [66%] symptomatic, 91 [34%] asymptomatic) were included in the study. Of the 248 infections in individuals who did a day 7 test, 67 (27%; 95% CI, 21%-33%) tests were still positive. Patients with symptomatic infections were significantly more likely to test positive on day 7 vs those who were asymptomatic (35%; 95% CI, 28%-43% vs 11%; 95% CI, 5%-18%; P P = .007).Conclusions and RelevanceIn this case series, rapid antigen tests remained positive in 27% of the individuals after 7 days of isolation, suggesting that the Centers for Disease Control and Prevention–recommended 5-day isolation period may be insufficient in preventing ongoing spread of disease. Further studies are needed to determine whether these findings are present in a more heterogeneous population and in subsequent variants.

Objective: We sought to determine prescribing patterns for opioid analgesia following anterior cruciate ligament (ACL) reconstruction among age- and gender-stratified adolescents in a nationally representative database. Design: A retrospective study. Setting: PearlDiver Patient Records. Patients, participants: Outpatient opioid claims within 30 days of surgery were extracted. The patients were defined into age groups 10-14 (“younger’) and 15-19 (“older”). A total of 1,139 patients were included in this study (536 female and 603 males) with 108 patients in the 10-14 age category and 1,034 patients in the 15-19 category. Main outcome measure(s): The primary study outcome measures the average number of opioid pills administered, average total morphine milligram equivalents (MMEs) prescribed, and the average prescription strength (MMEs/pill). Results: No difference was found in the average number of pills (p = 0.26) or normalized total MMEs (p = 0.312) prescribed by age group. Normalized total morphine equivalents per prescription was significantly lower in females than males (p = 0.005). Multivariate linear regression analysis demonstrated that increasing patient age was predictive of fewer total pills (p = 0.017), after accounting for gender. Conclusions: There are age- and gender-based disparities in prescription patterns for adolescent ACL reconstruction. Our findings indicate that patients in the older age group on average received fewer pills than the younger age group, which consequently trended toward receiving higher total MMEs prescribed. This suggests that surgeons may be inadvertently overprescribing in the younger cohort. Additional studies that account for concurrent factors should be conducted to observe potentially similar trends.

Background: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon–femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients. Purpose: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens. Study Design: Descriptive laboratory study. Methods: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface. Results: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts ( P < .047) and the younger and older cohorts ( P < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively. Conclusion: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens. Clinical Relevance: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.

Background: Trapezial pommel, or ulnar osteophyte positioned at the vertex of the saddle-shaped facet, is a consistent structural appearance in osteoarthritis (OA) of the first carpometacarpal. This study investigates its relation to radiographic measures (modified Eaton staging and thumb OA [ThOA] index) and wear patterns (trapezial surface morphology and cartilaginous eburnation). Methods: In all, 137 whole trapezia were explanted from 116 patients and evaluated for Eaton staging, morphology (saddle, cirque, or dish), and eburnation (degree of cartilaginous effacement) of the articular surface of the trapezium. In total, 131 Robert’s views and 126 stress views were reviewed by 2 blinded senior surgeons for ThOA index and pommel size. Statistical analyses included Spearman correlation and linear regression. Results: Standardized pommel size achieved good intrarater reliability (correlation coefficient: 0.80-0.98) and moderate interrater reliability (correlation coefficient: 0.60-0.67). The ThOA index and pommel size were significantly correlated across Robert’s ( rs = 0.51) and stress views ( rs = 0.64). The ThOA index better distinguished between stages compared with pommel size. All the radiographic measures inversely correlated with preserved cartilage and varied across morphologies. Pommel size differed significantly between dish and saddle, and the ThOA index was significantly different between all morphologies when using stress views. Conclusions: We reliably quantified the pommel feature and demonstrated significant correlations with other radiographic and topologic measures of arthritic disease. If future studies can demonstrate that the pommel is a pathogenic process in ThOA and its correction can curb disease progression, the identification of the pommel feature may help guide targeted intervention.

Mindset theory describes two different belief systems regarding ability: “fixed”, in which a particular personal characteristic is seen as unchangeable, and “growth”, in which the characteristic is viewed as malleable and subject to improvement. The purpose of this study is to evaluate how that mindset toward one’s health correlates with health-related quality of life assessments (HRQoL) in patients with adolescent idiopathic scoliosis (AIS). Patients undergoing brace treatment for AIS were prospectively recruited for this study and completed both an SRS-30 and Health Mindset Scale questionnaire. Inclusion criteria for patients are based on Scoliosis Research Society standardized criteria for bracing studies: diagnosis of AIS, a prescribed TLSO brace for full-time wear, skeletal immaturity at brace initiation (Risser 0–2), Cobb angles 25–50 degrees, no prior treatment, and, if female, no more than 1 year post-menarchal at the time of brace initiation. Statistical analysis was performed utilizing Mann–Whitney U tests for skewed data and two-sample t tests for normally distributed data. Multivariable models were also used to evaluate the relationships of SRS-30 subscores with health mindset, adjusting for age, gender, and pre-treatment curve magnitudes. Among the 110 enrolled patients, a stronger growth mindset was associated with significantly higher SRS-30 scores overall (p = 0.001), as well as in the appearance (p = 0.003), and mental (p = 0.001) subscores. We demonstrate that health mindset affects an AIS patients’ HRQoL. Prior studies have demonstrated that mindset is malleable and can be altered. Further studies are required to determine whether changing health mindset from a fixed to a growth mindset can also improve HRQoL in patients with scoliosis.

Objective Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic. Design/Setting/Participants/Intervention(s)/Main Outcome Measure(s) We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon’s reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. ‘Experience/anecdote,’ ‘First principles,’ ‘Trained to do it,’ ‘Arbitrary/instinct,’ ‘General study,’ ‘Specific study’). Results Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were ‘First principles’ (n = 310, 27.0%) and ‘Experience/anecdote’ (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions. Conclusions With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.

Purpose Forearm and distal radius fractures are among the most common fractures in children. Many fractures are definitively treated with closed reduction and casting, however, the risk for re-displacement is high (7% to 39%). Proper cast application and the three-point moulding technique are modifiable factors that improve the ability of a cast to maintain the fracture reduction. Many providers univalve the cast to accommodate swelling. This study describes how the location of the univalve cut impacts the pressure at three-point mould sites for a typical dorsally displaced distal radius fracture. Methods We placed nine force-sensing resistors on an arm model to collect pressure data at the three-point mould sites. Sensory inputs were sampled at 15 Hz. Cast padding and a three-point moulded short arm fibreglass cast was applied. The cast was then univalved on the dorsal, volar, radial or ulnar aspect. Pressure recordings were obtained throughout the procedure. Results A total of 24 casts were analyzed. Casts univalved in the sagittal plane (dorsal or volar surface) retained up to 16% more pressure across the three moulding sites compared with casts univalved in the coronal plane (radial or ulnar border). Conclusion Maintaining pressure at the three-point mould prevents loss of reduction at the fracture site. This study shows that univalving the cast dorsally or volarly results in less pressure loss at moulding sites. This should improve the chances of maintaining fracture reductions when compared with radial or ulnar cuts in the cast. Sagittal plane univalving of forearm casts is recommended.

Background:Meniscus root tears lead to de-tensioning of the meniscus, increased contact forces, and cartilage damage. Management of older patients with root tears is controversial and the efficacy of different treatment options is unclear.Purpose:To compare the clinical outcomes of patients with moderate knee osteoarthritis who underwent an all-inside meniscus root repair technique versus nonoperative management for either medial or lateral meniscus root tears.Study Design:Cohort study; Level of evidence, 2.Methods:Patients with a diagnosed posterior meniscus root tear who underwent arthroscopic repair (AR: 30 knees) or nonoperative treatment with observation (O: 18 knees) were followed for a minimum of 2 years (mean follow-up, 4.4 years). The arthroscopic repair included all-inside sutures to reduce the root back to its remnant (reduction sutures), thereby re-tensioning the meniscus, and 1 mattress suture to strengthen the repair by reapproximating the construct to the posterior capsule. The data collected included the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and Veterans RAND 12-Item Health Survey (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and conversion to total knee arthroplasty (TKA).Results:Medial meniscus root tears comprised 80.0% of the AR group and 77.8% of the O group. The average Kellgren-Lawrence grade was 2 in both groups. The baseline scores for the KOOS Symptoms subscale were lower for AR (50.2 ± 19.3) than for O (66.5 ± 16.1) ( P = .003), as were the KOOS Knee-Related Quality of Life scores (AR, 26.7 ± 16.1; O, 39.6 ± 22.1) ( P = .046). No differences were found between groups for the absolute values at follow-up except that follow-up Tegner scores were lower in the O group than in the AR group ( P = .004). Significant improvements were seen in the AR group from baseline to ultimate follow-up in average KOOS subscale scores ( P < .001), Lysholm scores ( P < .001), Tegner scores ( P = .0002), and VR-12 PCS scores ( P < .001), whereas the O group had a significant improvement only in average KOOS Pain ( P = .003), KOOS Function in Daily Living ( P = .006), and VR-12 PCS ( P = .038) scores. Compared with the O group, the AR group had a significantly larger improvement from baseline to follow-up in average KOOS Pain ( P = .009), KOOS Symptoms ( P = .029), and Lysholm scores ( P = .016). During follow-up, 3.3% of the AR group underwent a TKA compared with 33.3% of the O group ( P = .008). The hazard ratio of TKA conversion was 93.2% lower for the AR group compared with the O group ( P = .013).Conclusion:All-inside medial or lateral meniscus root repair showed improved functional outcomes and decreased TKA conversion rates compared with nonoperative treatment and may be considered as a treatment option for the management of meniscus root tears in older patients with moderate osteoarthritis.

Revision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear.Between January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental).A total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (-30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (-4.2, P = .050) scores, respectively.Isolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.III, cohort with control.

Objectives Femoroacetabular impingement (FAI) morphology is associated with hip pain and disability. Water polo players utilize the eggbeater motion (method of treading water with legs rotating like an “egg-beater”), and it is currently unclear what the relationship is between eggbeater and FAI morphology. Our objective was to associate hip range of motion during eggbeater motion to MRI findings. Methods 8 NCAA Division 1 varsity water polo athletes (5 females, 3 males) were filmed at orthogonal views performing the egg-beater motion using 2 waterproof cameras in synchrony. A model-based image-matching technique was used to determine hip joint angles which were recorded from the software. These athletes also underwent non-contrast MRI scans of both hips using a 3T MRI scanner and completed an iHOT-33 hip pain outcomes questionnaire. Descriptive statistics are reported as counts and percentages for categorical variables and as means, standard deviations, and a five-number summary for continuous variables. Relationships between range of motion measures with MRI measures and with iHOT33 scores were analyzed using linear regression models. All statistical analyses were completes using a two-sided level of significance of 0.05. Results The average alpha angles for the right and left hips were 71.80 ±7.50 and 74.10 ±8.40, respectively. There was no statistically significant correlation between hip range of motion in any plane and alpha angle or lateral center edge angle (CEA) on MR imaging. The average iHOT33 was 85.9±18.9. Participants who had a labral tear had significantly smaller hip abduction ranges compared with participants who did not have a labral tear (29 o ± 4.1vs. 35.3 o ± 0.6, p = 0.02), and those that had a labral tear had significantly increased hip flexion during eggbeater kicking as compared with participants who did not have a labral tear (28.2 o ± 6.1 vs. 16.3 o ± 4, p = 0.02). There were no differences between right and left alpha angles or between right and left CEA. Conclusion There were no significant correlations between hip range of motion and alpha angle or CEA, but hips with labral pathology had greater hip flexion and more limited hip abduction ranges.

Background: Prognosticating recovery times for individual athletes with a concussion remains a challenge for health care providers. Several preinjury and postinjury factors have been proposed to be predictive of prolonged return-to-play (RTP) times, but the data in this area are still sparse. Purposes: This study aimed to identify risk factors associated with prolonged recovery times and determine which are most predictive of prolonged recovery times in a head-to-head comparison. Study Design: Case-control study; Level of evidence, 3. Methods: All concussions occurring between September 2017 and August 2020 at a single National Collegiate Athletic Association Division I institution were reviewed and included in this study. Preinjury modifiers including age, sex, sport, concussion history, and past medical problems were collected from the electronic medical records. Postinjury modifiers analyzed included initial and follow-up Sport Concussion Assessment Tool 5th Edition scores, vestibular evaluation findings, and eye tracking results. Results: A total of 159 athletes and 187 concussion cases were included. Preinjury factors that were correlated with prolonged RTP times included a history of concussions ( P = .015), a history of migraines ( P = .013), and whether an athlete participated in an individual sport ( P = .009). Postinjury factors correlated with prolonged RTP times included the total number ( P = .020) and severity ( P = .023) of symptoms as well as abnormal Vestibular Ocular Motor Screening findings ( P = .002). Overall, 6 different symptoms (balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue/low energy, and difficulty remembering) were significantly correlated with prolonged RTP times. The study also found that the number and severity of symptoms were additive in a dose-dependent fashion. On multivariable analysis of all these factors, a history of concussions was found to be the most predictive of prolonged RTP times, while participation in an individual sport had the largest effect on recovery times. Conclusion: Several preinjury and postinjury risk factors were identified as being correlated with prolonged recovery times. Many of these risk factors were also found to be additive in nature. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes. The study also revealed that athletes participating in individual sports had longer RTP times compared with athletes in team sports, which is a novel finding that requires further research.

Background/Purpose Pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) commonly require non-emergent operative treatment. Expeditious treatment of these injuries is used as a marker for the quality of a hospital system. Given the incidence of these injuries, the U.S. News and World Report has chosen the timing of their management as a measure of hospital efficiency in managing trauma. A delay of more than 18 hours from admission to surgery negatively affects a hospital’s rank. Here, we describe the effect of a program allowing an early operating room start for uncomplicated trauma prior to an elective day. The goal of …

Purpose To better define the epidemiology of discoid meniscus by analyzing a large, national database for incidence rates and associations with demographic variables. Methods From Optum’s Clinformatics® Data Mart Database, incidence rates and proportions of reported racial categories - Asian, Black, Hispanic, and Caucasian - of diagnosed discoid meniscus cases (n = 198) in the study population of patients receiving arthroscopic meniscectomy or repair procedures (n = 60,042) were calculated and compared via chi-square tests to the total population. To control for age, sex, and socioeconomic factors such as income, multivariable logistic regression analysis was performed. Results Proportions of discoid meniscus patients who were Asian, Black, Hispanic, or Caucasian were

Background The aim of the present study was to evaluate the effectiveness of the Bedside Entertainment and Relaxation Theater (BERT) on fear, anxiety, and pain outcomes in pediatric orthopaedic patients associated with cast removal and/or pin removal in the outpatient clinic setting. Methods A total of 66 pediatric patients between the ages of 2 and 6 undergoing clinic procedures were recruited for this study and randomized into the control group or the intervention (BERT) group. Patients in the control group received standard of care during the cast room procedure; patients in the BERT group were given headphones and watched a movie on a projector during the procedure. Fear, anxiety, and pain were measured before and after the procedure. Procedures included cast removal, pin removal, or a combination of the 2. Results Patients in the BERT group reported less fear and anxiety overall after the procedure than patients in the control group (P=0.009, 0.015). Adjusting for procedure type (ie, pin removal), patients in the BERT group reported a 0.67 point decrease (95% confidence interval: 0.04, 1.30) on the fear scale after the procedure (P=0.039) and a 1.81 point decrease (95% confidence interval: 0.04, 3.59) on the anxiety scale associated with the procedure (P=0.045), compared with the control group. Patients and caregivers reported high satisfaction with BERT. Conclusion This randomized, controlled trial demonstrates an evidence-based distraction tool that can be implemented across medical centers for pediatric patients undergoing office based orthopaedic procedures. BERT can be used to reduce fear and anxiety associated with these procedures, and increased patient and parent satisfaction. Level of evidence Level I.

Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients.Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (± PO) between 2007 and 2015 in the IBMWe identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p 0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p = 0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p 0.001) and reoperation (2.03 [1.13-3.59]; p = 0.015) within 90 days, but there were no differences in the odds of reoperation within 2 years (p = 0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p 0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p 0.001).Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90 days. By 2 years, differences in reoperation rate were not significant.III.

OBJECTIVES To describe the incidence of and risk factors for vascular injury associated with P-SCD. METHODS We used data from the HCUP-NIS from 2015 to 2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics, and injury severity score in this cohort. RESULTS Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD

Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P =.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days ( P =.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days ( P P =.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [ Orthopedics . 2020; 43(1);8–12.]

BackgroundLeiomyosarcomas (LMS) are a heterogenous group of malignant mesenchymal neoplasms with smooth muscle origin and are classified as either non-uterine (NULMS) or uterine (ULMS). Metastatic pattern, prognostic factors, and ideal staging/surveillance studies for truncal and extremity LMS have not been defined.MethodsA retrospective analysis of patients diagnosed with histopathology-confirmed truncal or extremity LMS between 2009-2019 was conducted. Data collected included demographics, tumor characteristics, staging, surveillance, and survival endpoints. Primary site was defined as either 1. Extremity, 2. Flank/Pelvis, or 3. Chest wall/Spine.ResultsWe identified 73 patients, 23.3% of which had metastatic LMS at primary diagnosis, while 68.5% developed metastatic disease at any point. The mean metastatic-free survival from primary diagnosis of localized LMS was 3.0±2.8 years. Analysis of prognostic factors revealed that greater age (≥50 years) at initial diagnosis (OR=3.74, p=0.0003) and higher tumor grades II (OR=16, p=0.019) and III (OR=13, p=0.025) were significantly associated with metastases.ConclusionsTruncal and peripheral extremity LMS is an aggressive tumor with high metastatic potential. While there is a significant risk of metastases to lungs, extra-pulmonary tumors are relatively frequent. Older patients and patients with higher-grade (II/III) tumors carry an increased risk of developing metastatic disease.

Background/Purpose Spinal fusion for treatment of neuromuscular scoliosis often involves fusion to the pelvis. Pelvic fixation techniques for neuromuscular scoliosis have evolved from rod-based to mostly screw-based fixation. The Marchesi technique is a hybrid method described for Duchenne's-associated scoliosis involving the placement of S1 pedicle screws combined with the insertion of L shaped rods into the Ilium. We present a retrospective series of neuromuscular scoliosis …

Aims Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty. Methods We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score. Results Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon’s 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043). Conclusion Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347–352.

Background: Epidermolysis bullosa is a rare genetic skin disorder with four main types. One of the most debilitating subtypes is recessive dystrophic epidermolysis bullosa (RDEB). Patients experience frequent blister formation that occurs spontaneously or as a result of minor pressure or friction. This often leads to scarring and fibrosis of the skin, contracture development, pseudosyndactyly of the hands, and chronic pain. Functionally patients experience decreased independence in their activities of daily living and quality of life. The relationship of engagement in activities of daily living and perceived quality of life has not been studied for this population. The aims of this cross-sectional study were to find evidence to support this relationship through the correlation of a patient-reported independence in activities of daily living questionnaire and a patient-reported quality of life measure developed for persons with EB. Results: 19 subjects with RDEB aged 9-25 were recruited from a multidisciplinary EB center from 2014-2017. The results demonstrate a slight positive trend in the correlation of independence in activities of daily living and quality of life, though the data was not sufficient to be statistically significant. Conclusion: The results of this study have implications for further research with recommendations to recruit a greater number of subjects. Use of a more sensitive and robust assessment of activities of daily living that also includes leisure skills may yield more statistically significant data. In addition, the findings confirm the important role that occupational therapy has in addressing patient needs and facilitating greater functional independence.

Pediatric fractures are a common injury, and treatment often includes cast immobilization. For pediatric patients being treated in a cast, cast damage is among the most common reasons patients return to the emergency room. The figure-of-eight wrapping technique interdigitates layers of fiberglass which may create a stronger cast. The aim of this study was to assess the strength of the figure-of-eight wrapping technique in comparison to the spiral wrapping technique. A total of 10 casts were wrapped with a three-inch fiberglass using the spiral technique and 10 casts were wrapped using the figure-of-eight technique. Each cast was then subjected to a three-point bending test and loaded until failure using an Instron machine. The figure-of-eight technique had an average load to failure of 278.2 + 27.6 N/mm which was similar to the spiral technique's load to failure of 281.2 + 25.4 N/mm (p=0.795). Prior to normalizing for thickness, the load to failure of the figure-of-eight technique was 949.8 + 109.5 N, which was significantly higher than the spiral technique of 868.2 + 65.1 N (p=0.038). The figure-of-eight casts were slightly thicker than the spiral casts (average 0.3 mm, p=0.004). This suggests that the thickness of the fiberglass cast may improve the strength. The figure-of-eight wrapping technique had similar biomechanical characteristics to spiral wrapping techniques. Providers should wrap in whichever technique they feel most comfortable performing as there is no difference in strength of the cast. If a stronger cast is desired, then thickness of the cast can be increased.

Background: The female athlete triad (Triad) has been associated with increased risk of bone stress injury (BSI) in certain populations. Purpose: The purpose of this study is to evaluate the prevalence of Triad risk factors and identify hormonal and extrinsic factors that may influence Triad risk in high school (HS) distance runners. Methods: Thirty-nine female HS distance runners completed a questionnaire, which included disordered eating (DE)/eating disorder (ED), menstrual irregularities, BSI history, and height/weight. Serum labs were obtained, including ferritin, 25-hydroxyvitamin D, estradiol, insulin-like growth factor, and free T3. Runners completed dual-energy x-ray absorptiometry to measure bone mineral density (BMD) using Z-scores that are age, sex and ethnicity-matched. Body fat percentage was also obtained. A risk score was then calculated using energy availability (EA), body mass index (BMI), age of menarche, oligomenorrhea, BMD, and history of BSI. The statistical model used was Spearman correlation coefficient. P-values

Background: Young athletes have the highest rates of primary and recurrent anterior cruciate ligament (ACL) tears, and recent research has identified graft diameter as a predictor of graft failure. Newer ACL reconstruction techniques have been developed to increase graft diameter and reduce re-rupture rates. Graft diameter can be modified based upon graft length, number of graft strands/configuration, and native ACL length. While the ACL has been well-studied in adult populations, there is limited research examining the ACL dimensional characteristics in a pediatric population. Appropriate preoperative anatomic dimensions may help surgeons plan for optimal graft length, diameter and bundle arrangement Purpose: To develop MRI-based predictors of native ACL graft length in pediatric populations and enhance preoperative planning to optimize graft length, strand configuration and graft diameter to lower the risk of recurrent ACL injury. Methods: One hundred and ten subjects were included from the STRIDE database (64 females and 46 males, median age 10 years, range 1-13 years). Our exclusion criteria were if the subjects had musculoskeletal diseases or history of knee injury. Using MRIs, researchers evaluated ACL length, sagittal and coronal inclination of the ACL, inclination and width of the intercondylar notch, depth and width of the femoral condyles, and the medial and lateral tibial slopes. Association between measurements, sex, and age were investigated using linear and multivariate regression models. Results: When examining the predictors for ACL length by sex, the best predictor (R⁁2 = 0.65) for female ACL lengths was the depth of the lateral femoral condyle taken in the sagittal view (pConclusion: When predicting the ACL length in pediatric populations, femoral condylar depth and width, and patient age may be valuable predictors for those undergoing ACL reconstructions. Surgical planning to maximizing graft diameter is contingent upon native ACL graft length, and the use of this information to optimize graft utilization may lower the rates of ACL graft failure in the highest risk pediatric populations. Tables/Figures: [Table: see text][Figure: see text][Figure: see text]

Leiomyosarcomas (LMS) are a heterogenous group of malignant mesenchymal neoplasms with smooth muscle origin and are classified as either non-uterine (NULMS) or uterine (ULMS). Metastatic pattern, prognostic factors, and ideal staging/surveillance studies for truncal and extremity LMS have not been defined. A retrospective analysis of patients diagnosed with histopathology-confirmed truncal or extremity LMS between 2009 and 2019 was conducted. Data collected included demographics, tumor characteristics, staging, surveillance, and survival endpoints. The primary site was defined as: (1) extremity, (2) flank/Pelvis, or (3) chest wall/Spine. We identified 73 patients, 23.3% of which had metastatic LMS at primary diagnosis, while 68.5% developed metastatic disease at any point. The mean metastatic-free survival from primary diagnosis of localized LMS was 3.0 ± 2.8 years. Analysis of prognostic factors revealed that greater age (≥50 years) at initial diagnosis (OR = 3.74, p = 0.0003), higher tumor differentiation scores (OR = 12.09, p = 0.002), and higher tumor necrosis scores (OR = 3.65, p = 0.026) were significantly associated with metastases. Older patients (≥50 years, OR = 4.76, p = 0.017), patients with larger tumors (≥5 cm or ≥10 cm, OR = 2.12, p = 0.02, OR = 1.92, p = 0.029, respectively), higher differentiation scores (OR = 15.92, p = 0.013), and higher necrosis scores (OR = 4.68, p = 0.044) show worse survival outcomes. Analysis of imaging modality during initial staging and during surveillance showed greater tumor detection frequency when PET imaging was employed, compared to CT imaging (p < 0.0001). In conclusion, truncal and peripheral extremity LMS is an aggressive tumor with high metastatic potential and mortality. While there is a significant risk of metastases to lungs, extra-pulmonary tumors are relatively frequent, and broad surveillance may be warranted.

Mindset theory describes two different belief systems regarding ability: "fixed", in which a particular personal characteristic is seen as unchangeable, and "growth", in which the characteristic is viewed as malleable and subject to improvement. The purpose of this study is to evaluate how that mindset toward one's health correlates with health-related quality of life assessments (HRQoL) in patients with adolescent idiopathic scoliosis (AIS).Patients undergoing brace treatment for AIS were prospectively recruited for this study and completed both an SRS-30 and Health Mindset Scale questionnaire. Inclusion criteria for patients are based on Scoliosis Research Society standardized criteria for bracing studies: diagnosis of AIS, a prescribed TLSO brace for full-time wear, skeletal immaturity at brace initiation (Risser 0-2), Cobb angles 25-50 degrees, no prior treatment, and, if female, no more than 1 year post-menarchal at the time of brace initiation. Statistical analysis was performed utilizing Mann-Whitney U tests for skewed data and two-sample t tests for normally distributed data. Multivariable models were also used to evaluate the relationships of SRS-30 subscores with health mindset, adjusting for age, gender, and pre-treatment curve magnitudes.Among the 110 enrolled patients, a stronger growth mindset was associated with significantly higher SRS-30 scores overall (p = 0.001), as well as in the appearance (p = 0.003), and mental (p = 0.001) subscores.We demonstrate that health mindset affects an AIS patients' HRQoL. Prior studies have demonstrated that mindset is malleable and can be altered. Further studies are required to determine whether changing health mindset from a fixed to a growth mindset can also improve HRQoL in patients with scoliosis.

Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P.05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

Study design This was a retrospective cohort study. Objective The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity. Summary of background data Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws). Methods Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection. Results A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%). Conclusion We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

Purpose Patient-reported outcome measures are increasingly used to measure patient status, impairments, and disability, but often require lengthy surveys and place a considerable burden on patients. We hypothesized that the Single Assessment Numeric Evaluation (SANE), composed of a single question, would be a valid and responsive instrument to provide a global assessment of hand function. Methods The SANE, Patient-Reported Outcomes Measurement Information System–Upper Extremity (PROMIS-UE), and Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH) data are routinely collected electronically in our hand and upper-extremity center. To identify our cohort, we used Current Procedural Terminology codes to query our electronic medical record research data repository for the 7 most common hand surgery procedures performed over 2 years from December 2016 to 2018. These procedures included carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, wrist arthroscopy, distal radius fracture fixation, first dorsal compartment release, and cubital tunnel release. Patients undergoing a single isolated procedure with questionnaires obtained in the preoperative and/or postoperative period were included in the analysis. Convergent validity, coverage, and responsiveness for each instrument were assessed. Results We identified 214 patients for inclusion. The SANE score had a moderate to strong correlation with the QuickDASH and PROMIS-UE. Floor and ceiling effects for the SANE were less than 10% at baseline and follow-up. Overall, the QuickDASH was the most responsive, followed by SANE and PROMIS-UE; all 3 instruments exceeded the acceptable thresholds for responsiveness and demonstrated significant changes before to after surgery. Responsiveness of the SANE varied by procedure and was acceptable for carpal tunnel release, carpometacarpal arthroplasty, wrist arthroscopy, and trigger finger release. Conclusions The single-item SANE is a reasonable measure of global function in patients undergoing common hand procedures and demonstrates psychometric properties comparable to those of the PROMIS-UE and QuickDASH outcome scores. Clinical relevance The SANE score is a reasonable outcome measure of global hand function that may have utility in demonstrating response to treatment in a practice setting and may provide a useful adjunct to multiple-item measures in clinical research studies.

Background: Discoid meniscus epidemiology remains poorly defined for race and sex, in part, due to limitations of retrospective studies and small case series. A better understanding of epidemiology may improve clinical care and diagnostic precision. Purpose: Our purpose is to better define the epidemiology of discoid meniscus by analyzing a large, national database for incidence rates by sex and race. Methods: Analysis was conducted on the national-scale Clinformatics Data Mart Database by Optum. Proportions of the database’s racial categories (Asian, Black, Hispanic, White, and Unknown) in the total population of diagnosed discoid meniscus cases (n = 1,006) were calculated and compared via chi-squared tests to the total database population (n = 65,759,970). This analysis was repeated for the population of patients who received knee arthroscopies (81,205). Incidence rates were calculated from these populations as well. Finally, a multivariable logistic regression analysis based on the population of arthroscopy-receiving patients was performed to control for age, reported gender, and income. Results: Proportions of Asian, Black, Hispanic, and White racial categories in the discoid meniscus group were 5.7%, 7.3%, 20.6%, 66.4%, respectively; the proportions of each racial category in the total population were 5.2%, 10.3%, 13.5%, 71.0%, respectively. Incidence rates (per 10,000) for these groups in the arthroscopy population were 72.9, 25.6, 49.2, 25.6, respectively. Our logistic regression model indicated that race was not a statistically significant predictor for our dataset after income adjusting. Adjusting for other covariates, the odds of a discoid meniscus diagnosis decreased by 6% for each increase in age (p < 0.001) and were 41% lower for males compared to females (p < 0.001). Conclusion: Prior studies have suggested that race (Asian and Hispanic, is a predictor of higher incidence of discoid meniscus – this study did not show a difference in incidence based upon race. Patient sex and age was identified as significant predictors for discoid meniscus, and increasing age showed a decreasing incidence of this condition. This study’s analysis of a large, national claims database allows for a comprehensive epidemiological study on this topic, offering proportions and incidence rates by race appropriate for application to the US population. Its conclusions promote patient sex and age as significant predictors and question the beliefs on race-associated incidence often based on comparing results from the corpus of single-site cohort studies. Tables/Figures: [Table: see text]

Background: As regards anterior cruciate ligament (ACL) reconstruction (ACLR), graft diameter has been identified as a major predictor of failure in skeletally mature patients; however, this topic has not been well-studied in the higher risk pediatric population. Hamstring tendon autograft configuration can be adjusted to increase graft diameter, but tendon length must be adequate for ACLR. Historical parameters of expected tendon length have been variable, and no study has quantified pediatric ACL morphology with other osseous parameters. Purpose: To develop magnetic resonance imaging (MRI)–derived predictors of native ACL graft length in pediatric patients so as to enhance preoperative planning for graft preparation in this skeletally immature patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: MRI scans of 110 patients were included (64 girls, 46 boys; median age, 10 years; range, 1-13 years). Patients with musculoskeletal diseases or prior knee injuries were excluded. The following measurements were taken on MRI: ACL length; sagittal and coronal ACL inclination; intercondylar notch width and inclination; and femoral condyle depth and width. Associations between these measurements and patient sex and age were investigated. Univariate linear regression and multivariable regression models were created for each radiographic ACL measure to compare R 2. Results: Female ACL length was most strongly associated with the depth of the lateral femoral condyle as viewed in the sagittal plane ( R 2 = 0.65; P < .001). Other statistically significant covariates of interest included distal femoral condylar width, age, and coronal notch width ( P < .05). For males, the ACL length was most strongly associated with the distal femoral condyle width as viewed in the coronal plane ( R 2 = 0.70; P < .001). Other statistically significant covariates of interest for male ACL lengths were lateral femoral condyle depth, age, and coronal notch width ( P < .05). Conclusion: In pediatric populations, femoral condylar depth/width and patient age may be valuable in assessing ACL size and determining appropriate graft dimensions and configuration for ACLRs. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in this high-risk group.

Background: Investigations of the female athlete triad (Triad) in high school athletes have found that 36% had low energy availability, 54% had menstrual abnormalities, and 16% had low bone mineral density (BMD). Limited data are available showing the prevalence of these risk factors in high school distance runners or regarding best practice on screening for the Triad in the adolescent population. Purpose: To (1) evaluate the prevalence of Triad risk factors and iron supplementation in high school distance runners and (2) pilot a screening tool for Triad risk score. Study Design: Descriptive epidemiology study. Methods: The study population included female high school athletes who participated in cross-country/track. Participants completed a survey including questions regarding dietary habits, menstrual history, and bone stress injury (BSI) history. They then underwent evaluation of 25-hydroxyvitamin D, free triiodothyronine (T3), and dual-energy x-ray absorptiometry scan to measure body fat and BMD through use of age-, sex-, and ethnicity-matched Z scores. Triad scores were calculated. Relationships were analyzed using Spearman correlation coefficient. Results: There were 38 study participants (mean age, 16.9 years). Average body mass index was 19.8 kg/m2. Disordered eating or eating disorders were reported in 76.3% of runners; in addition, 23.7% reported delayed menarche, 45.9% had a history of amenorrhea or oligomenorrhea, 42.1% had low BMD ( Z score < –1.0), and 15.8% reported prior BSI. Low free T3 was significantly associated with higher Triad risk scores ( r S = –0.36; P = .028). More than 42% of athletes were supplementing iron. Conclusion: The prevalence of Triad risk factors in high school distance runners was high. Free T3 was inversely associated with Triad score, which may serve as an indicator of low energy availability. Nearly half of the athletes were using iron supplementation.

Objectives: The menisci of the knee (Figure 1) play a critical role in maintaining structural integrity, as well as in load bearing and shock absorption. In adolescent patients, meniscal tear is a very common sports injury, and is frequently associated with concomitant traumatic injuries including tibial eminence fracture or ACL tear. Depending on the severity of meniscal tear, surgical treatment options include arthroscopic partial or total meniscectomy, with a reported 78-88% success rate. Given the high incidence of pediatric meniscal injuries and reliance on landmarks to guide arthroscopic meniscus repair, surprisingly few human pediatric cadaveric studies are reported in the current literature. The primary purpose of our research was to evaluate the rates at which different zones of the meniscus rim lengthen with age during early adolescence. Our null hypothesis was that meniscus rim length is unrelated to patient age, tibial plateau width, or to lateral-medial meniscus width. Methods: From images of 29 dissected cadaveric knee specimens between 1 month and 132 months of age obtained on a copy stand (14 left knee, 15 right knee), we made direct length measurements from the inner to outer meniscus rim at 45 degree intervals (12, 1:30/10:30, 3:00/9:00, 4:30/7:30 o’clock, 6 o’clock) using Autodesk Fusion 360 software (Figure 2). We also measured width between the outer medial and lateral meniscus rims, as well as CT measurements of coronal and sagittal width of the tibial plateau using OsiriX DICOM software. Generalized linear models were used to evaluate the associations of meniscal length measurements with age, tibial width, and meniscal width measurements. All statistical analyses were completed with a two-sided level of significance of 0.05. Results: All meniscal length measurements were predicted to increase significantly as age increases (p < 0.01 for all), as coronal tibial width increases (p < 0.05 for all), and as lateral-medial meniscal width increases (p < 0.001 for all). Other than the lateral 3 o’clock measurement (p = 0.119), all meniscal length measurements were predicted to increase significantly as sagittal tibial width increases (p < 0.05 for the rest). Interestingly, the posterior zones of the medial meniscus (6 o’clock and 4:30/7:30 o’clock) were found to increase in length at a faster rate than the anterior zones (Figure 3), which supports our hypothesis that increased weight bearing is correlated with meniscus growth. The same length correlation was not identified in the lateral meniscus. Furthermore, the anterior zones of the medial meniscus (12 o’clock and 1:30/10:30 o’clock) were found to have the slowest rate of growth, presumably due to reduced weight bearing function anteriorly. Conclusions: We reject our null hypothesis that meniscus rim length is unrelated to age, tibial plateau width, or to lateral-medial meniscus width. Surprisingly, the posterior zones of the medial meniscus were found to grow at a faster rate with age compared to the anterior zones, which we attribute to the effect of increased weight bearing experienced by the posterior zones during knee bending exercise. Additionally, the anterior, lesser-weight bearing regions of the medial meniscus were found to develop at the slowest rate out of all zones measured. Further studies are underway to generalize these observations to all adolescent patients. This information will be useful for meniscus repair and transplantation surgical planning.