Editorial Commentary: Osteochondral Allograft of the Knee-Diffuse Edema at 6 Months on Magnetic Resonance Imaging Predicts Failure.

Cartilage defects alter natural function of articular cartilage and can predispose patients to further cartilage wear and eventual osteoarthritis. These injuries present a challenging problem with a multitude of treatment options and lack of consensus on when to employ each. Options include conservative measures (limited weightbearing and immobilization), debridement, microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft. Indications may be based on defect size, joint alignment, age, activity level, body mass index, and sex. One option, osteochondral allograft (OCA) transplantation, is typically reserved for large and severe defects or revision. With regard to OCA prognosis, older patients, revision cases, patellar defects, and bipolar lesions confer elevated risk of failure, whereas traumatic or idiopathic cases, unipolar lesions, and short duration of symptoms have reported higher levels of satisfaction. Following surgery, the patient with persistent symptoms can present a conundrum. Recent research shows that in such cases, diffuse edema at 6 months on magnetic resonance imaging often predicts ultimate failure, in which case arthroplasty may be required.

Achilles Tendon Injuries Requiring Surgical Treatment in the Pediatric and Adolescent Population: A Case Series.

ABSTRACT: Pediatric Achilles tendon injuries requiring surgical treatment are considered rare and have not been well described. A retrospective chart review was conducted from 2010 to 2020 to identify cases of acute Achilles tendon rupture or laceration that required surgical repair in individuals 19 years or younger. A total of 24 individuals with acute Achilles tendon ruptures (n = 8) and lacerations (n = 16) were identified. All spontaneous ruptures occurred in skeletally mature individuals during sports. One subject was on minocycline at the time of injury, while two had a body mass index (BMI) ≥ 99% for age. Another had a history of clubfoot surgery on the injured side. Patients with lacerations were younger (9.9 ± 3.3 vs 16.3 ± 1.6 years) and had lower BMI (17.3 ± 3.8 vs. 28.0 ± 9.4) than those with spontaneous ruptures. The majority of cases had good outcomes with no postoperative complications.

Outcomes of MPFL Reconstruction Utilizing a Quadriceps Turndown Technique in the Adolescent/Pediatric Population.

PURPOSE: Recurrent instability following a lateral patellar dislocation is a common indication for surgical intervention. Several surgical procedures are described in the literature to address recurrent patellar instability. Medial patellofemoral ligament (MPFL) reconstruction utilizing the quadriceps turndown technique attempts to restore medial stability. Results of the quadriceps turndown technique have previously only been reported in adult populations. The purpose of this study was to assess the safety, efficacy, and patient-reported outcomes following a quadriceps turndown MPFL reconstruction in the pediatric and adolescent population. METHODS: Records of all patients who underwent MPFL reconstruction using a quadriceps turndown technique between 2011 and 2018 were reviewed for demographics, risk factors, complications, mechanism of injury, and concomitant procedures. Return to activities of daily living (ADLs), return to presurgery level of sport, length of bracing, and recurrent instability were assessed with the administration of the Kujala Anterior Knee Pain Score. All analyses were completed using IBM SPSS Statistics 26. RESULTS: Thirty-six knees [14 female (39%), 22 male (61%)] from 34 patients met inclusion/exclusion criteria. The average follow-up length was 35.9±15.2 months. The average age was 16.3±1.8 years at the time of surgery. The average time for resumption of ADLs was 8.1±6.0 weeks after surgery. Ninety-four percent of patients returned to preinjury level of sport at an average of 23.6±12.0 weeks after surgery. Mean Kujala Anterior Knee Pain Score was 90.7±10.3. Female patients (P<0.001) reported significantly lower Kujala scores. Three patients (8%) experienced recurrent instability during ADLs and an additional 4 (11%) reported subjective feelings of instability only during sport or elevated activity. One knee required a return to the operating room for irrigation and debridement due to infection. CONCLUSION: This study demonstrates that the quadriceps turndown technique for MPFL reconstruction is a safe and effective procedure for the management of recurrent patellar instability in pediatric and adolescent patients. LEVEL OF EVIDENCE: Level III-therapeutic.

Biomechanical Evaluation of Two Arthroscopic Biceps Tenodesis Techniques: Proximal Interference Screw and Modified Percutaneous Intra-Articular Transtendon.

The percutaneous intra-articular transtendon (PITT) technique has recently been shown to have results comparable to those of more accepted techniques. Its mode of failure was secondary to the suture pulling through the tendon substance. A modification was made whereby the tendon is locked within the suture configuration in an attempt to avoid pullout. We compared this new technique with a well-accepted technique of all-arthroscopic interference screw. In each of 8 pairs of cadaveric shoulders (mean age, 55 years; range, 51-59 years), one shoulder was randomized to be treated with either modified PITT or interference screw (Biceptor; Smith & Nephew) biceps tenodesis, and the other shoulder was treated with the other technique. The tendons were preloaded at 10 N and then cycled at 0 to 50 N for 100 cycles at 1 Hz. Load to failure was calculated at a rate of 1.0 mm per second until peak load was observed. Mean (SD) ultimate load to failure was 157 (41) N for the modified PITT technique and 107 (29) N for the interference screw technique (P = .003). In 7 of 8 specimens, the interference screw technique failed at the junction of the tendon, the screw, and the bone interface. In 7 of 8 specimens, the PITT technique failed by the tendon slipping through the suture or pulling through transverse ligament/rotator interval tissue. Study results showed the modified PITT technique was a biomechanically superior construct.

Intercondylar Roof Inclination Angle: Is It a Risk Factor for ACL Tears or Tibial Spine Fractures?

BACKGROUND: The relationship between the angle of inclination of the intercondylar roof [roof inclination angle (RIA)] and likelihood of knee injury has not been previously investigated in children. METHODS: Twenty-five skeletally immature patients with a tibial spine fracture were age matched (±1 y) and sex matched with 25 patients with an anterior cruciate ligament (ACL) tear and with 50 control knees (2 for each patient). Demographic and diagnostic information was collected, and radiographic measurements were performed on notch and lateral radiographs of the knee. RESULTS: Patients with a tibial spine fracture had an increased RIA compared with controls and patients with an ACL tear. Patients with ACL tears had a steeper notch roof, as indicated by a decreased RIA when compared with controls and patients with tibial spine fractures. CONCLUSIONS: Our results demonstrated that a decreased RIA was associated with ACL tear and that an increased RIA was associated with tibial spine fracture. LEVEL OF EVIDENCE: Level III-prognostic.

Rupture of the Long Head of the Biceps Tendon in a Pediatric Athlete: A Case Report.

CASE: We report a case of an adolescent athlete who sustained an isolated rupture of the long head of the biceps tendon and was subsequently treated with subpectoral biceps tenodesis. CONCLUSION: Provided that there is no damage to the rotator cuff, an open biceps tenodesis may be performed in this young patient population with good short-term outcomes and return to full activity.

Is there still a place for cast wedging in pediatric forearm fractures?

BACKGROUND: Forearm fractures are common skeletal injuries in childhood and can usually be treated nonoperatively with closed reduction and casting. Trends toward increasing operative treatment of these fractures have emerged. We aim to demonstrate the safety and efficacy of cast wedging for treatment of pediatric forearm fractures. METHODS: We performed a prospective chart review of patients with forearm fractures, including distal radius (DR) fractures, treated with cast wedging at a single large pediatric hospital from June 2011 to September 2012. Inclusion criteria specified open distal radial physis, closed injury, loss of acceptable reduction, and availability of clinical and radiographic data from injury to cast removal. Exclusion criteria included pathologic fractures, neurovascular injury, fracture dislocations, open fractures, and closed DR physis. Reductions were performed and patients followed according to standard protocol at our institution, including placement into long-arm casts, initial follow-up visit within 5 to 10 days postinjury, and weekly visits for 2 weeks thereafter. If alignment were deemed unacceptable within 3 weeks of injury, cast wedging was utilized. Radiographic measurements of alignment included both radius and ulna on the injury film, postreduction, prewedge, postwedge, and final films. Radiographic technique was standardized, with repeatability testing demonstrating a precision of ±2 degrees. RESULTS: Over 15 months, our hospital treated 2124 forearm or DR fractures with closed reduction and casting. There were 60 fractures treated either with percutaneous fixation (36) or open treatment (24). A total of 79 forearm or DR fractures were treated with cast wedging secondary to loss of reduction, of which 70 patients had complete clinical and radiographic data. Average age was 8.4 years (range, 3 to 14 y), with 25 females and 45 males. Significant improvement in angulation for both-bone forearm fracture from prewedge to final films was seen in 69 children, with no major complications. One patient failed wedging and required surgical reduction and fixation. CONCLUSIONS: Cast wedging is a simple, safe, noninvasive, and effective method for treatment of excessive angulation in pediatric forearm fractures. LEVEL OF EVIDENCE: Level IV.

Weight-bearing osteochondral lesions of the lateral femoral condyle following patellar dislocation in adolescent athletes.

In patients with patellar dislocation, osteochondral injury is often an indication for early surgical intervention. However, no studies have identified a relationship between injury to the weight-bearing surface of the lateral femoral condyle following a patellar dislocation and the eventual need for surgical treatment. The authors hypothesized that a significant number of patients sustain injury to the weight-bearing surface of the lateral femoral condyle following an acute patellar dislocation.Radiographs and magnetic resonance images were retrospectively reviewed and the patterns of injury were evaluated for 80 patients with a diagnosis of acute patellar dislocation, including the presence of osteochondral damage, the location of the medial patellofemoral ligament injury, and concomitant meniscal pathology. Magnetic resonance imaging identified a 27.5% incidence of osteochondral injury involving the articular, weight-bearing region of the lateral femoral condyle following an acute lateral patellar dislocation. Surgical intervention was performed in more than 60% of these injuries, and most were not identified with plain radiographs. Injury to the weight-bearing surface of the lateral femoral condyle following patellar dislocation was 3.6 times more common in boys in the current study population.Osteochondral injury to the weight-bearing surface of the lateral femoral condyle may occur in a high percentage of patients following a lateral patellar dislocation and in a higher percentage of boys than girls. Patients with tenderness over the lateral femoral condyle following an acute lateral patellar dislocation should undergo magnetic resonance imaging.

Assessment of musculoskeletal physical examination skills and attitudes of orthopaedic residents.

BACKGROUND: Although the musculoskeletal physical examination is an essential part of patient encounters, we believe that it is underemphasized in residency education and that residents' physical examination skills may be lacking. We sought to assess attitudes regarding teaching of the physical examination in orthopaedic residencies, to assess physical examination knowledge and skills among residents, and to develop a method to track the skill level of residents in order to improve our physical examination curriculum. METHODS: We created a thirty-question multiple-choice musculoskeletal physical examination test and administered it to our residents. We created a five-question survey assessing attitudes toward physical examination teaching in orthopaedic residencies and distributed it to U.S. orthopaedic department chairs We developed an Objective Structured Clinical Examination (OSCE), in which standardized patients enact four clinical scenarios, to observe and assess physical examination skills. RESULTS: The mean score on the multiple-choice physical examination test was 76% despite the fact that our residents consistently scored above 90% on the Orthopaedic In-Training Examination. Department chairs and residents agreed that, although learning to perform the physical examination is important, there is not enough time in the clinical setting to observe and critique a resident's patient examination. The overall score of our residents on the OSCE was 66%. CONCLUSIONS: We have exposed a deficiency in the physical examination knowledge and skills of our residents. Although the musculoskeletal physical examination is a vital practice component, our data indicate that it is likely underemphasized in training. Clinic time alone is likely insufficient for the teaching and learning of the musculoskeletal physical examination.

Implementation of an objective structured clinical exam (OSCE) into orthopedic surgery residency training.

OBJECTIVE: While the musculoskeletal (MSK) physical examination (PE) is an essential part of a patient encounter, we believe it is an underemphasized component of orthopedic residency education and that resident PE skills may be lacking. The purpose of this investigation was to (1) assess the attitudes regarding PE teaching in orthopedic residencies today; (2) develop an MSK objective structured clinical examination (OSCE) to assess the MSK PE knowledge and skills of our orthopedic residents. DESIGN: Prospective, uncontrolled, observational. SETTING: A major Midwestern tertiary referral center and academic medical center. PARTICIPANTS: The orthopedic surgery residents in our program. Twenty-two of 24 completed the OSCE. RESULTS: Surveys showed that residents agreed that although learning the PE is important, there is not enough time in clinic to actually observe and critique a resident examining a patient. For the 22 residents (postgraduate year [PGY] 2-5) who participated in the OSCE, the overall score was 66%. Scores were significantly better for the trauma scenario (78%; p < 0.05) than for the shoulder (67%), spine (64%), and knee (59%) encounters. The overall scores for each component of the OSCE were: (1) history 53%; (2) PE 60%; (3) 5-question posttest 64%; and (4) communication skills 90%. CONCLUSIONS: We have exposed a deficiency in the PE knowledge and skills of our residents. Clinic time alone may be insufficient to both teach and learn the MSK PE. The use of a MSK OSCE, while novel in orthopedics, will allow more direct observation of our residents MSK PE skills and also allow us to follow resident skills longitudinally through their training. We hope that our efforts will encourage other programs to assess their PE curriculum and perhaps prompt change.

Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review.

OBJECTIVE: The purpose is to systematically evaluate the literature regarding treatment of chronic glenoid bone defects in the setting of recurrent anterior shoulder instability to determine if, from an evidence-based outcomes approach, one technique may be recommended over the other. METHODS: PubMed 1966-2009, Embase 1980-2009, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials databases were searched for human studies in English. Keywords were osseous glenoid defects, glenoid bone grafting, Latarjet procedure, iliac crest and glenoid defects, and glenoid rim fractures. Inclusion criteria were all articles evaluating chronic glenoid deficiency in the setting of recurrent anterior glenohumeral instability. Exclusion criteria were surgical techniques not reporting follow-up, glenoid rim fractures treated by open reduction internal fixation, and investigations not quantifying glenoid deficiency assessments. RESULTS: Six articles met all inclusion and exclusion criteria. All articles were level IV (case series), most (5/6) were retrospective. Multiple techniques involving coracoid transfer and allograft or autograft reconstruction have been described for management of chronic glenoid deficiency. Lack of high level evidence in the form of prospective randomized trials limits our ability to recommend one technique over another. The 6 techniques reviewed here were all effective at preventing recurrent instability. CONCLUSIONS: Chronic glenoid deficiency in the setting of recurrent anterior instability is an extremely challenging problem. There remains a lack of strong evidence guiding the surgeon in the decision-making process. Additional research is needed to optimize the preoperative glenoid defect assessment, further evaluate the reconstruction techniques, and follow the long-term effects of reconstruction on the development of glenohumeral arthrosis.