Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study.

BACKGROUND: Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS: Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis). METHODS: Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS: Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION: Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE: Level III.

Effects of Therapeutic Ultrasound on Growth Plates: A Systematic Review.

PURPOSE: The aim of this systematic review was to evaluate studies reporting on the effects of therapeutic ultrasound on the physis. SUMMARY OF KEY POINTS: Eight studies were included in the final analysis, all of which were animal studies. At higher doses, studies found skin and bone necrosis and inhibition of growth, while in lower doses some studies found that ultrasound had a transient stimulatory effect on growth, increased thickness of the hypertrophic zone, and increased thickness of the whole growth plate. Overall, experimental evidence in animal models suggests that therapeutic ultrasound, even at low doses, might induce microscopic changes to the histology of the growth plate. CONCLUSION: While we found no reports of growth disturbance in humans, given the histological changes found in animal studies, the current limited literature seems to support the recommendation that the application of therapeutic ultrasound around the physis should be avoided.

Open reduction of radial neck fractures in children: injury severity predicts the radiographic and clinical outcomes.

BACKGROUND: Radial neck fractures are the third most common elbow fracture in children. Open reduction may be required if closed or mini-open techniques are not successful in reducing the fracture. Previous reports on open reduction have noted poor outcomes and complications with this treatment approach. However, it is unknown whether it is the open procedure itself or the severity of the initial injury that leads to the poor results. The purpose of this study was to evaluate the correlation between intraoperative findings at the time of open reduction of radial neck fractures and the clinical and radiographic outcomes. METHODS: Data from patients who underwent open reduction for an acute radial neck fracture between January 2009 and December 2018 were abstracted and reviewed. Patients undergoing open treatment for a nonunion or malunion and those with inadequate follow-up were excluded. Demographic data, injury characteristics, treatment strategies, intraoperative findings, and clinical and radiographic outcomes were assessed. RESULTS: Twenty-two patients met the inclusion criteria. Of these patients, 14 were girls. The mean age was 9.7 ± 3 years, and the mean follow-up period was 15.8 months. Fifteen patients had a Judet grade IV displacement. Fair or poor outcomes were observed in 12 patients (55%). Ten reoperations were recorded during the study period. Age, weight, and associated injuries were not predictive of poor outcomes. Intraoperative findings of soft-tissue stripping and radial head comminution were the only significant predictors of fair or poor clinical outcomes (P < .001) and subsequent radiographic changes including fragmentation and collapse of the radial head and arthritic changes (P < .001). The quality of reduction and the choice of hardware were not significantly associated with either clinical or radiographic outcomes. CONCLUSION: Our findings support the notion that the outcomes of open reduction of radial neck fractures are most closely correlated with the injury severity, with the intraoperative findings of complete soft-tissue stripping or comminution of the radial head fragment being significant predictors of poor clinical and radiographic outcomes. The choice of hardware and the quality of reduction achieved at the time of surgery have less significance than injury severity.

Which Children Are at Risk for Contralateral Anterior Cruciate Ligament Injury After Ipsilateral Reconstruction?

BACKGROUND: Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction. METHODS: After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival. RESULTS: A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01). CONCLUSIONS: After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years. LEVEL OF EVIDENCE: Level III-prognostic study.

Simulation Training of Orthopaedic Residents for Distal Radius Fracture Reductions Improves Radiographic Outcomes.

BACKGROUND: Most distal radius fractures can be treated with closed reduction and casting in pediatric patients. These skills are traditionally developed treating real patients, however, there is growing interest in the use of simulation training to supplement traditional learning strategies. METHODS: Seventy-eight children with distal radius fractures that underwent closed reduction and casting by novice orthopaedic surgery residents were retrospectively reviewed. Radiographic measures of patients treated by simulation-trained residents were compared with patients treated by residents without simulation training. RESULTS: Patients treated by simulation-trained residents had less residual angulation in the anteroposterior radiograph (3.7 vs. 6.3 degrees, P=0.006) and translation on the lateral (14% vs. 21%, P=0.040) and anteroposterior radiograph (10% vs. 16%, P=0.029). Patients treated by simulation-trained residents also had lower rates of redisplacement (50% vs. 79%, P=0.016). CONCLUSIONS: Loss of reduction is common, particularly when novice trainees perform their first independent reductions. Residents who underwent simulation training had lower rates of loss of reduction, thus simulation training has potential as a supplement to the traditional apprentice model of medical education. LEVEL OF EVIDENCE: Level III.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures.

BACKGROUND: Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. METHODS: Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. RESULTS: A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). CONCLUSIONS: A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. LEVEL OF EVIDENCE: Level II-economic.

Glove Perforation in Orthopaedics: Probability of Tearing Gloves During High-Risk Events in Trauma Surgery.

OBJECTIVE: To assess the risk of glove perforation during common maneuvers or events in trauma-related orthopaedic surgical procedures. METHODS: Four investigators executed 6 high-risk maneuvers in a simulated laboratory setting. Alternative techniques were also performed for most maneuvers. Glove integrity was examined by 2 standard methods of fluid leak testing. The rates of perforation were compared between techniques using χ and Fisher exact tests. RESULTS: Investigators were only able to identify 14.3% of perforations. Cleaning drill bit flutes by hand had the highest overall tear rate (85%). Catching a glove along the guide wire when passing a cannulated drill bit resulted in a 50% perforation rate. Catching a glove around a rotating drill shaft had a tear rate of 40%. Palpating the end of a flexible nail cut with a wire cutter had a significantly higher perforation rate than a nail cut with a proprietary, nail-specific tool (35% vs. 5%, P = 0.022). Blind digital fracture reduction had a tear rate that was not statistically different than directly visualizing the reduction (20% vs. 15%, P = 0.5). Inserting screws while stabilizing the threads with one's fingers resulted in a perforation rate of 15%. CONCLUSIONS: Orthopaedic surgeons should be aware that microperforation of surgical gloves often goes undetected and should consider modifying or using alternative techniques when performing certain surgical maneuvers. The results of this study can be used by orthopaedic and surgical first assist training programs to promote safe surgical practice.

Can a Novel, Low-Cost Simulation Model be Used to Teach Anterior Cruciate Ligament Graft Preparation?

BACKGROUND: This study evaluated an anterior cruciate ligament (ACL) graft preparation simulation learning model for use by orthopaedic surgery trainees. METHODS: A simulation model for ACL graft preparation was constructed using shoelace as graft material and a wooden graft preparation board that matched the dimensions of existing products. A 12-minute instructional video targeted at novice learners was created to accompany the simulation model. A prospective randomized controlled trial was conducted on orthopaedic surgery residents divided into 2 groups with equal distributions of postgraduate year (PGY) status. The intervention group learned ACL graft preparation via the Shoelace ACL Simulation Guide, whereas a control group viewed a standard instructional video. All participants then prepared an 8-strand ACL graft using allograft materials and were evaluated via a checklist of critical steps and a global assessment rating as provided by an expert blinded to group allocation. Participants' preintervention and postintervention self-assessment scores were also collected. RESULTS: Ten orthopaedic surgery residents from a single institution participated in the study, with even distributions across study groups of PGY-1, PGY-3, and PGY-4 residents. Preintervention self-assessments of knowledge and technical ability were similar between participant groups. The mean overall performance score was significantly greater in the shoelace simulation intervention group (22.6±1.5) than in the instructional video only control group (16.0±5.1) (P=0.043). Participants in the intervention group showed greater improvement in self-confidence in their technical ability than those in the control group (P=0.012). Groups demonstrated similar postintervention improvements in self-reported knowledge of ACL graft preparation (P=0.128). All participants who learned via the Shoelace ACL Simulation Guide strongly agreed that they would use the learning tool to prepare for ACL reconstruction surgery. CONCLUSIONS: A self-directed low-cost simulation model for soft tissue ACL graft preparation utilizing shoelaces resulted in improved performance metrics compared with standard video instruction. The teaching model may be incorporated easily and inexpensively into simulation curricula at other training programs. LEVEL OF EVIDENCE: Level II-therapeutic study.