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BackgroundAnterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) show promise in lowering the risk of rerupture after anterior cruciate ligament reconstruction (ACLR), but there are little data on surgeon practices and preferences in children and adolescents.PurposeTo quantify surgeon practices regarding ALLR and LET in the pediatric population.Study designCross-sectional study.MethodsAn electronic survey was administered to 87 surgeons in the Pediatric Research in Sports Medicine society. The questionnaire asked several questions about surgeon and practice characteristics as well as indications, preferences, and techniques for ALLR or LET in the context of primary and revision pediatric ACLR. Chi-square and Fisher exact tests were used to evaluate factors that affect surgical preferences.ResultsA total of 63 surgeons completed the survey, of whom 62% performed ≥50 pediatric ACLRs annually; 56% sometimes performed anterolateral augmentation with primary ACLR, and 79% with revision ACLR. The most common indications for ALLR or LET in the primary setting were high-grade pivot shift, knee hyperextension, generalized laxity, and type of sports participation. Surgeons whose practice was >75% sports medicine were more likely to perform ALLR or LET with both primary and revision ACLR (P = .005 and P < .001, respectively). Those who had completed a sports medicine fellowship were more likely to perform these procedures than those with only pediatric orthopaedic training, in both primary (68% vs 36%; P = .01) and revision scenarios (92% vs 60%; P = .002). Of the 28 respondents who did not perform ALLR or LET with primary ACLR, 75% cited insufficient evidence as the reason. However, 96% of surgeons who did perform these procedures expressed interest in studying them prospectively, and 87% were willing to randomize patients.ConclusionFindings indicated that 56% of pediatric sports surgeons sometimes perform anterolateral augmentation with primary ACLR and 79% with revision ACLR. Surgeons with sports medicine fellowship training or a mostly sports practice were more likely to perform these procedures. Insufficient evidence was the most common reason given by surgeons who did not perform anterolateral augmentation. However, there was substantial willingness to prospectively study and even randomize pediatric patients to assess the impact of ALLR or LET in this population.

Background: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. Purpose: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. Results: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P <.001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P =.008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). Conclusion: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs. [ABSTRACT FROM AUTHOR]

Since 2004, the US Food and Drug Administration (FDA) has had the authority to allow access to unapproved medical products via the Emergency Use Authorization (EUA) pathway during times of emergency. It was rarely used until the COVID-19 pandemic, when concerns arose regarding the role of political pressure in the FDA's issuance of some EUAs, such as for hydroxychloroquine. Although US government officials should be responsive to the public, democratic accountability must be balanced against the need for thoughtful science-based decision-making. Inadequate agency independence can diminish public confidence in government leaders and the FDA. To consider whether reform of the EUA process might be appropriate, we considered three possible sources of inspiration for balancing independence and accountability in government scientific decision-making: models in other countries, models in other US agencies, and models within the FDA itself. Strategies used in these settings include: (1) expanding the role of advisory committees, (2) increasing transparency of the agency's decision-making process and supporting rationale, and (3) improving management of internal agency disagreement. Such reforms could improve public trust in public health regulation both related to and separate from future emergencies. [ABSTRACT FROM AUTHOR]