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Kevin Shea, MD

Health care is a team sport, and I work with families and patients to help them develop a team for their recovery and improvement. Patients and families are at the core of this team, and their 'teammates' include office staff, athletic trainers, physical therapists, coaches, teachers and more.

I am very fortunate to work in a healing profession and to be part of a process that improves the lives of our patients and families. It is a privilege to get to know patients and families and be part of the community.

Before going to medical school, I worked as a teacher. I was planning to be a high school teacher and football, soccer and wrestling coach. My high school biology teacher convinced me to become a physician and to work with athletes, much like a coaching. Specializing in orthopedics has allowed me to continue to teach, work with athletes, and watch kids and teens grow and develop. It is a great privilege to care for my patients, and I continue to learn from them every day.

Specialties

Orthopaedic Surgery

Work and Education

Professional Education

UCLA David Geffen School Of Medicine Registrar, Los Angeles, CA, 06/01/1991

Internship

University of Utah General Surgery Residency, Salt Lake City, UT, 6/30/1992

Residency

University of Utah - Dept of Orthopaedics, Salt Lake City, UT, 6/30/1997

Fellowship

Rady Childrens Hospital Pediatric Orthopedic Fellowship, San Diego, CA, 7/30/1998

Board Certifications

Orthopaedic Sports Medicine, American Board of Orthopaedic Surgery

Orthopaedic Surgery, American Board of Orthopaedic Surgery

All Publications

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents. Journal of pediatric orthopedics Parikh, S. N., Schlechter, J. A., Veerkamp, M. W., Stacey, J. D., Gupta, R., Pendleton, A. M., Shea, K. G., Friel, N. A., Molony, J. T., Yaniv, M., Rhodes, J., Finlayson, C. J., Williams, B. A., Ellington, M., PRISM Patellofemoral Research Interest Group (PRISM PF RIG), Green, D. W., Mikutis, J. L., Milbrandt, T. A., Pace, J. L., Redler, L. H., Safier, S. D., Shubin Stein, B. E., VandenBerg, C., Wall, E. J. 2024

Abstract

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture.METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer.RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%).CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice.CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

View details for DOI 10.1097/BPO.0000000000002616

View details for PubMedID 38258884

Physeal Sparing Approaches for MPFL Reconstruction. Current reviews in musculoskeletal medicine Stavinoha, T. J., Shea, K. G. 2023

Abstract

To update and concepts for pediatric physeal-sparing patellofemoral stabilization surgery.Recent studies have demonstrated positive results in patellofemoral stabilization in pediatric populations with physeal-sparing techniques that limit the potential for physeal damage. Comprehensive analysis remains limited by population and technique heterogeneity. Physeal-sparing patellofemoral stabilization, most significantly through physeal-sparing reconstruction of the medial patellofemoral ligament complex remains a viable option for pediatric patients with recurrent patellofemoral instability.

View details for DOI 10.1007/s12178-023-09864-w

View details for PubMedID 38079082

View details for PubMedCentralID 6551554

Cell Count and Cell Density Decrease as Age Increases in Cadaveric Pediatric Medial Menisci. Arthroscopy, sports medicine, and rehabilitation Albersheim, M., Fedje-Johnston, W., Carlson, C., Arnoczky, S. P., Toth, F., Shea, K., Harper, L., Rendahl, A., Tompkins, M. 2023; 5 (6): 100795

Abstract

To examine the histologic changes in terms of cellularity, cell density, and nuclear shape in medial meniscal cellularity during skeletal development using pediatric cadaver specimens.Medial menisci from 26 pediatric cadavers, 11 female and 15 male (total 36 menisci), were obtained from tissue bank. Mean age of female donors was 34 months (1-108 months) and of male donors was 52 months (1-132 months). Menisci were processed and embedded in paraffin blocks. Each tissue block containing 6 representative areas of meniscus (anterior root, anterior horn, body [n= 2], posterior horn, and posterior root) was sectioned at 4 microns and stained with hematoxylin and eosin for evaluation of chondrocyte nuclei. Each of the 6 representative areas was imaged at 10; one image on peripheral one-third of section, the second image on central two-thirds of the section. FIJI imaging software was used to measure cell count, cell density, and nuclear morphology (1= perfect circle). Data analysis included linear mixed models, Type II analysis of variance tests, and pairwise tests with the Tukey correction to assess statistical significance.Peripheral meniscus was more cellular than central meniscus. The cell count was found to decrease by 14% per year of age. Peripheral cell count decreased at a rate similar to the cell count in the central meniscus. Meniscal cell density was 2 higher peripherally than centrally. Overall average cell density in all locations in the menisci decreased by an average of 14% per year of age.The results of this study reveal decreases in cell count, cell density, and circularity as age increases in cadaveric pediatric medial menisci.To better understand the development of pediatric menisci at a cellular level and use this knowledge in the future on how to maintain the menisci in a younger, healthier state.

View details for DOI 10.1016/j.asmr.2023.100795

View details for PubMedID 37868658

View details for PubMedCentralID PMC10585640

Changes in tissue sodium concentration and sodium relaxation times during the maturation of human knee cartilage: Ex vivo 23 Na MRI study at 10.5T. Magnetic resonance in medicine Zb, ., Ludwig, K. D., Watkins, L. E., Lagore, R. L., Nowacki, A., Tth, F., Tompkins, M. A., Zhang, L., Adriany, G., Gold, G. E., Shea, K. G., Nagel, A. M., Carlson, C. S., Metzger, G. J., Ellermann, J. M. 2023

Abstract

To evaluate the influence of skeletal maturation on sodium (23 Na) MRI relaxation parameters and the accuracy of tissue sodium concentration (TSC) quantification in human knee cartilage.Twelve pediatric knee specimens were imaged with whole-body 10.5T MRI using a density-adapted 3D radial projection sequence to evaluate 23 Na parameters: B1 + , T1 , biexponential T 2 * $$ {\mathrm{T}}_2^{\ast } $$ , and TSC. Water, collagen, and sulfated glycosaminoglycan (sGAG) content were calculated from osteochondral biopsies. The TSC was corrected for B1 + , relaxation, and water content. The literature-based TSC (TSCLB ) used previously published values for corrections, whereas the specimen-specific TSC (TSCSP ) used measurements from individual specimens. 23 Na parameters were evaluated in eight cartilage compartments segmented on proton images. Associations between 23 Na parameters, TSCLB -TSCSP difference, biochemical content, and age were determined.From birth to 12years, cartilage water content decreased by 18%; collagen increased by 59%; and sGAG decreased by 36% (all R2 0.557). The short T 2 * $$ {\mathrm{T}}_2^{\ast } $$ ( T 2 * S $$ {{\mathrm{T}}_2^{\ast}}_{\mathrm{S}} $$ ) decreased by 72%, and the signal fraction relaxing with T 2 * S $$ {{\mathrm{T}}_2^{\ast}}_{\mathrm{S}} $$ ( fT 2 * S $$ {{\mathrm{fT}}_2^{\ast}}_{\mathrm{S}} $$ ) increased by 55% during the first 5years but remained relatively stable after that. TSCSP was significantly correlated with sGAG content from biopsies (R2 =0.739). Depending on age, TSCLB showed higher or lower values than TSCSP . The TSCLB -TSCSP difference was significantly correlated with T 2 * S $$ {{\mathrm{T}}_2^{\ast}}_{\mathrm{S}} $$ (R2 =0.850), fT 2 * S $$ {{\mathrm{fT}}_2^{\ast}}_{\mathrm{S}} $$ (R2 =0.651), and water content (R2 =0.738).TSC and relaxation parameters measured with 23 Na MRI provide noninvasive information about changes in sGAG content and collagen matrix during cartilage maturation. Cartilage TSC quantification assuming fixed relaxation may be feasible in children older than 5years.

View details for DOI 10.1002/mrm.29930

View details for PubMedID 37997011

Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database. The American journal of sports medicine Adsit, E., Albright, J., Algan, S., Beck, J., Bowen, R. E., Brey, J., Marc Cardelia, J., Clark, C., Coello, P., Crepeau, A., Edmonds, E., Ellington, M., Ellis, H. B., Fabricant, P. D., Frank, J. S., Ganley, T. J., Green, D. W., Gupta, A., Heyworth, B., Kemper, W. C., Latz, K., Mansour, A., Mayer, S., McKay, S. D., Milewski, M. D., Niu, E., Pacicca, D. M., Parikh, S. N., Pupa, L., Rhodes, J., Saper, M., Schmale, G. A., Schmitz, M., Shea, K., Silverstein, R. S., Storer, S., Wilson, P. L. 2023: 3635465231206173

Abstract

Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy.To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci.Cohort study; Level of evidence, 3.A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete).In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients 14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair.To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

View details for DOI 10.1177/03635465231206173

View details for PubMedID 37899536

Association of Hip Dysplasia With Trochlear Dysplasia in Skeletally Mature Patients. Orthopaedic journal of sports medicine Fithian, A. T., Richey, A. E., Sherman, S. L., Shea, K. G., Pun, S. Y. 2023; 11 (10): 23259671231200805

Abstract

Developmental dysplasia of the hip (DDH) and trochlear dysplasia (TD) are distinct pathologies with several important features in common. In addition to shared risk factors, both forms of dysplasia cause abnormal joint kinematics and force transmission, predisposing patients to pain, injuries to cartilage and soft tissue stabilizers, and ultimately arthritis.To evaluate for an association between hip dysplasia and TD in skeletally mature patients with symptomatic hip dysplasia.Cross-sectional study; Level of evidence, 3.A total of 48 patients with DDH who underwent periacetabular osteotomy were compared with 48 sex-matched patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) between July 2014 and February 2021. All patients were skeletally mature. The Tnnis angle and lateral center-edge angle were measured on preoperative pelvis radiographs. Femoral version, trochlear depth, lateral trochlear inclination (LTI), tibial tubercle-trochlear groove distance (TTTG-d), and posterior lateral condylar angle (PLCA) were measured on preoperative magnetic resonance imaging scans of the symptomatic hip and ipsilateral knee. Continuous variables were compared between the patient groups using 2-sample t tests. Interobserver reliability was measured using the intraclass correlation coefficient.Patients with DDH demonstrated a reduced trochlear depth compared with patients with FAI (3.6 vs 4.6 mm; P < .001). There were no differences between groups in femoral anteversion, LTI, TTTG-d, or PLCA. Two (4.2%) patients with FAI and 17 (35.4%) patients with DDH had a trochlear depth <3 mm (P < .001). One (2.1%) patient with FAI and 7 (14.6%) patients with DDH had an LTI <11 (P = .027). There was no difference between groups in frequency of a convex proximal trochlea, patient-reported ipsilateral knee pain, or ipsilateral knee procedures.Patients with DDH had reduced trochlear depth compared with patients with FAI, demonstrating a higher incidence of dysplastic trochlear features that may predispose patients to patellofemoral joint disease. Further research is needed to determine whether screening at-risk patients and treating TD will help to prevent symptomatic patellofemoral disease.

View details for DOI 10.1177/23259671231200805

View details for PubMedID 37822419

View details for PubMedCentralID PMC10563471

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study. Journal of pediatric orthopedics Perkins, C. A., Coene, R. P., Miller, P. E., Anderson, C. N., Nunally, K. D., Parikh, S. N., Busch, M. T., Chambers, H. G., Christino, M. A., Cordasco, F. A., Edmonds, E. W., Fabricant, P. D., Ganley, T. J., Green, D. W., Heyworth, B. E., Lawrence, J. T., Matava, M. J., Micheli, L. J., Milewski, M. D., Nepple, J., Pennock, A. T., Saluan, P. M., Shea, K. G., Wall, E. J., Willimon, S. C., Kocher, M. S. 2023; 43 (9): e695-e700

Abstract

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.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.Cohort study (diagnosis).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.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.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 III.

View details for DOI 10.1097/BPO.0000000000002495

View details for PubMedID 37694605

Evaluating the Readability and Quality of Online Patient Education Materials for Pediatric ACL Tears. Journal of pediatric orthopedics Thomas, N. D., Mahler, R., Rohde, M., Segovia, N., Shea, K. G. 2023; 43 (9): 549-554

Abstract

As the rate of anterior cruciate ligament (ACL) tears increases in children, the internet has become a major source of information and education. In the United States, the average adult reads at about an eighth grade level. The National Institutes of Health recommends that patient education materials do not exceed a sixth-grade reading level. Therefore, the most accessed resources on the internet should be created with this in mind. The purpose of this study is to assess the readability and quality of online patient resources for pediatric ACL tears.Google was queried using the term "Pediatric ACL Tear" on May 26, 2022. The most popular sites were identified through page one of a Google search. All content was evaluated to assure information was directed toward patients. To determine reading difficulty, the most widely accepted readability tests: Flesch Reading Ease Index, Flesch-Kincaid Grade Level, and Gunning Fog Index were calculated through plain text in Microsoft Word and URL in online readability checker Readable.io.The average grade level for all resources was above the recommended reading level based on both Microsoft Word and Readable.io calculations. Each source exceeded the NIH recommendation by 2.6 grade levels on average (Mean grade level readability was 8.6 1.9). Four of the 6 sites were above the average US reading level, exceeding the eighth grade by an average of 1.5 grade levels. All 6 sites analyzed had a mean DISCERN score of 61.9,meeting the 'good quality' criteria.The most readily available online materials for Pediatric ACL tears were of 'good quality' but above both the NIH-recommended readability level and the average US adult reading level. With the increasing need for treatment of ACL tears in pediatric and adolescent patients and greater internet accessibility in these populations, it is important to consider the readability of these resources in support of increased health literacy and improved outcomes.It is important for physicians treating young patients with ACL tears to be aware of all sources of information and support, including content shared online as these platforms are increasingly utilized, especially by patients and families of lower socioeconomic status.

View details for DOI 10.1097/BPO.0000000000002490

View details for PubMedID 37694607

MRI of patellar stabilizers: Anatomic visibility, inter-reader reliability, and intra-reader reproducibility of primary and secondary ligament anatomy. Skeletal radiology Zandee van Rilland, E. D., Payne, S. R., Gorbachova, T., Shea, K. G., Sherman, S. L., Boutin, R. D. 2023

Abstract

To compare MRI features of medial and lateral patellar stabilizers in patients with and without patellar instability.Retrospective study of 196 patients (mean age, 33.118.5years; 119 women) after diagnosis of patellar instability (cohort-1, acute patellar dislocation; cohort-2, chronic patellar maltracking) or no patellar instability (cohort-3, acute ACL rupture; cohort-4, chronic medial meniscus tear). On MRI, four medial and four lateral stabilizers were evaluated for visibility and injury by three readers independently. Inter- and intra-reader agreement was determined.Medial and lateral patellofemoral ligaments (MPFL and LPFL) were mostly or fully visualized in all cases (100%). Of the secondary patellar stabilizers, the medial patellotibial ligament was mostly or fully visualized in 166 cases (84.7%). Other secondary stabilizers were mostly or fully visualized in only a minority of cases (range, 0.5-32.1%). Injury scores for all four medial stabilizers were higher in patients with acute patellar dislocation than the other 3 cohorts (p<.05). Visibility inter- and intra-reader agreement was good for medial stabilizers ( 0.61-0.78) and moderate-to-good for lateral stabilizers ( 0.40-0.72). Injury inter- and intra-reader agreement was moderate-to-excellent for medial stabilizers ( 0.43-0.90) and poor-to-moderate for lateral stabilizers ( 0-0.50).The MPFL and LPFL were well visualized on MRI while the secondary stabilizers were less frequently visualized. The secondary stabilizers were more frequently visualized medially than laterally, and patellotibial ligaments were more frequently visualized compared to the other secondary stabilizers. Injury to the medial stabilizers was more common with acute patellar dislocation than with chronic patellar maltracking or other knee injuries.

View details for DOI 10.1007/s00256-023-04432-2

View details for PubMedID 37704830

View details for PubMedCentralID 7723147

Knee MRI: Meniscus Roots, Ramps, Repairs, and Repercussions. Radiographics : a review publication of the Radiological Society of North America, Inc Tomsan, H., Gorbachova, T., Fritz, R. C., Abrams, G. D., Sherman, S. L., Shea, K. G., Boutin, R. D. 2023; 43 (7): e220208

Abstract

Menisci play an essential role in maintaining normal pain-free function of the knee. While there are decades of MRI literature on the tears involving the meniscus body and horns, there is now a surge in knowledge regarding injuries at the meniscus roots and periphery. The authors briefly highlight new insights into meniscus anatomy and then summarize recent developments in the understanding of meniscus injuries that matter, emphasizing meniscus injuries at the root and peripheral (eg, ramp) regions that may be missed easily at MRI and arthroscopy. Root and ramp tears are important to diagnose because they may be amenable to repair. However, if these tears are left untreated, ongoing pain and accelerated cartilage degeneration may ensue. The posterior roots of the medial and lateral menisci are most commonly affected by injury, and each of these injuries is associated with distinctive clinical profiles, MRI findings, and tear patterns. Specific diagnostic pitfalls can make the roots challenging to evaluate, including MRI artifacts and anatomic variations. As with root tears, MRI interpretation and orthopedic treatment have important differences for injuries at the medial versus lateral meniscus (LM) periphery (located at or near the meniscocapsular junction). Medially, ramp lesions typically occur in the setting of an anterior cruciate ligament rupture and are generally classified into five patterns. Laterally, the meniscocapsular junction may be injured in association with tibial plateau fractures, but disruption of the popliteomeniscal fascicles may also result in a hypermobile LM. Updated knowledge of the meniscus root and ramp tears is crucial in optimizing diagnostic imaging before repair and understanding the clinical repercussions. RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available in the Online Learning Center.

View details for DOI 10.1148/rg.220208

View details for PubMedID 37384542

Screws or Sutures? A Pediatric Cadaveric Study of Tibial Spine Fracture Repairs. The American journal of sports medicine Johnstone, T. M., Baird, D. W., Cuellar-Montes, A., van Deursen, W. H., Tompkins, M., Ganley, T. J., Yen, Y. M., Ellis, H. B., Chan, C. K., Green, D. W., Sherman, S. L., Shea, K. G. 2023: 3635465231181059

Abstract

Tibial spine fractures are common in the pediatric population because of the biomechanical properties of children's subchondral epiphyseal bone. Most studies in porcine or adult human bone suggest that suture fixation performs better than screw fixation, but these tissues may be poor surrogates for pediatric bone. No previous study has evaluated fixation methods in human pediatric knees.To quantify the biomechanical properties of 2-screw and 2-suture repair of tibial spine fracture in human pediatric knees.Controlled laboratory study.Cadaveric specimens were randomly assigned to either 2-screw or 2-suture fixation. A standardized Meyers-Mckeever type 3 tibial spine fracture was induced. Screw-fixation fractures were reduced with two 4.0-mm cannulated screws and washers. Suture-fixation fractures were reduced by passing 2 No. 2 FiberWire sutures through the fracture fragment and the base of the anterior cruciate ligament. Sutures were secured through bony tunnels over a 1-cm tibial cortical bridge. Each specimen was mounted at 30 of flexion. A cyclic loading protocol was applied to each specimen, followed by a load-to-failure test. Outcome measures were ultimate failure load, stiffness, and fixation elongation.Twelve matched pediatric cadaveric knees were tested. Repair groups had identical mean (8.3 years) and median (8.5 years) ages and an identical number of samples of each laterality. Ultimate failure load did not significantly differ between screw (mean SD, 143.52 41.9 7 N) and suture (135.35 47.94 N) fixations (P = .760). Screws demonstrated increased stiffness and decreased elongation, although neither result was statistically significant at the .05 level (21.79 vs 13.83 N/mm and 5.02 vs 8.46 mm; P = .076 and P = .069, respectively).Screw fixation and suture fixation of tibial spine fractures in human pediatric tissue were biomechanically comparable.Suture fixations are not biomechanically superior to screw fixations in pediatric bone. Pediatric bone fails at lower loads, and in different modes, compared with adult cadaveric bone and porcine bone. Further investigation into optimal repair is warranted, including techniques that may reduce suture pullout and "cheese-wiring" through softer pediatric bone. This study provides new biomechanical data regarding the properties of different fixation types in pediatric tibial spine fractures to inform clinical management of these injuries.

View details for DOI 10.1177/03635465231181059

View details for PubMedID 37382335

Biomechanical Forces of the Lateral Knee Joint Following Meniscectomy and Meniscus Transplantation in Pediatric Cadavers. The Journal of the American Academy of Orthopaedic Surgeons Gupta, A., Sanchez, M., Storaci, H. W., Rohde, M. S., Shea, K. G., Sherman, S. L. 2023

Abstract

Lateral meniscus transplantation successfully treats symptomatic meniscus deficiency in children. Although clinical outcomes are well-characterized, joint forces in meniscus-deficient and transplant states are unknown. The purpose of this study was to characterize contact area (CA) and contact pressures (CP) of transplanted lateral meniscus in pediatric cadavers. We hypothesize that (1) compared with the intact state, meniscectomy will decrease femorotibial CA and increase CP, and increase contact pressure (CP) and (2) compared with the meniscectomy state, meniscus transplantation will improve contact biomechanics toward the intact meniscus state.Pressure-mapping sensors were inserted underneath the lateral meniscus of eight cadaver knees aged 8 to 12 years. CA and CP on the lateral tibial plateau were measured in the intact, meniscectomy, and transplant states each at 0, 30, and 60 of knee flexion. Meniscus transplant was anchored with transosseous pull-out sutures and sutured to the joint capsule with vertical mattresses. The effects of meniscus states and flexion angle on CA and CP were measured by a two-way analysis of variance repeated measures model. One-way analysis of variance measured pairwise comparisons between meniscus states.Regarding CA, at 0, no differences between the groups reached significance. Meniscectomy reduced CA at 30 (P = 0.043) and 60 (P = 0.001). Transplant and intact states were comparable at 30. At 60, transplant significantly increased CA (P = 0.04). Regarding contact pressure, the average pressure increased with meniscectomy at all angles of flexion (0 P = 0.025; 30 P = 0.021; 60 P = 0.016) and decreased with transplant relative to respective intact values. Peak pressure increased with meniscectomy at 30 (P = 0.009) and 60 (P = 0.041), but only reached intact comparable values at 60. Pairwise comparisons support restoration of average CP with transplant, but not peak CP.Pediatric meniscus transplantation improves average CP and CA more than peak CP, but does not completely restore baseline biomechanics. Net improvements in contact biomechanics after transplant, relative to the meniscectomy state, support meniscus transplant.Descriptive laboratory study, Level III.

View details for DOI 10.5435/JAAOS-D-22-00832

View details for PubMedID 37285585

ACI & MACI for the Management of Osteochondritis Dissecans OPERATIVE TECHNIQUES IN SPORTS MEDICINE Johnstone, T., Shea, K. 2023; 31 (2)
Patellar Tracking: An Old Problem with New Insights. Radiographics : a review publication of the Radiological Society of North America, Inc Watts, R. E., Gorbachova, T., Fritz, R. C., Saad, S. S., Lutz, A. M., Kim, J., Chaudhari, A. S., Shea, K. G., Sherman, S. L., Boutin, R. D. 2023; 43 (6): e220177

Abstract

Patellofemoral pain and instability are common indications for imaging that are encountered in everyday practice. The authors comprehensively review key aspects of patellofemoral instability pertinent to radiologists that can be seen before the onset of osteoarthritis, highlighting the anatomy, clinical evaluation, diagnostic imaging, and treatment. Regarding the anatomy, the medial patellofemoral ligament (MPFL) is the primary static soft-tissue restraint to lateral patellar displacement and is commonly reconstructed surgically in patients with MPFL dysfunction and patellar instability. Osteoarticular abnormalities that predispose individuals to patellar instability include patellar malalignment, trochlear dysplasia, and tibial tubercle lateralization. Clinically, patients with patellar instability may be divided into two broad groups with imaging findings that sometimes overlap: patients with a history of overt patellar instability after a traumatic event (eg, dislocation, subluxation) and patients without such a history. In terms of imaging, radiography is generally the initial examination of choice, and MRI is the most common cross-sectional examination performed preoperatively. For all imaging techniques, there has been a proliferation of published radiologic measurement methods. The authors summarize the most common validated measurements for patellar malalignment, trochlear dysplasia, and tibial tubercle lateralization. Given that static imaging is inherently limited in the evaluation of patellar motion, dynamic imaging with US, CT, or MRI may be requested by some surgeons. The primary treatment strategy for patellofemoral pain is conservative. Surgical treatment options include MPFL reconstruction with or without osseous corrections such as trochleoplasty and tibial tubercle osteotomy. Postoperative complications evaluated at imaging include patellar fracture, graft failure, graft malposition, and medial patellar subluxation. RSNA, 2023 Quiz questions for this article are available in the supplemental material.

View details for DOI 10.1148/rg.220177

View details for PubMedID 37261964

Pediatric meniscus morphology varies with age: a cadaveric study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Rohde, M. S., Trivedi, S., Randhawa, S., Wright, C. E., Vuong, B. B., Pham, N., Stavinoha, T., Ellis, H. B., Ganley, T. J., Green, D. W., Fabricant, P. D., Tompkins, M., Shea, K. G. 2023

Abstract

PURPOSE: In adolescent patients, meniscal tear injury can occur either in isolation (e.g., discoid lateral meniscus tears) or in association with other traumatic injuries including tibial eminence fracture or ACL tear. Damage to meniscal integrity has been shown to increase contact pressure in articular cartilage, increasing risk of early onset osteoarthritis. In symptomatic patients failing conservative management, surgical intervention via meniscus repair or meniscus transplant is indicated. The purpose of this study was to evaluate the radial dimensions of pediatric menisci throughout development. The hypothesis was that the average radial meniscus dimensions will increase as specimen age increases, and mean medial and lateral region measurements will increase at a linear rate.METHODS: Seventy-eight skeletally immature knee cadaver specimens under age 12years were included in this study. The meniscal specimens were photographed in the axial view with ruler in the plane of the tibial plateau and analyzed using computer-aided design (CAD) software (Autodesk Fusion 360). Measurements were taken from inner to outer meniscus rims at five 45 degree intervals using the clockface as a reference (12:00, 1:30, 3:00, 4:30, 6:00), and total area of meniscus and tibial plateau was recorded. Generalized linear models were used to evaluate the associations of radial width measurements with age, tibial coverage, and lateral vs. medial meniscus widths.RESULTS: All radial width measurements increased significantly with specimen age (p0.002), and all lateral-medial meniscal widths increased (p<0.001). The anterior zones of the meniscus were found to increase at the slowest rate compared to other regions. Tibial plateau coverage was found to not significantly vary with age.CONCLUSIONS: Meniscus radial width and lateral-medial meniscus width are related to age. The anterior width of the meniscus varied least with age. Improved anatomic understanding may help surgeons more effectively plan for meniscus repair, discoid resection/saucerization/repair, and also support appropriate selection of meniscus allograft for transplantation.

View details for DOI 10.1007/s00167-023-07447-3

View details for PubMedID 37178242

Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group. The American journal of sports medicine Heyworth, B. E., Ganley, T. J., Liotta, E. S., Hergott, K. A., Miller, P. E., Wall, E. J., Myer, G. D., Nissen, C. W., Edmonds, E. W., Lyon, R. M., Chambers, H. G., Milewski, M. D., Green, D. W., Weiss, J. M., Wright, R. W., Polousky, J. D., Nepple, J. J., Carey, J. L., Kocher, M. S., ROCK Group, Shea, K. G. 2023: 3635465231165290

Abstract

BACKGROUND: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness.PURPOSE/HYPOTHESIS: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery.STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1.METHODS: Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months.RESULTS: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049).CONCLUSION: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD.REGISTRATION: NCT01754298 (ClinicalTrials.gov identifier).

View details for DOI 10.1177/03635465231165290

View details for PubMedID 37039536

A scoping review of portable sensing for out-of-lab anterior cruciate ligament injury prevention and rehabilitation. NPJ digital medicine Tan, T., Gatti, A. A., Fan, B., Shea, K. G., Sherman, S. L., Uhlrich, S. D., Hicks, J. L., Delp, S. L., Shull, P. B., Chaudhari, A. S. 2023; 6 (1): 46

Abstract

Anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) surgery are common. Laboratory-based biomechanical assessment can evaluate ACL injury risk and rehabilitation progress after ACLR; however, lab-based measurements are expensive and inaccessible to most people. Portable sensors such as wearables and cameras can be deployed during sporting activities, in clinics, and in patient homes. Although many portable sensing approaches have demonstrated promising results during various assessments related to ACL injury, they have not yet been widely adopted as tools for out-of-lab assessment. The purpose of this review is to summarize research on out-of-lab portable sensing applied to ACL and ACLR and offer our perspectives on new opportunities for future research and development. We identified 49 original research articles on out-of-lab ACL-related assessment; the most common sensing modalities were inertial measurement units, depth cameras, and RGB cameras. The studies combined portable sensors with direct feature extraction, physics-based modeling, or machine learning to estimate a range of biomechanical parameters (e.g., knee kinematics and kinetics) during jump-landing tasks, cutting, squats, and gait. Many of the reviewed studies depict proof-of-concept methods for potential future clinical applications including ACL injury risk screening, injury prevention training, and rehabilitation assessment. By synthesizing these results, we describe important opportunities that exist for clinical validation of existing approaches, using sophisticated modeling techniques, standardization of data collection, and creation of large benchmark datasets. If successful, these advances will enable widespread use of portable-sensing approaches to identify ACL injury risk factors, mitigate high-risk movements prior to injury, and optimize rehabilitation paradigms.

View details for DOI 10.1038/s41746-023-00782-2

View details for PubMedID 36934194

A Stepwise Replicable Approach to Negotiating Value-driven Supply Chain Contracts for Orthobiologics. The Journal of the American Academy of Orthopaedic Surgeons Gupta, A., Lee, J., Chawla, A., Rajagopalan, V., Kohler, M., Moelling, B., McFarlane, K. H., Sheth, K. R., Ratliff, J. K., Hu, S. S., Wall, J. K., Shea, K. G. 2023

Abstract

Orthobiologics are increasingly used to augment healing of tissues. Despite growing demand for orthobiologic products, many health systems do not enjoy substantial savings expected with high-volume purchases. The primary goal of this study was to evaluate an institutional program designed to (1) prioritize high-value orthobiologics and (2) incentivize vendor participation in value-driven contractual programs.A three-step approach was used to reduce costs through optimization of orthobiologics supply chain. First, surgeons with orthobiologics expertise were engaged in key supply chain purchasing decisions. Second, eight orthobiologics formulary categories were defined. Capitated pricing expectations were established for each product category. Capitated pricing expectations were established for each product using institutional invoice data and market pricing data. In comparison with similar institutions, products offered by multiple vendors were priced at a lower benchmark (10th percentile of market price) than more rare products priced at the 25th percentile of the market price. Pricing expectations were transparent to vendors. Third, a competitive bidding process required vendors to submit pricing proposals for products. Clinicians and supply chain leaders jointly awarded contracts to vendors that met pricing expectations.Compared with our projected estimate of $423,946 savings using capitated product prices, our actual annual savings was $542,216. Seventy-nine percent of savings came from allograft products. Although the number of total vendors decreased from 14 to 11, each of the nine returning vendors received a larger, three-year institutional contract. Average pricing decreased across seven of the eight formulary categories.This study demonstrates a three-step replicable approach to increase institutional savings for orthobiologic products, engaging clinician experts, and strengthening relationships with select vendors. Vendor consolidation permits a symbiotic win-win relationship: Health systems achieve increased value by reducing unnecessary complexity of multiple contracts, and vendors obtain larger contracts with increased market share.Level IV study.

View details for DOI 10.5435/JAAOS-D-21-01008

View details for PubMedID 36801893

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients. The American journal of sports medicine Rohde, M. S., Shea, K. G., Dawson, T., Heyworth, B. E., Milewski, M. D., Edmonds, E. W., Adsit, E., Wilson, P. L., Albright, J., Algan, S., Beck, J., Bowen, R., Brey, J., Cardelia, M., Clark, C., Crepeau, A., Edmonds, E. W., Ellington, M., Ellis, H. B., Fabricant, P., Frank, J., Ganley, T., Green, D., Gupta, A., Heyworth, B. E., Latz, K., Mansour, A., Mayer, S., McKay, S., Milewski, M., Niu, E., Pacicca, D., Parikh, S., Rhodes, J., Saper, M., Schmale, G., Schmitz, M., Shea, K., Storer, S., Wilson, P. L., Ellis, H. B. 2023: 3635465221145939

Abstract

The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options.To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears.Case series; Level of evidence, 4.Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort.There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs.In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

View details for DOI 10.1177/03635465221145939

View details for PubMedID 36629442

Optimizing Orthopaedic Trauma Implant Pricing Through a Data-Driven and Surgeon-Integrated Approach. Journal of orthopaedic trauma Seltzer, R., Johnson, J. R., McFarlane, K., Chawla, A., Chamberlain, S., Kohler, M., Sheth, K., Wall, J. K., Bishop, J., Gardner, M., Shea, K. G. 2022

Abstract

To determine if market-based pricing could be coupled with surgeon integration into negotiation strategies to achieve lower pricing levels for orthopaedic trauma implants. A secondary aim was to identify specific types of implants that may offer larger opportunities for cost savings.Market pricing levels were reviewed from two industry implant databases. This information was used by surgeons and supply chain management (SCM) at our institution to select appropriate target pricing levels (25th percentile) for commonly used orthopaedic trauma implants. Target price values were provided to the existing 12 vendors utilized by our institution with a clear expectation that vendors meet these thresholds.Benchmark modeling projected a potential savings of 20.0% over our prior annual spend on trauma implants. Following two rounds of negotiation, savings amounted to 23.0% of prior annual spend. Total savings exceeded 1,000,000 USD with 11 of 12 vendors (91.7%) offering net savings. Total percent savings were highest for external fixators, drill bits, and K-wires. Plates and screws comprised the greatest proportion of our prior annual spend and achieved similar savings.A surgeon and supply chain coordinated effort led to major cost savings without a need for consolidation of vendors.

View details for DOI 10.1097/BOT.0000000000002560

View details for PubMedID 36728607

Public Interest in Hyaluronic Acid Injections for Knee Osteoarthritis in the United States and Europe: An International Google Trends Analysis. Arthroplasty today Cohen, S. A., Brophy, R. H., Chen, A. F., Roberts, K. C., Quinn, R. H., Shea, K. G. 2022; 18: 157-162

Abstract

Background: Hyaluronic acid injections remain a common nonsurgical alternative for the treatment of knee osteoarthritis despite limited clinical evidence and varying global recommendations regarding its use. We used the Google Trends tool to provide a quantitative analysis of public interest in hyaluronic acid injections for knee osteoarthritis in the United States and Europe.Methods: We customized Google Trends parameters to obtain search data from January 2009 to December 2019 in both the United States and Europe. Combinations of "arthritis", "osteoarthritis", "hyaluronic acid", "knee arthritis", "knee osteoarthritis", and "knee injection" were entered into the Google Trends tool, and trend analyses were performed.Results: The models generated to describe public interest in hyaluronic acid for knee injections in both the United States and Europe showed increased Google queries as time progressed (P < .001). The United States growth model displayed linear growth (r2= 0.90) while the European growth model displayed exponential growth (r2= 0.90).Conclusions: Our results indicate a significant increase in Google queries related to hyaluronic acid injections for knee osteoarthritis since 2009 in both the United States and Europe. Our models suggest that despite mixed evidence supporting its use, orthopedic surgeons should expect continued public interest in hyaluronic acid for knee osteoarthritis. The results of our study may help to prepare surgeons for patient inquiries, inform the creation of evidence-based shared decision-making tools, and direct future research.

View details for DOI 10.1016/j.artd.2022.09.003

View details for PubMedID 36353188

An Activity Scale for All Youth Athletes? Clinical Considerations for the HSS Pedi-FABS. Orthopaedic journal of sports medicine Carpenter, C. M., Cooper, S. B., Wilson, P. L., Miller, S. M., Wyatt, C. W., Johnson, B. L., Shea, K. G., Ellis, H. B. 2022; 10 (12): 23259671221143534

Abstract

Background: The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) has demonstrated normally distributed scores in children aged 10 to 18 years. It has been used to evaluate knee injuries; however, there is limited information regarding its use in evaluating other injury types.Purpose: To (1) assess the validity and utility of HSS Pedi-FABS in youth athletes with injuries to different parts of the body and (2) evaluate the association between the HSS Pedi-FABS and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health 7 (PGH), as well as PROMIS-Pain Interference (PGH-PI) and PROMIS-Fatigue (PGH-F) components.Study Design: Cohort study (diagnosis); Level of evidence, 3.Methods: The authors performed a retrospective review of youth athletes aged 10 to 18 years who completed the HSS Pedi-FABS as part of their previsit intake questionnaire between April 2016 and July 2020. HSS Pedi-FABS score distributions were compared and evaluated for ceiling effects in cohorts determined by demographic, injury characteristic, and sports participation variables; a ceiling effect was determined to be present if >15% of respondents received the highest possible score. HSS Pedi-FABS scores were analyzed for a correlation with PGH, PGH-PI, and PGH-F components.Results: Included were 2274 patients (mean age, 14.6 2.1 years; 53.0% female) participating in 21 distinct primary sports for 9.6 7.9 hours per week. The mean HSS Pedi-FABS scores by injury group were as follows: elbow (22.7 6.7), shoulder (21.0 8.7), ankle (20.2 8.8), knee (19.5 9.1), and hip (15.4 10.4) (P < .001). Broad distribution was seen in each cohort, with no floor or ceiling effects. The HSS Pedi-FABS score correlated with patient-reported hours per week (r = 0.33), days per week (r = 0.33), and years of participation (r = 0.21) (P < .001 for all). All 3 PROMIS components correlated with HSS Pedi-FABS: PGH (r = 0.28), PGH-PI (r = -0.11), and PGH-F (r = -0.15) (P < .001).Conclusion: Study findings indicated that the HSS Pedi-FABS is a valid tool for measuring physical activity level in most injured youth athletes, not just those with knee injuries. The correlation of HSS Pedi-FABS with the PGH suggests a positive relationship of childhood physical activity with general health.

View details for DOI 10.1177/23259671221143534

View details for PubMedID 36582933

Transtibial Repair of Lateral Meniscus Posterior Root Tears Improves Contact Biomechanics in Pediatric Cadavers. Arthroscopy, sports medicine, and rehabilitation Gupta, A., Sanchez, M., Storaci, H. W., Rohde, M. S., Sherman, S. L., Shea, K. G. 2022; 4 (6): e2011-e2018

Abstract

A paucity of data exists on the treatment of pediatric lateral meniscus root tears (LMPRTs). This study aims to characterize the biomechanics of the lateral knee joint in pediatric cadavers following LMPRT and root repair. Our hypotheses were: (1) compared with the intact state, LMPRT would be associated with decreased contact area; (2) compared with the intact state, LMPRT would be associated with increased contact pressures; and (3) compared with LMPRT, root repair would restore contact area and pressures toward intact meniscus values.Eight cadaver knees (ages 8-12 years) underwent contact area and pressure testing of the lateral compartment. Tekscan pressure mapping sensors covering the tibial plateau were inserted underneath the lateral meniscus. Appropriate pressure load equivalents were applied by a robot at degrees of flexion: 0, 30, 60. Three meniscus conditions were tested: (1) intact, (2) complete root tear, and (3) repaired root tear. Root repairs were performed with transtibial pullout sutures. Statistical analysis was performed.Root tear significantly decreased mean contact area at 30 (P= .0279) and 60 (P= .0397). Root repair increased mean contact area and did not significantly differ from intact states. Differences in contact pressures between meniscus states were not statistically significant. Relative to the intact state. the greatest increase in contact pressures occurred between 0 and 30. Root repair decreased mean contact pressures at 0 and 30. At 60, mean contact pressures of the repair state were closer in magnitude to the tear state than the intact state. Conclusions: LMPRT decreases contact area and increases contact pressures in the lateral knee compartment. Repair of LMPRT improves tibiofemoral contact area at high (>30) degrees of flexion and contact pressures at low (<30) degrees of flexion.Transosseous pullout repair is a clinically validated treatment for LMPRT. This study provides baseline biomechanics data of transtibial pullout repair of pediatric LMPRTs.

View details for DOI 10.1016/j.asmr.2022.08.010

View details for PubMedID 36579044

View details for PubMedCentralID PMC9791837

Analysis of limb kinetic asymmetry during a drop vertical jump in adolescents post anterior cruciate ligament reconstruction. Clinical biomechanics (Bristol, Avon) Bakal, D. R., Morgan, J. J., Lyons, S. M., Chan, S. K., Kraus, E. A., Shea, K. G. 2022; 100: 105794

Abstract

BACKGROUND: Limb asymmetry after ACL reconstruction is often cited as a risk factor for ACL reinjury. We assessed ground reaction forces on each limb during a drop vertical jump, and compared kinetic symmetry between limbs in adolescents post-ACL reconstruction versus healthy controls.METHODS: Forty-four participants who underwent an ACL reconstruction (16 male/28 female, mean age 16.11.5, mean 7.30.9months post-ACL reconstruction) and 34 controls (20 male/14 female, mean age 14.91.1) completed a drop vertical jump captured on a Vicon system and Bertec force plates. Kinetic variables were calculated individually for each limb. Inter-limb asymmetry was calculated as an index between each limb (involved versus uninvolved for the ACL reconstruction group, and left versus right for controls), and was compared between groups using independent t-tests.FINDINGS: Asymmetry was significantly more pronounced in the ACL reconstruction group versus the controls for peak contact ground reaction force (11.6% vs 4.4%, p=0.009), eccentric impulse (8.8% vs 3.8%, p=0.009), eccentric mean force (8.0% vs 3.4%, p=0.006), concentric peak ground reaction force (4.1% vs 0.8%, p=0.003), concentric impulse (5.1% vs 1.1%, p=0.001), and peak landing ground reaction force (12.7% vs 1.7%, p<0.001).INTERPRETATION: Limb kinetic asymmetry during a drop vertical jump was more pronounced in adolescents post-ACL reconstruction versus controls for both eccentric- and concentric-phase variables, which may indicate the use of compensatory strategies to offload the post-operative limb. Targeted interventions to produce more symmetric loading and unloading during jumping tasks should be developed, tested, and monitored to determine the impact on rehabilitation programs, return-to-sport evaluations, and injury prevention outcomes.

View details for DOI 10.1016/j.clinbiomech.2022.105794

View details for PubMedID 36270179

A Pilot Program: Remote Summer Program to Improve Opportunity and Mentorship Among Underrepresented Students Pursuing Orthopaedic Surgery. JB & JS open access Hastings, K. G., Freiman, H. D., Amanatullah, D. F., Gardner, M. J., Frick, S., Shea, K. G. 2022; 7 (4)

Abstract

The purpose of this study was to evaluate the impact of an 8-week remote summer program in supporting underrepresented students interested in orthopaedic surgery.Methods: We received 115 applications, and a total of 17 students participated in the program (14.8%). Nine faculty mentors were matched with 1 or 2 students each. The program delivered a curriculum from June-August 2021 consisting of (1) weekly instructional courses on research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic topics, diversity in medicine, leadership, and work-life balance; and (3) a research experience paired with a faculty mentor and peer mentor. We surveyed students to measure skill progression, satisfaction, and overall program evaluation. Preprogram/postprogram evaluation, midprogram check-in, and student feedback surveys were collected.Results: Program participants represented a range of race and ethnic backgrounds, research experience levels, and various geographic locations across the United States. The cohort included a high rate of female (42%) and Black (35%) participants. On average, postprogram survey scores indicated that participants believed that the summer program improved their research skills (9.6 of 10), improved their orthopaedic interest (8.9 of 10), and improved mentorship and networking (9.1 of 10). For feedback surveys, 14 respondents of 15 total responses (93%) felt they were adequately matched to their faculty mentor. Twelve (80%) felt they had realistic deliverables for research projects within the 8-week program. Thirteen (87%) indicated they contributed to an abstract or manuscript as a coauthor.Conclusion: Our findings indicate that students improved their research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. The long-term goal is to improve the accessibility and quality of mentorship for underrepresented students in order to foster an equitable pathway into the field of orthopaedic surgery.

View details for DOI 10.2106/JBJS.OA.22.00059

View details for PubMedID 36338797

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19 JOURNAL OF ATHLETIC TRAINING Kiani, S. N., Yellin, J. L., Houlihan, N., Talwar, D., Shea, K. G., Ganley, T. J. 2022; 57 (9-10): 972-977
Evaluating Information About Osteochondritis Dissecans Shared Across Social Media Platforms. Journal of pediatric orthopedics Gussner, A., Baskar, D., Rohde, M., Ganley, T., Shea, K. 2022

Abstract

BACKGROUND: With the rise of social media, patients are using a variety of online resources to gather information about medical conditions and connect with others for support. Osteochondritis dissecans (OCD) occurs most commonly among children and adolescents, necessitating early diagnosis and management. The purpose of this study is to evaluate content on social media about OCD to quantify the reach of information shared and themes of discussion surrounding this condition.METHODS: A search was performed across Facebook, Instagram, YouTube, and TikTok using the term "osteochondritis dissecans" to identify information shared related to this topic which was then analyzed based on engagement using number of followers, posts, and/or views.RESULTS: Facebook groups provided a forum for online support and information sharing among patients with OCD and their families. The 4 identified groups had a cumulative following of over 4000 people with posts that shared personal recovery stories, solicited treatment advice, and provided updates on patient progress. Review of related Instagram hashtags revealed over 4500 posts, many of which shared personal accounts of living with OCD. The top 5 most viewed YouTube videos collectively had over 189,000 views and were focused on educational information about OCD, relevant surgical techniques, and pertinent anatomy. The top 3 OCD-related TikTok hashtags had over 4 million total views centered on factual knowledge and sharing changes before and after surgical treatment.CONCLUSION: Patients with OCD and their families seek information about their condition and treatment on online sources including social media. Although social media provides a supportive community to share and receive advice, the quality of information shared in these groups is a subject for concern. Increasing physician involvement and awareness of the information shared across social media platforms may improve accuracy of information and content available to patients.CLINICAL RELEVANCE: It is important for physicians treating patients with OCD to be aware of all sources of information and support, including content shared on social media as these platforms allow for the sharing of personal stories, recommendations for treatment, and educational content.

View details for DOI 10.1097/BPO.0000000000002244

View details for PubMedID 36037441

Distance to the Neurovascular Bundle for Iliotibial Band Graft Passage During Anterior Cruciate Ligament Reconstruction: A Pediatric Cadaveric Study. Orthopaedic journal of sports medicine Thomas, N. D., Ayala, S., Rohde, M., Gupta, A., Sanchez, M., Ellis, H., Tompkins, M., Wilson, P., Sherman, S., Green, D., Ganley, T. J., VandenBerg, C., Yen, Y., Shea, K. G. 2022; 10 (8): 23259671221113832

Abstract

Background: The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients.Purposes: To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery.Study Design: Descriptive laboratory study.Methods: Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90 to 100. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure.Results: The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of 8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for 8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005).Conclusion: The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances <1 cm in many specimens in this study. When passing the graft through the knee for an over-the-top position, surgeons should consider these small distances between the path of graft passage and critical neurovascular structures.Clinical Relevance: As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.

View details for DOI 10.1177/23259671221113832

View details for PubMedID 35990874

Quality Measures for Pediatric Orthopaedic Surgery: A Systematic Review. Journal of pediatric orthopedics Montgomery, B. K., Welch, J. M., Shapiro, L. M., Shea, K. G., Kamal, R. N. 2022; 42 (6): e682-e687

Abstract

BACKGROUND: Quality measures provide a way to assess health care delivery and to identify areas for improvement that can inform patient care delivery. When operationalized by a hospital or a payer, quality measures can also be tied to physician or hospital reimbursement. Prior work on quality measures in orthopaedic surgery have identified substantial gaps in measurement portfolios and have highlighted areas for future measure development. This study aims to identify the portfolio of quality measures in pediatric orthopaedic surgery.METHODS: We used methodology of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and reviewed PubMed/ MEDLINE and EMBASE, the American Academy of Orthopaedic Surgery (AAOS), National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ), for quality measures and candidate quality measures. Quality measure and candidate quality measures were categorized as structure, process, or outcome. Measures were also classified into 1 of the 6 National Quality Strategy priorities (safety, effective, patient centered, timely, efficient, and equitable).RESULTS: A review of PubMed/EMBASE returned 1640 potential quality measures and articles. A review of AAOS, NQF, and AHRQ databases found 80 potential quality measures. After screening we found a total of 18 quality measures and candidate quality measures specifically for pediatric orthopaedic surgery. Quality measures addressed conditions such as supracondylar humerus fractures, developmental dysplasia of the hip, and osteochondritis dissecans. There were 10 process measures, 8 outcome measure, and 0 structure measures. When we categorized by National Quality Strategy priorities and found 50% (9/18) were effective clinical care, 44% (8/18) were person and care-giver centered experience and outcomes, 6% (1/18) were efficient use of resources.CONCLUSIONS: There are few quality measures and candidate quality measures to assess pediatric orthopaedic surgery. Of the quality measure available, process measures are relatively over-represented. Pediatric orthopaedic surgeons can lead the development of outcome (eg, patient-reported outcomes after surgery) and structure measures (eg, subspecialty training certification) to assess quality of care in pediatric orthopaedic surgery.LEVEL OF EVIDENCE: Level II-systematic review.

View details for DOI 10.1097/BPO.0000000000002126

View details for PubMedID 35667057

Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study. The American journal of sports medicine Baskar, D., Stavinoha, T. J., Sanchez, M., Gupta, A., Randhawa, S. D., Rohde, M. S., Vuong, B., Tompkins, M. A., Ganley, T. J., Ellis, H. B., Wilson, P. L., Fabricant, P. D., VandenBerg, C., Green, D. W., Segovia, N. A., Shea, K. G. 2022: 3635465221103250

Abstract

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.To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens.Descriptive laboratory study.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.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.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.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.

View details for DOI 10.1177/03635465221103250

View details for PubMedID 35763589

Pediatric reference anatomy for ACL reconstruction and secondary Anteroalteral ligament or lateral extra-articular tenodesis procedures. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Randhawa, S., Stavinoha, T. J., Trivedi, S., Ganley, T. J., Tompkins, M., Ellis, H., Wilson, P., Green, D. W., Fabricant, P. D., Musahl, V., Shea, K. G. 2022

Abstract

OBJECTIVES: For iliotibial band (ITB) lateral extra-articular tenodesis (LET) or anterolateral ligamentous/capsular (ALL) reconstruction with anterior cruciate ligament (ACL) reconstruction, a clear understanding of the referenced anterolateral knee anatomy is critical-especially given the risk of injury to the physis or key anterolateral structures in the pediatric population, which is at high risk for primary and secondary ACL injury. This study's purpose was to quantitatively assess the anatomy of the knee physes, pediatric lateral collateral ligament (LCL) origin, popliteus origin, and ITB tibial insertion.METHODS: Nine pediatric cadaveric knee specimens with average age 4.2 years (range 2 months-10 years) underwent dissection to identify the LCL's and popliteus' femoral origins and the ITB's tibial insertion. Metallic marking pins demarcated precise anatomic attachment sites, and subsequent computerized tomography scans enabled quantified measurements among them.RESULTS: LCL & Popliteus: On the femur, the popliteus origin lay consistently deep to the LCL and inserted both distally and anteriorly to the LCL a mean distance of 4.6 mm (range 1.9 - 7.6; std dev 2.0). From the joint line, the LCL lay a mean distance of 12.5 mm proximally while the popliteus measured a mean of 8.2 mm. Both were consistently distal to the physis. The LCL was a mean distance of 4.4 mm (range 1.0 - 9.5) and the popliteus was a mean distance of 8.2 (range 1.7 - 12.5) from the physis. ITB insertion: The ITB insertion at Gerdy's tubercle had an average footprint measuring 28.2 mm2 (range 10.3 -58.4), and the ITB center lay proximal to the physis in 6 specimens (mean age 4.2 years, median 2.5 years) and distal in 3 specimens (mean age 1.5 years, median 4 months). Mean distance from the footprint center to the physis was 1.6 mm proximal (range 7.1 proximal - 2.2 distal).CONCLUSION: This study describes relative and quantitative positions of the femoral LCL and popliteus origins and tibial ITB attachment and their respective physeal relationships. Knowledge of pediatric anterolateral knee anatomy will help guide essential future research and procedures providing extra-articular anterolateral rotatory stabilization and may help reduce iatrogenic physeal injury risk.LEVEL OF EVIDENCE: N/A (descriptive anatomic study).

View details for DOI 10.1016/j.jisako.2022.04.008

View details for PubMedID 35589081

Does healthcare system device volume correlate with price paid for spinal implants: a cross-sectional analysis of a national purchasing database. BMJ open Cahan, E., McFarlane, K., Segovia, N., Chawla, A., Wall, J., Shea, K. 2022; 12 (4): e057547

Abstract

OBJECTIVES: Amid continuously rising US healthcare costs, particularly for inpatient and surgical services, strategies to more effectively manage supply chain expenses are urgently necessary. Across industries, the 'economy of scale' principle indicates that larger purchasing volumes should correspond to lower prices due to 'bulk discounts'. Even as such advantages of scale have driven health system mergers in the USA, it is not clear whether they are being achieved, including for specialised products like surgical implants which may be more vulnerable to cost inefficiency. The objective of this observational cross-sectional study was to investigate whether purchasing volumes for spinal implants was correlated with price paid.SETTING: USA.PARTICIPANTS: Market data based on pricing levels for spine implants were reviewed from industry implant price databases. Filters were applied to narrow the sample to include comparable institutions based on procedural volume, patient characteristics and geographical considerations. Information on the attributes of 619 health systems representing 12471 provider locations was derived from national databases and analytics platforms.PRIMARY OUTCOME MEASURE: Institution-specific price index paid for spinal implants, normalised to the national average price point achieved.RESULTS: A Spearman's correlation test indicated a weak relationship between purchasing volume and price index paid (rho=-0.35, p<0.001). Multivariable linear regression adjusting for institutional characteristics including type of hospital, accountable care organisation status, payer-mix, geography, number of staffed beds, number of affiliated physicians and volume of patient throughput also did not exhibit a statistically significant relationship between purchasing volume and price index performance (p=0.085).CONCLUSIONS: National supply chain data revealed that there was no significant relationship between purchasing volume and price paid by health systems for spinal implants. These findings suggest that factors other than purchasing or patient volume are responsible for setting prices paid by health systems to surgical vendors and/or larger healthcare systems are not negotiating in a way to consistently achieve optimal pricing.

View details for DOI 10.1136/bmjopen-2021-057547

View details for PubMedID 35473724

Longitudinal 3T MRI T2 * Mapping of Juvenile Osteochondritis Dissecans (JOCD) Lesions Differentiates Operative from Non-operative Patients - Pilot Study. Journal of orthopaedic research : official publication of the Orthopaedic Research Society Kajabi, A. W., Zbyn, S., Johnson, C. P., Tompkins, M. A., Nelson, B. J., Takahashi, T., Shea, K. G., Marette, S., Carlson, C. S., Ellermann, J. M. 2022

Abstract

Juvenile osteochondritis dissecans (JOCD) is an orthopedic joint disorder of children and adolescents that can lead to premature osteoarthritis. Thirteen patients (mean age: 12.3 years, 4 females), 15 JOCD-affected and five contralateral healthy knees, that had a baseline and a follow-up MRI (mean interval of 8.9 months) and were treated non-operatively during this interval were included. Retrospectively, patients were assigned to operative or non-operative groups based on their electronic medical records. Volumetric mean T2 * values were calculated within regions of interest (progeny lesion, interface, parent bone) and region matched control bone in healthy contralateral knees and condyles. The normalized percentage difference of T2 * between baseline and follow up MRI in non-operative patients significantly increased in progeny lesion (-47.8%, p < 0.001), parent bone (-13.9%, p < 0.001), and interface (-32.3%, p = 0.011), whereas the differences in operative patients were non-significant and below 11%. In non-operative patients, the progeny lesion (p < 0.001) and interface T2 * values (p = 0.012) were significantly higher than control bone T2 * at baseline, but not at follow-up (p = 0.219, p=1.000, respectively). In operative patients, the progeny lesion and interface T2 * values remained significantly elevated compared to the control bone both at baseline (p < 0.001, p < 0.001) and follow-up (p < 0.001, p < 0.001), respectively. Clinical Significance: Longitudinal T2 * mapping differentiated non-healing from healing JOCD lesions following initial non-operative treatment, which may assist in prognosis and improve the ability of surgeons to make recommendations regarding operative versus non-operative treatment. This article is protected by copyright. All rights reserved.

View details for DOI 10.1002/jor.25343

View details for PubMedID 35430743

The Spectrum of ACL Reconstruction Options for the Pediatric and Adolescent Patient: A Narrative Review. Journal of athletic training Cinque, M. E., LaPrade, C. M., Rohde, M. S., Ganley, T. J., Shea, K. G. 2022

Abstract

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) are increasingly common in pediatric patients. Historically, ACL reconstructions were delayed in pediatric patients to avoid physeal damage with potential for possible leg-length discrepancy or angular deformity. Current research shows delaying reconstruction or choosing non-operative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction with techniques to avoid physeal growth disturbance is now widely accepted amongst physicians. The purpose of this review was to first describe the pediatric ACL in terms of relevant anatomy and biomechanics, physical exam, and diagnostic imaging. Secondly, the importance of skeletal age and concern for physeal injury is then discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

View details for DOI 10.4085/1062-6050-0542.21

View details for PubMedID 35380680

Vascularity of the early post-natal human distal femoral chondroepiphysis: Quantitative MRI analysis. Journal of children's orthopaedics Lin, K. M., Gadinsky, N. E., Klinger, C. E., Kleeblad, L. J., Shea, K. G., Dyke, J. P., Helfet, D. L., Rodeo, S. A., Green, D. W., Lazaro, L. E. 2022; 16 (2): 152-158

Abstract

Injury to or abnormality of developing distal femoral chondroepiphysis blood supply has been implicated in osteochondritis dissecans development. Progressive decrease in epiphyseal cartilage blood supply occurs in normal development; however, based on animal studies, it is hypothesized that there is greater decrease in regions more prone to osteochondritis dissecans lesions. We aimed to quantify differential regional perfusion of the immature distal femoral chondroepiphysis. We hypothesized there is decreased perfusion in the lateral aspect of the medial femoral condyle, the classic osteochondritis dissecans lesion location.Five fresh-frozen human cadaveric knees (0-6months old) were utilized. The superficial femoral artery was cannulated proximally and contrast-enhanced magnetic resonance imaging performed using a previously reported protocol for quantifying osseous and soft tissue perfusion. Regions of interest were defined, and signal enhancement changes between pre- and post-contrast images, normalized to background muscle, were compared.When comparing average normalized post-contrast signal enhancement of whole condyles, as well as distal, posterior, and inner (toward the notch) aspects of the medial and lateral condyles, no significant perfusion differences between condyles were found. In the medial condyle, no significant perfusion difference was found between the medial and lateral aspects.We quantified immature distal femoral chondroepiphysis regional vascularity in the early post-natal knee. In specimens aged 0-6months, no distinct watershed region was detected. Despite possible limitations, given small sample size, as well as resolution of magnetic resonance imaging and analysis, our results suggest the hypothesized vascular abnormality predisposing osteochondritis dissecans either does not occur universally or occurs after this developmental age.

View details for DOI 10.1177/18632521221084179

View details for PubMedID 35620125

View details for PubMedCentralID PMC9127880

Biomechanical properties of common graft choices for anterior cruciate ligament reconstruction: A systematic review. Clinical biomechanics (Bristol, Avon) Malige, A., Baghdadi, S., Hast, M. W., Schmidt, E. C., Shea, K. G., Ganley, T. J. 2022; 95: 105636

Abstract

BACKGROUND: This systematic review explores the differences in the intrinsic biomechanical properties of different graft sources used in anterior cruciate ligament (ACL) reconstruction as tested in a laboratory setting.METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two authors conducted a systematic review exploring the biomechanical properties of ACL graft sources (querying PubMed, Cochrane, and Embase databases). Using the keywords "anterior cruciate ligament graft," "biomechanics," and "biomechanical testing," relevant articles of any level of evidence were identified as eligible and included if they reported on the biomechanical properties of skeletally immature or mature ACL grafts solely and if the grafts were studied in vitro, in isolation, and under similar testing conditions. Studies were excluded if performed on both skeletally immature and mature or non-human grafts, or if the grafts were tested after fixation in a cadaveric knee. For each graft, failure load, stiffness, Young's modulus, maximum stress, and maximum strain were recorded.FINDINGS: Twenty-six articles were included. Most studies reported equal or increased biomechanical failure load and stiffness of their tested bone-patellar tendon-bone, hamstring, quadriceps, peroneus longus, tibialis anterior and posterior, Achilles, tensor fascia lata, and iliotibial band grafts compared to the native ACL. All recorded biomechanical properties had similar values between graft types.INTERPRETATION: Most grafts used for ACL reconstruction are biomechanically superior to the native ACL. Utilizing a proper graft, combined with a standard surgical technique and a rigorous rehabilitation before and after surgery, will improve outcomes of ACL reconstruction.

View details for DOI 10.1016/j.clinbiomech.2022.105636

View details for PubMedID 35428007

Youth athletes sleep more, practice less, and may lose interest in playing sports due to social distancing mandates. Preventive medicine reports Ellis, H. B., Ulman, S. M., John Wagner, K., Carpenter, C. M., Gale, E. B., Shea, K. G., Wilson, P. L. 2022; 26: 101722

Abstract

In-person sport participation was suspended across the United States in the spring of 2020 to slow the spread of the novel coronavirus (COVID-19). The purpose of this study was to survey the impact of COVID-19 on young athletes during a period of social and organized sports restrictions. An anonymous cross-sectional survey study was conducted of youth athletes in the midst of social distancing mandates and consisted of six components: demographics, sport participation, changes in sport-related goals/aspirations, sleep habits, and measures of anxiety and depression. 711 individuals who accessed the survey link yielded 575 (81%) participants with responses available for analysis. All respondents (aged 13.0years) played organized sports, 62% were single-sport athletes, and 74% considered high-level. Participants were training 3.3h less per week, spending more time outside, and 86% of participants continued to train while social distancing. Sleep duration increased (1.2h/night) and sleep quality improved in 29% of young athletes. Additionally, 22% and 28% reported PROMIS anxiety and depression scores characterized as 'mild', 'moderate', or 'severe'. Older single-sport participants reported higher depression scores, while higher anxiety scores were seen in female participants with fewer years played. 10% of young athletes and 20% of teenagers changed their sports-related goals. Training style modifications, decreased training, and increased sleep quantity and quality were positive effects of COVID-19 restrictions, while athletic aspirational changes were undesirable effects. Single-sport athletes may be at greater risk for psychological symptoms when their routine is altered.

View details for DOI 10.1016/j.pmedr.2022.101722

View details for PubMedID 35132371

Vascularity of the early post-natal human distal femoral chondroepiphysis: Quantitative MRI analysis JOURNAL OF CHILDRENS ORTHOPAEDICS Lin, K. M., Gadinsky, N. E., Klinger, C. E., Kleeblad, L. J., Shea, K. G., Dyke, J. P., Helfet, D. L., Rodeo, S. A., Green, D. W., Lazaro, L. E. 2022; 16 (2): 152-158
Medial and Lateral Posterior Tibial Slope in the Skeletally Immature: A Cadaveric Study. Orthopaedic journal of sports medicine Anchustegui, N., Grimm, N. L., Milbrandt, T. A., Rustad, A., Shea, C., Troyer, S., Dingel, A. B., Ganley, T. J., Fabricant, P. D., Shea, K. G. 2022; 10 (4): 23259671221088331

Abstract

An increased posterior tibial slope (PTS) results in greater force on the anterior cruciate ligament (ACL) and is a risk factor for ACL injuries. Biomechanical studies have suggested that a reduction in the PTS angle may lower the risk of ACL injuries. However, the majority of these investigations have been in the adult population.To assess the mean medial and lateral PTS on pediatric cadaveric specimens without known knee injuries.Cross-sectional study; Level of evidence, 3.A total of 39 pediatric knee specimens with computed tomography scans were analyzed. Specimens analyzed were between the ages of 2 and 12 years. The PTS of each specimen was measured on sagittal computed tomography slices at 2 locations for the medial and lateral angles. The measurements were plotted graphically by age to account for the variability in development within age groups. The anterior medial and lateral tibial plateau widths were measured. The distance between the top of the tibial plateau and the physis was measured. The independent-samples t test and analysis of variance were used to analyze the measurements.The mean PTS angle for the medial and lateral tibial plateaus was 5.53 4.17 and 5.95 3.96, respectively. The difference between the PTS angles of the medial and lateral tibial plateaus was not statistically significant (P > .05). When plotted graphically by age, no trend between age and PTS was identified.This data set offers values for the PTS in skeletally immature specimens without a history of ACL injury and suggests that age may not be an accurate predictive factor for PTS.

View details for DOI 10.1177/23259671221088331

View details for PubMedID 35400135

View details for PubMedCentralID PMC8984849

The Axillary Nerve Danger Zone in Percutaneous Fixation in the Pediatric Shoulder: The "1-Mountain-3-Valleys" Principle. The Journal of bone and joint surgery. American volume Stavinoha, T. J., Randhawa, S. D., Trivedi, S., Dingel, A., Shea, K. G., Frick, S. L. 2022

Abstract

Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters.A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis.Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP.All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury.This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.

View details for DOI 10.2106/JBJS.21.01202

View details for PubMedID 35344511

Trends in Pediatric ACL Reconstruction: The impact of COVID-19. Journal of athletic training Kiani, S. N., Yellin, J. L., Houlihan, N. V., Talwar, D., Shea, K. G., Ganley, T. J. 2022

Abstract

CONTEXT: The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004 to 2014. Interestingly, there are limited recent data on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19.OBJECTIVE: Given the impact of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period.DESIGN: Retrospective cohort study.SETTING: This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016 to June 2021, with March 1, 2020 considered the "start" of the COVID-19 pandemic.PATIENTS OR OTHER PARTICIPANTS: Using CPT codes, patients 18 years old and younger who underwent ACLR surgery were identified.INTERVENTIONS: None.MAIN OUTCOME MEASURES: Patient demographics and overall rates of surgery pre- and intra-pandemic were compared. Data were analyzed using bivariate, mixed model, and time series analyses.RESULTS: A total of 24,843 ACLRs were identified during this time period. In total, 1,853 fewer surgeries were performed after March 2020 than expected given pre-pandemic trends. Examining demographics, intra-pandemic, there was an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. There was also a significant shift in the proportion of ACLRs by region, with increased surgeries performed in the Midwest and decreased in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant.CONCLUSIONS: Based on pre-pandemic trends, there were fewer patients than projected who underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

View details for DOI 10.4085/1062-6050-0582.21

View details for PubMedID 35271733

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians. The Journal of pediatrics Taylor, I. K., Burlile, J. F., O'Brien, K., Schaeffer, E. K., Mulpuri, K., Shea, K. G. 2022

Abstract

OBJECTIVE: To evaluate decision-making processes OF pediatricians regarding developmental dysplasia of the hip (DDH) diagnosis and management by conducting a survey of pediatricians in the US.STUDY DESIGN: An electronic survey was sent to multiple AAP state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated.RESULTS: We received 139 responses and included 126 in analyses. Only 50% of pediatricians (63/126) practice in an institution that endorses a care pathway for DDH. 5.6% of pediatricians (7/125) have referred patients between 12-18 months to a specialist for suspected DDH, and 9.5% (12/125) have referred patients between 6-9 months. 23% of pediatricians (29/126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist. Only 72.2% of pediatricians (91/126) indicated that family history of DDH warrants an ultrasound regardless of examination findings. Several surveyed pediatricians (10.3%, 13/126) are only "somewhat" or "moderately" familiar with Barlow and Ortolani maneuvers.CONCLUSION: The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

View details for DOI 10.1016/j.jpeds.2022.02.047

View details for PubMedID 35231491

Epidemiological Study of the Discoid Meniscus: Investigating Demographic-Based Predictors in Large-Scale Claims Database CUREUS Randhawa, S. S., Tran, E. P., Segovia, N. A., Ganley, T. J., Tompkins, M., Ellis, H., Shea, K. G. 2021; 13 (11)
Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort. The American journal of sports medicine Nissen, C. W., Albright, J. C., Anderson, C. N., Busch, M. T., Carlson, C., Carsen, S., Chambers, H. G., Edmonds, E. W., Ellermann, J. M., Ellis, H. B., Erickson, J. B., Fabricant, P. D., Ganley, T. J., Green, D. W., Grimm, N. L., Heyworth, B. E., Po, J. H., Kocher, M. S., Kostyun, R. O., Krych, A. J., Latz, K. H., Loveland, D. M., Lyon, R. M., Mayer, S. W., Meenen, N. M., Milewski, M. D., Myer, G. D., Nelson, B. J., Nepple, J. J., Nguyen, J. C., Pace, J. L., Paterno, M. V., Pennock, A. T., Perkins, C. A., Polousky, J. D., Saluan, P., Shea, K. G., Shearier, E., Tompkins, M. A., Wall, E. J., Weiss, J. M., Willimon, S. C., Wilson, P. L., Wright, R. W., Zbojniewicz, A. M., Carey, J. L., ROCK Group 2021: 3635465211057103

Abstract

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

View details for DOI 10.1177/03635465211057103

View details for PubMedID 34818065

Epidemiological Study of the Discoid Meniscus: Investigating Demographic-Based Predictors in Large-Scale Claims Database. Cureus Randhawa, S., Tran, E., Segovia, N. A., Ganley, T., Tompkins, M., Ellis, H., Shea, K. G. 2021; 13 (11): e20050

Abstract

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-squaretests 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 <6%, <7%, 15.7%, and 73.7%, respectively; proportions of each racial category in the study population were 2.2%, 7.4%, 9.9%, and 80.5%, respectively. Incidence rates per 1000 for these were 5.95, 2.92, 5.19, and 3.01, respectively. After adjusting for age, sex, and income, race was not a statistically significant predictor. Odds of a discoid meniscus diagnosis decreased by 6% for each increment in age (p <0.001) and by 40% if male (p <0.001) in our total study population. In patients <=20 years old, sex was not a significant risk factor. Conclusions Younger age and female sex were identified as significant predictors for symptomatic discoid meniscus in the total study population. Unlike prior studies, this investigation did not show a significant association between this condition and race in the US, potentially increasing the diagnostic accuracy and estimated pretest probabilities for this condition based on patient demographics. What this study adds to existing knowledge This study provides new data on the role racial category plays in estimating the risk of having a symptomatic discoid meniscus requiring arthroscopic management, finding that it is unlikely to be a significant factor when controlling for other demographic variables. Furthermore, we report incidence statistics for this pathology in Black and Latinx populations, which so far have had little representation in peer-reviewed published literature on discoid meniscus epidemiology. In addition, this study suggests that age and sex possess statistically significant associations with a diagnosis of discoid meniscus requiring arthroscopic management, with the risk of diagnosis decreasing with age and increasing if female.

View details for DOI 10.7759/cureus.20050

View details for PubMedID 34993027

View details for PubMedCentralID PMC8720039

An Update on the Accessibility and Quality of Online Information for Pediatric Orthopaedic Surgery Fellowships CUREUS Cohen, S. A., Imrie, M., Shea, K. 2021; 13 (9)
An Update on the Accessibility and Quality of Online Information for Pediatric Orthopaedic Surgery Fellowships. Cureus Cohen, S. A., Shea, K., Imrie, M. 2021; 13 (9): e17802

Abstract

Introduction The internet is an important tool for applicants seeking information on pediatric orthopaedic surgery fellowship programs. Previous analysis of pediatric orthopaedic surgery fellowship websites demonstrated they were often inaccessible and incomplete. As such, the purpose of this study was to (1) perform an updated assessment of the accessibility and content of pediatric orthopaedic fellowship program websites and (2) compare the results to the previous study to discern temporal trends in website accessibility and quality. Methods A list of pediatric orthopaedic fellowship programs was compiled from the San Francisco Match (SF Match) and the Pediatric Orthopaedic Society of North America (POSNA) online databases. All identified websites were evaluated for (1) accessibility and (2) the presence of 12 education and 12 recruitment criteria. These criteria were determined by prior fellowship website analyses and the needs of current fellowship applicants. Website accessibility and quality were compared with previously reported metrics. Results Approximately 91% of pediatric orthopaedic surgery fellowship programs had a functioning website. While the SF Match and POSNA databases listed nearly identical programs, there were discrepancies in the information provided by the two databases, and individual program website links provided on both databases were often nonfunctional. Fellowship program websites contained an average of 15.1 3.9 total education and recruitment criteria (range: 3 - 21). The most common education criteria featured on program websites included information about research, affiliated hospital information, and rotations. The most common recruitment criteria featured on program websites included program descriptions, contact information, and social media links. There was an increased frequency in nearly all education and recruitment criteria evaluated when compared with 2014 metrics. Discussion Although website accessibility and content have improved since 2014, information on pediatric orthopaedic fellowship program websites remains incomplete, with many websites failing to provide information on criteria deemed important by fellowship applicants. In addition, many discrepancies exist between the SF Match and POSNA databases, the two primary sources of information for pediatric orthopaedic fellowship applicants.Increased consistency on pediatric orthopaedic fellowship websites and both the SF Match and POSNA databases may help applicants to better assess which programs to apply to and which programs to rank highly on their match list.

View details for DOI 10.7759/cureus.17802

View details for PubMedID 34660012

View details for PubMedCentralID PMC8497116

Joint Level Analysis Of Mechanical Power During Drop Vertical Jumps In Youth Post ACL Reconstruction Morgan, J. J., Lyons, S. M., Chan, S. K., Shea, K. G., Kraus, E. A. LIPPINCOTT WILLIAMS & WILKINS. 2021: 145
Hospital Value Committees: The Role of the Surgeon in New Technology Adoption. Surgical innovation Perl, J. R., Sheth, K. R., Shea, K. G., Wall, J. 2021: 15533506211031094

View details for DOI 10.1177/15533506211031094

View details for PubMedID 34281433

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review. The American journal of sports medicine Fury, M. S., Paschos, N. K., Fabricant, P. D., PLUTO Study Group, Anderson, C. N., Busch, M. T., Chambers, H. G., Christino, M. A., Cordasco, F. A., Edmonds, E. W., Ganley, T. J., Green, D. W., Heyworth, B. E., Lawrence, J. T., Matava, M. J., Micheli, L. J., Milewski, M. D., Nepple, J. J., Parikh, S. N., Pennock, A. T., Perkins, C. A., Saluan, P. M., Shea, K. G., Wall, E. J., Willimon, S. C., Kocher, M. S. 2021: 3635465211008656

Abstract

BACKGROUND: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients.PURPOSE: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance.STUDY DESIGN: Systematic review; Level of evidence, 4.METHODS: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted.RESULTS: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity 5, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity.CONCLUSION: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment.REGISTRATION: CRD42019136059 (PROSPERO).

View details for DOI 10.1177/03635465211008656

View details for PubMedID 33984243

Race Predicts Unsuccessful Healing of Osteochondritis Dissecans in the Pediatric Knee ORTHOPEDICS Patel, N. M., Helber, A. R., Gandhi, J. S., Shea, K. G., Ganley, T. J. 2021; 44 (3): E378-E384

Abstract

The purpose of this study was to evaluate the effect of race, insurance status, and socioeconomic status on successful or unsuccessful healing of osteochondritis dissecans (OCD) lesions in the pediatric knee. The authors retrospectively reviewed patients younger than 18 years who were treated for a knee OCD lesion between 2006 and 2017. Patients were required to have at least 6 months of clinical and radiographic follow-up to be included, unless complete healing was achieved sooner. The primary outcome of interest was healing of the OCD lesion based on radiographic and clinical examination. A total of 204 OCD lesions in 196 patients with a mean follow-up of 15.86.4 months were included. The mean age at initial presentation was 12.42.8 years. At most recent follow-up, 28 (13.7%) lesions did not show radiographic or clinical evidence of healing. Nonhealing lesions were found in 25.0% of Black children compared with 9.4% of White children (P=.02). After controlling for age, sex, sports participation, lesion size and stability, skeletal maturity, and operative vs nonoperative treatment in a multivariate model, Black children had 6.7 times higher odds of unsuccessful healing compared with their White counterparts (95% CI, 1.1-41.7; P=.04). In this study, Black children with OCD of the knee were significantly less likely to heal than were White patients, even when controlling for numerous other factors in a multivariate model. Although the exact etiology of this finding is unclear, future work should focus on the social, economic, and cultural factors that may lead to disparate outcomes. [Orthopedics. 2021;44(3):e378-e384.].

View details for DOI 10.3928/01477447-20210414-09

View details for Web of Science ID 000654062300012

View details for PubMedID 34039200

Patterns of Articular Cartilage Thickness in Pediatric and Adolescent Knees: A Magnetic Resonance Imaging-Based Study. Arthroscopy, sports medicine, and rehabilitation Sidharthan, S., Yau, A., Almeida, B. A., Shea, K. G., Greditzer, H. G., Jones, K. J., Fabricant, P. D. 2021; 3 (2): e381-e390

Abstract

Purpose: To establish normative values for articular cartilage thickness in pediatric and adolescent knees using magnetic resonance imaging (MRI) and investigate for any associations with age and skeletal maturity.Methods: MRI scans were analyzed in patients 7 to 18 years old without osteochondral lesions, chondral wear/pathology, intra-articular fractures, or history of knee surgery. Measurements of articular cartilage thickness at the patella (medial facet, lateral facet, median ridge), femur (medial condyle, lateral condyle, lateral trochlea), and tibia (medial plateau, lateral plateau) were made on axial, coronal, and sagittal MRI. Descriptive statistics were used to calculate mean cartilage thickness by age and sex. Analysis of variance with repeated measures, analysis of covariance, independent samples t test, and linear regression were performed to determine differences in mean cartilage thickness by anatomic location, sex, physeal status, and age, respectively.Results: A total of 240 knee MRI scans were included. Articular cartilage was thickest at the patella and did not vary with age or skeletal maturity. On the femur, articular cartilage was thickest at the lateral trochlea with mean cartilage thickness of 4.4 1.4 mm in male patients and 3.6 1.3 mm in female patients (P < .001). Patients with open distal femoral physes had significantly thicker cartilage at the medial femoral condyle, lateral femoral condyle, and lateral trochlea compared to patients with closing/closed physes (P < .001). Linear regression analysis revealed a significant inverse association between cartilage thickness at the femur and age.Conclusions: In pediatric and adolescent knees, articular cartilage is thickest at the patella, where it does not strongly correlate with age. In contrast, there is a strong inverse association between increasing age and articular cartilage thickness of the distal femoral condyles.Clinical Relevance: The longitudinal reference data presented in this study can aid in pre-operative interpretation of knee cartilage under pathologic conditions in pediatric and adolescent patients.

View details for DOI 10.1016/j.asmr.2020.09.029

View details for PubMedID 34027446

Quantitative assessment of the vascularity of the skeletally immature patella: a cadaveric study using MRI JOURNAL OF CHILDRENS ORTHOPAEDICS Gadinsky, N. E., Lin, K. M., Klinger, C. E., Dyke, J. P., Kleeblad, L. J., Shea, K. G., Helfet, D. L., Rodeo, S. A., Green, D. W., Lazaro, L. E. 2021; 15 (2): 157-165

Abstract

While predominant blood supply to the adult patella enters inferomedially, little is known about skeletally immature patellar perfusion. Improved knowledge of immature patella vascularity can further understanding of osteochondritis dissecans, dorsal defects of the patella and bipartite patella, and help ensure safe surgical approaches. We hypothesized that the immature patella would exhibit more uniform blood flow. The study purpose was to quantify immature patella regional perfusion in comparison with adults.Ten cadaveric knees were utilized (five immature, five mature). The superficial femoral artery was cannulated proximally. Signal enhancement increases were compared from pre- to post-contrast MRI to assess relative arterial contributions to patella regions (quadrants, anterior/posterior, superior/inferior, medial/lateral, and outer/inner).Quantitative-MRI analysis revealed similar distribution of enhancement between the immature and mature patella. The inferior pole exhibited significantly higher arterial contribution versus superior pole in both immature and mature groups (p = 0.009; both groups), while the inferomedial quadrant had the highest arterial contribution of all quadrants in both groups. The superolateral quadrant demonstrated the lowest arterial contribution in the immature group and second lowest in the adult group. The patella outer periphery had significantly greater arterial contribution than the inner central region in both immature (p = 0.009) and mature (p = 0.009) groups.Distribution of arterial contributions between the immature and mature patella was similar. Our results highlight the importance of inferior and inferomedial blood supply in both immature and mature patellas. These findings have implications for paediatric and adult patients; surgical damage to inferior patellar vessels should be avoided to prevent associated complications.

View details for DOI 10.1302/1863-2548.15.200261

View details for Web of Science ID 000642209000009

View details for PubMedID 34040662

View details for PubMedCentralID PMC8138784

Paediatric knee anterolateral capsule does not contain a distinct ligament: analysis of histology, immunohistochemistry and gene expression. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Iseki, T., Rothrauff, B. B., Kihara, S., Novaretti, J. V., Shea, K. G., Tuan, R. S., Fu, F. H., Alexander, P. G., Musahl, V. 2021; 6 (2): 8287

Abstract

OBJECTIVES: The presence of a discrete ligament within the knee anterolateral capsule (ALC) is controversial. Tendons and ligaments have typical collagens, ultrastructure, transcription factors and proteins. However, these characteristics have not been investigated in paediatric ALC. The purpose of this study was to characterise the paediatric ALC in terms of tissue ultrastructure and cellular expression of ligament markers scleraxis (SCX)-a basic helix-loop-helix transcription factor-and the downstream transmembrane glycoprotein tenomodulin (TNMD), as compared with the paediatric lateral collateral ligament (LCL) and paediatric quadriceps tendon (QT). We hypothesised that, in comparison to the LCL and QT, the ALC would possess poor collagen orientation and reduced SCX and TNMD expression.METHODS: 15 paediatric ALCs (age 6.33.3 years), 5 paediatric LCLs (age 3.41.3 years) and 5 paediatric QTs (age 2.01.2 years) from fresh cadaveric knees were used in this study. Fresh-frozen samples from each region were cryosectioned and then stained with H&E to evaluate collagen alignment and cell morphology. Expression of SCX and TNMD was determined by gene expression analysis and immunohistochemistry.RESULTS: The histological sections of the paediatric LCL and QT showed well-organised, dense collagenous tissue fibres with elongated fibroblasts, while the ALC showed more random collagen orientation without clear cellular directionality. The aspect ratio of cells in the ALC was significantly lower than that of the LCL and QT (p<0.0001and p<0.0001, respectively). The normalised distribution curve of the inclination angles of the nuclei in the ALC was more broadly distributed than that of the LCL or QT, indicating random cell alignment in the ALC. SCX immunostaining was apparent in the paediatric LCL within regions of aligned fibres, while the comparatively disorganised structure of the ALC was negative for SCX. The paediatric LCL also stained positive for TNMD, while the ALC was only sparsely positive for this tendon/ligament cell-surface molecule. Relative gene expression of SCX and TNMD were higher in the LCL and QT than in the ALC.CONCLUSION: In this study, a distinct ligament could not be discerned in the ALC based on histology, immunohistochemistry and gene expression analysis.LEVEL OF EVIDENCE: Controlled laboratory study.

View details for DOI 10.1136/jisakos-2019-000339

View details for PubMedID 33832981

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India. Indian journal of orthopaedics Hooper, N., Aroojis, A., Narasimhan, R., Schaeffer, E. K., Habib, E., Wu, J. K., Taylor, I. K., Burlile, J. F., Agrawal, A., Shea, K., Mulpuri, K. 2021; 55 (1): 158-168

Abstract

We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India.An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019.173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12months, and 49.1% had assessed children with DDH aged>2years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays.In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

View details for DOI 10.1007/s43465-020-00233-0

View details for PubMedID 33569110

View details for PubMedCentralID PMC7851210

Trochlear Development in Children From 1 Month to 10 Years of Age: A Descriptive Study Utilizing Analysis by Magnetic Resonance Imaging. Orthopaedic journal of sports medicine Pagliazzi, G., Ellermann, J. M., Carlson, C. S., Shea, K. G., Arendt, E. A. 2021; 9 (9): 23259671211028269

Abstract

Understanding the morphology of cartilage/bony maturation in preadolescents may help explain adult trochlear variation.To study trochlear morphology during maturation in children and infants using magnetic resonance imaging (MRI).Descriptive laboratory study.Twenty-four pediatric cadaveric knees (10 male and 14 female knees; age, 1 month to 10 years) were included. High-resolution imaging of the distal femoral secondary ossification center was performed using 7-T or 9.4-T MRI scanners. Three-dimensional MRI scans were produced, and images were reformatted; 3 slices in the axial, sagittal, and coronal planes images were analyzed, with coronal and sagittal imaging used for image orientation.Biometric analysis included lateral and medial trochlear height (TH); cartilaginous sulcus angle (CSA); osseous sulcus angle (OSA); trochlear depth; and trochlear facet (TF) length symmetry. Sex comparisons were considered when 1 specimen from both sexes of the same age was available; these included 11 knees spanning 4 age groups (ages 1, 3, 4, and 7 years).The analysis of trochlear morphology showed a lateral TH greater than the medial TH at all ages. The thickest cartilage was found on the lateral TF in the younger specimens. Regarding the development of osseous and cartilaginous trochlear contour, a cartilaginous sulcus was present in the 3-month-old specimen and continued to deepen up to the age of 4 years. The shape of the osseous center evolved from round (1 month) to oval (9 months) to rectangular (2 years); no distinct bony trochlear sulcus was present, although a well-formed cartilaginous sulcus was present. The first evidence of formation of a bony sulcus was at 4 years. By the age of 7 to 8 years, the bony contour of the adult distal femur resembled its cartilaginous contour. Female samples had a shallower CSA and OSA than did the male ones in all samples that had a defined OSA.Female trochlear grooves tended to be shallower (flatter). The lateral trochlea was higher (TH) and wider (TF length) during growth than was the medial trochlea in both sexes; furthermore, the development of the osseous sulcus shape lagged behind the development of the cartilaginous sulcus shape in the authors' study population.Bony anatomy of the trochlear groove did not match the cartilaginous anatomy in preadolescent children, suggesting that caution should be used when interpreting bony anatomy in this age group.

View details for DOI 10.1177/23259671211028269

View details for PubMedID 34552991

View details for PubMedCentralID PMC8450999

Changes in Pediatric Sports Injury Presentation During the COVID-19 Pandemic: A Multicenter Analysis. Orthopaedic journal of sports medicine Johnson, M. A., Halloran, K. n., Carpenter, C. n., Pascual-Leone, N. n., Parambath, A. n., Sharma, J. n., Seltzer, R. n., Ellis, H. B., Shea, K. G., Ganley, T. J. 2021; 9 (4): 23259671211010826

Abstract

The current coronavirus 2019 (COVID-19) pandemic has prompted a multitude of public health response measures including social distancing, school cancellations, and cessation of organized sports.To examine the impact of COVID-19 and corresponding public health measures on the characteristics of common pediatric musculoskeletal injuries associated with sports.Cohort study; Level of evidence, 3.This was a multicenter retrospective cohort study comparing patients with sports injuries presenting to 3 geographically diverse level I pediatric trauma hospitals and outpatient orthopaedic surgery clinics in the United States during the COVID-19 pandemic and a prepandemic period at the same institutions. Patients were included if they presented for care between February 15 and July 15 in 2020 (pandemic cohort) or between March 15 and April 15 in 2018 and 2019 (prepandemic cohort).Included were 1455 patients with an average age of 12.1 4.5 years. When comparing patients presenting in 2018 and 2019 with those presenting in 2020, we observed a decrease in mean age during the pandemic (12.6 4.0 vs 11.0 5.2 years; P = .048). Additionally, a decrease in the proportion of injuries attributed to sports (48.8% vs 33.3%; P < .001) and those occurring at school (11.9% vs 4.0%; P = .001) was observed. The proportion of injuries attributable to clavicle fractures increased during the early stages of the pandemic (13.2% vs 34.7%; P < .001). There was no statistically significant delay to care in injuries presenting during the pandemic (41.5 141.2 vs 19.23 79.1 days; P = .175).Across 3 tertiary care institutions, patients were seen without significant delay during the pandemic. We observed a significant decline in pediatric musculoskeletal injuries associated with sports during the COVID-19 pandemic. This decrease has been accompanied by a shift in both injury type and mechanism.

View details for DOI 10.1177/23259671211010826

View details for PubMedID 33997072

View details for PubMedCentralID PMC8107815

Radial Width of the Lateral Meniscus at the Popliteal Hiatus: Relevance to Saucerization of Discoid Lateral Menisci. The American journal of sports medicine Gamble, J. G., Abdalla, A. B., Meadows, M. G., Rauer, T., Chan, C. M., Ganley, T. J., Tompkins, M., Shea, K. G., Gamble, J. G. 2021: 3635465211056661

Abstract

A discoid lateral meniscus (DLM) is a congenital anomaly of the knee in which the lateral meniscus has an "O" shape and contains irregular, abnormal collagenous tissue. A DLM can cause mechanical symptoms and pain. Treatment of a symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached at the capsule. Reports in the literature recommend a residual width of 6 to 8 mm.The purpose of this research was to determine the width of the lateral meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6 to 8 mm will be sufficient to approximate normal anatomy.Cross-sectional study; Level of evidence, 3.We made direct measurements of the radial width of the lateral meniscus from the outer rim at the popliteal hiatus to the inner edge in 19 specimens (age, 2-120 months.) We measured one 4-year-old specimen with a bilateral complete DLM. We also measured 39 digital images of specimens (age, 1-132 months) using ImageJ. Finally, we made direct arthroscopic measurements of 8 skeletally mature specimens.The average width of specimens <3 years old was 5.5 mm. The average width of the 10-year-old specimens was 12 mm. The average width of the skeletally mature specimens was 16 mm. A 4-year-old DLM specimen measured 19 mm.We rejected our null hypothesis. Direct measurements suggest that a residual width of 6 to 8 mm is insufficient for children 8 years old. A width of at least a full centimeter approximates the normal for 8-year-olds and at least 15 mm for adolescents.

View details for DOI 10.1177/03635465211056661

View details for PubMedID 34780308

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions. Indian journal of orthopaedics Li, J., Aroojis, A., Mulpuri, K., Shea, K. G., Schaeffer, E. K. 2021: 1-10

Abstract

In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasivesurgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country's needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway.The Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country's immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.In Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways.Level III.

View details for DOI 10.1007/s43465-021-00534-y

View details for PubMedID 34720173

View details for PubMedCentralID PMC8533670

Anterior Cruciate Ligament Length in Pediatric Populations: An MRI Study. Orthopaedic journal of sports medicine Tran, E. P., Dingel, A. B., Terhune, E. B., Segovia, N. A., Vuong, B., Ganley, T. J., Fabricant, P. D., Green, D. W., Stavinoha, T. J., Shea, K. G. 2021; 9 (4): 23259671211002286

Abstract

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.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.Cross-sectional study; Level of evidence, 3.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.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).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.

View details for DOI 10.1177/23259671211002286

View details for PubMedID 35146026

View details for PubMedCentralID PMC8822022

Complications and Controversies in the Management of 5 Common Pediatric Sports Injuries. JBJS reviews Striano, B. M., Aoyama, J. T., Ellis, H. B., Kocher, M. S., Shea, K. G., Ganley, T. J. 2020; 8 (12): e20000139

View details for DOI 10.2106/JBJS.RVW.20.00013

View details for PubMedID 33298679

Changes in Matrix Components in the Developing Human Meniscus. The American journal of sports medicine Fedje-Johnston, W., Toth, F., Albersheim, M., Carlson, C. S., Shea, K. G., Rendahl, A., Tompkins, M. 2020: 363546520972418

Abstract

BACKGROUND: Treatment of meniscal tears is necessary to maintain the long-term health of the knee joint. Morphological elements, particularly vascularity, that play an important role in meniscal healing are known to change during skeletal development.PURPOSE: To quantitatively evaluate meniscal vascularity, cellularity, collagen, and proteoglycan content by age and location during skeletal development.STUDY DESIGN: Descriptive laboratory study.METHODS: Medial and lateral menisci from 14 male and 7 female cadavers aged 1 month to 11 years were collected and evaluated. For each meniscus, histologic and immunohistologic techniques were used to establish the ratio of the area of proteoglycan (safranin O) positivity to the total area (proteoglycan ratio), collagen type I and type II immunostaining positivity, number of blood vessels, and cell density. These features were evaluated over the entire meniscus and also separately in 5 circumferential segments: anterior root, anterior horn, body, posterior horn, and posterior root. Additionally, cell density and number of blood vessels were examined in 3 radial regions: inner, middle, and periphery.RESULTS: Age was associated with a decrease in meniscal vessel count and cell density, while the proteoglycan ratio increased with skeletal maturity. Differences in vessel counts, cellular density, and proteoglycan ratio in different anatomic segments as well as in the inner, middle, and peripheral regions of the developing menisci were also observed. Collagen immunostaining results were inconsistent and not analyzed.CONCLUSION: The cellularity and vascularity of the developing meniscus decrease with age and the proteoglycan content increases with age. All of these parameters are influenced by location within the meniscus.CLINICAL RELEVANCE: Age and location differences in meniscal morphology, particularly in the number of blood vessels, are expected to influence meniscal healing.

View details for DOI 10.1177/0363546520972418

View details for PubMedID 33237814

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study AMERICAN JOURNAL OF SPORTS MEDICINE Bram, J. T., Aoyama, J. T., Mistovich, R., Ellis, H. B., Schmale, G. A., Yen, Y., McKay, S. D., Fabricant, P. D., Green, D. W., Lee, R., Cruz, A. I., Kushare, I. V., Shea, K. G., Ganley, T. J. 2020: 363546520951192

Abstract

Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.Case-control study; Level of evidence, 3.This was a multicenter study of 249 patients 18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10 deficit in extension and/or 25 deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean SD, 11.3 2.7 vs 12.3 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA.Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

View details for DOI 10.1177/0363546520951192

View details for Web of Science ID 000568745400001

View details for PubMedID 32898426

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India INDIAN JOURNAL OF ORTHOPAEDICS Hooper, N., Aroojis, A., Narasimhan, R., Schaeffer, E. K., Habib, E., Wu, J. K., Taylor, I. K., Burlile, J. F., Agrawal, A., Shea, K., Mulpuri, K. 2020
Relationship Between Dynamic Limb Symmetry And Subjective Limb Confidence Post ACL Reconstruction In Youth Athletes Morgan, J. J., Lyons, S. M., Chan, S. K., Chan, C. M., Shea, K. G., Kraus, E. A. LIPPINCOTT WILLIAMS & WILKINS. 2020: 23
Strategies and Tools to Enhance Patient Safety: HROs, HEROs, and Safety Culture. Journal of pediatric orthopedics Shea, K. G. 2020; 40 Suppl 1: S30S32

Abstract

INTRODUCTION: The Institute of Medicine has defined multiple domains to improve safety, efficiency, and effectiveness of health care. High-Reliability Organizations (HROs) address these issues and promote safety/reliability at the highest level.METHODS: HROs create a bottom-up, top-down culture that focuses upon continuous improvement by withholding blame on individuals yet requiring all members to be accountable for continuous improvement.RESULTS: Supporting staff to speak up, identify, and engage on the path to perfect care and zero harm are elements of a safety culture. In addition to safety, HROs can also focus on effectiveness and efficiency. This may be accomplished by creating consistent care practices that reduce irrational variation, decrease complexity, and lower risk.DISCUSSION: Developing a culture focused upon reliability, safety, and staff resilience is critical for HROs. HROs support and empower all staff to be vigilant and report concerns about any issue related to safety and support the development of a "Safety Culture." HROs focus upon safety will be enhanced by an expanded focus upon effectiveness and efficiency to improve value. A focus on standard clinical practices and clinician integration into the supply chain will help organizations produce better value and be an essential tool to reduce complexity and risk within health care systems.

View details for DOI 10.1097/BPO.0000000000001500

View details for PubMedID 32502068

Increased Vascularity in the Neonatal versus Adult Meniscus: Evaluation with Magnetic Resonance Imaging. Cartilage Lin, K. M., Gadinsky, N. E., Klinger, C. E., Dyke, J. P., Rodeo, S. A., Green, D. W., Fabricant, P. D., Helfet, D. L., Shea, K. G., Lazaro, L. E. 2020: 1947603520923143

Abstract

Objective. Quantification of meniscus vascularity has been limited with previous techniques, and minimal data exist describing differential vascular zones in the skeletally immature meniscus. The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in neonatal specimens with adults. We hypothesized that the developing meniscus has greater and more uniform vascularity throughout all zones. Design. Ten fresh-frozen human cadaveric knees (5 neonatal, age 0-6 months; 5 adult, 34-67 years) underwent gadolinium-enhanced MRI using an established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement within the same regions (normalized against background tissue) was compared between pre- and post-contrast images. Results. The medial and lateral menisci had similar distribution of perfusion (45.8% 8.1% medial vs. 54.2% 8.1% lateral in neonatal knees; 50.6% 11.3% medial vs. 49.4% 11.3% lateral in adult knees, P = 0.47). Increased perfusion was demonstrated in the periphery compared with the central zone (2.3:1 in neonatal knees and 3.25:1 in adult knees, P = 0.31). Neonatal specimens demonstrated 6.0-fold greater overall post-contrast meniscal signal enhancement compared with adults (P < 0.0001), with the 0-month specimen demonstrating the greatest proportional signal enhancement. Conclusions. While blood flow to the periphery is greater than to central zones in all menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including to the central zone, suggesting that the immature meniscus is a more biologically active tissue than its adult counterpart.

View details for DOI 10.1177/1947603520923143

View details for PubMedID 32447965

A Quality Improvement Project to Reduce Combination Acetaminophen-opioid Prescriptions to Pediatric Orthopedic Patients. Pediatric quality & safety Caruso, T. J., Trivedi, S., Chadwick, W., Gaskari, S., Wang, E., Marquez, J., Lagasse, S., Bailey, M., Shea, K. 2020; 5 (3): e291

Abstract

Background: Acetaminophen-opioid analgesics are among the most commonly prescribed pain medications in pediatric orthopedic patients. However, these combined opioid analgesics do not allow for individual medication titration, which can increase the risk of opioid misuse and hepatoxicity from acetaminophen. The primary aim of this quality improvement project was to alter the prescribing habits of pediatric orthopedic providers at our institution from postoperative acetaminophen-opioid analgesics to independent acetaminophen and opioids.Methods: The study took place in a level 1 trauma center at a children's hospital. A multidisciplinary team of health professionals utilized lean methodology to develop a project plan. Guided by a key driver diagram, we removed acetaminophen-oxycodone products from hospital formulary, implemented a revised inpatient and outpatient electronic order set, and conducted multiple education efforts. Outcomes included inpatient and outpatient percent combined acetaminophen-opioid orders by surgical providers over 27 months.Results: Before the intervention, inpatient acetaminophen-opioid products accounted for an average of 46% of all opioid prescriptions for orthopedic patients. After the intervention and multiple educational efforts, we reported a reduction in the acetaminophen-opioid products to 2.9%. For outpatient prescriptions, combined analgesics accounted for 88% before the intervention, and we reported a reduction to 15% after the intervention.Conclusions: By removing acetaminophen-oxycodone products from hospital formulary, educating the medical staff, and employing revised electronic order sets, the prescribing practice of pediatric orthopedic surgeons changed from the routine use of acetaminophen-opioid analgesics to independent medications.

View details for DOI 10.1097/pq9.0000000000000291

View details for PubMedID 32607456

Supply Chain Optimization and Waste Reduction. JAMA Cahan, E. M., Chawla, A., Shea, K. G. 2020; 323 (6): 57273

View details for DOI 10.1001/jama.2019.20854

View details for PubMedID 32044938

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatric Orthopaedic Surgeons in North America. Journal of pediatric orthopedics Taylor, I. K., Burlile, J. F., Schaeffer, E. K., Geng, X., Habib, E., Mulpuri, K., Shea, K. G. 2020

Abstract

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common condition, affecting 1% to 2% of full-term infants. The American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Pediatrics have published guidelines detailing best practices for DDH screening and treatment. The purpose of this survey was to determine DDH treatment practices of pediatric orthopaedic surgeons in North America.METHODS: We queried orthopaedic surgeon members of the Pediatric Orthopaedic Society of North America (POSNA) about referral patterns, treatment practices, and use of DDH guidelines. The survey included demographics, clinical scenarios, referrals patterns, and ultrasound practices.RESULTS: Of the 1392 members of POSNA, we received 432 total responses and included 353 in statistical analyses. Results show that 68% (233/342) of surgeons practice in an institution that does not endorse a standard care pathway for DDH. Of surgeons who personally use a DDH care pathway, the AAOS guidelines were most cited (143/353, 41%). The majority (94%, 316/337) of surgeons do not believe that universal ultrasound screening should be adopted in the United States. Responses regarding ultrasound screening for "high risk" infants as outlined by AAOS varied based on risk factor. Many (57%, 200/353) surgeons have performed initial evaluations for patients over 12 months of age. While 80% (260/327) of orthopaedic surgeons believe that primary care providers are referring patients appropriately, only 57% (183/323) believe that primary care providers are ordering imaging studies appropriately.CONCLUSIONS: Results from this survey of POSNA membership indicate an opportunity to better distribute and implement DDH guidelines. In addition, the implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by: (1) reducing the total cost of care, (2) increasing the use of appropriate imaging, (3) increasing timely referral for DDH care, and (4) reducing the presentation rate of walking age DDH patients.LEVEL OF EVIDENCE: The level of evidence rating for this survey-based study is level IV.

View details for DOI 10.1097/BPO.0000000000001505

View details for PubMedID 31904613

Autologous Chondrocyte Implantation as Treatment for Unsalvageable Osteochondritis Dissecans: 10- to 25-Year Follow-up. The American journal of sports medicine Carey, J. L., Shea, K. G., Lindahl, A. n., Vasiliadis, H. S., Lindahl, C. n., Peterson, L. n. 2020: 363546520908588

Abstract

An unsalvageable osteochondritis dissecans (OCD) fragment has been defined as one that cannot be saved. Unsalvageable OCD lesions have been treated with various techniques, including fragment excision, microfracture, osteochondral autograft transfer, fresh osteochondral allograft transplantation, and autologous chondrocyte implantation (ACI).Patients who underwent ACI as treatment for unsalvageable OCD more than 10 years ago would maintain satisfactory patient-oriented outcome measures and have a low need for additional open surgery, especially arthroplasty.Case series; Level of evidence, 4.All Swedish and Norwegian patients (59 patients with 67 OCD lesions) who underwent ACI for OCD under the direction of the senior author between 1990 and 2005 were identified through manual chart review. Features of the patient, OCD lesion, and surgery were extracted from the medical record and intraoperative photographs. Patients were sent questionnaires to assess the Knee injury and Osteoarthritis Outcome Score, Tegner-Wallgren activity score, and Lysholm score. In addition, patients were asked whether they had to undergo further surgery, including knee replacement, of the knee that underwent ACI. They were asked whether they would have the surgery again if in the same situation.A total of 55 patients (93%) with 61 OCD lesions (91%) responded. The median follow-up duration was 19 years (range, 10-26 years) and the median age at follow-up was 43 years (range, 28-69 years). Subsequent arthroscopy was performed in the majority of cases, although many of these were scheduled "second looks" as part of a study. With respect to other subsequent surgery, 12 knees (20%) underwent any additional open surgery, but only 2 knees (3%) underwent arthroplasty. Eight knees (13%) underwent revision ACI. Most patients reached their preinjury activity level (62%) and would undergo ACI again if in the same situation (85%). If failure is defined as revision of the graft or conversion to arthroplasty, then survivorship after ACI for OCD in the current study would be 87% at 10 years, 85% at 15 years, and 82% at 20 years.ACI for OCD provides a durable treatment option. At a median follow-up of 19 years, there was a very low (~3%) conversion to total knee arthroplasty.

View details for DOI 10.1177/0363546520908588

View details for PubMedID 32181674

Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review. The American journal of sports medicine Sochacki, K. R., Shea, K. G., Varshneya, K. n., Safran, M. R., Abrams, G. D., Donahue, J. n., Sherman, S. L. 2020: 363546520904685

Abstract

The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies.To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants.Systematic review.A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean SD. Categorical variable data were reported as frequency with percentage.Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 2.4 mm.The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.

View details for DOI 10.1177/0363546520904685

View details for PubMedID 32109145

Quality Improvement and Patient Safety: How Leadership Can Create a Culture of Safety: AOA Critical Issues Symposium. The Journal of bone and joint surgery. American volume Samora, J. B., Shea, K. G., Chen, A. F., Turner, P., Frick, S. L. 2019

Abstract

Orthopaedic leaders need to create a shared vision and must establish trust, open lines of communication, and buy-in from all team members in order to establish a culture that is supportive of quality improvement. Leaders should encourage teams to follow evidence-based guidelines, reduce variation, take an active role in supply chain processes, and develop new ideas to improve quality and safety of care. With rapidly changing medical and surgical advancements, orthopaedic leaders must continually adapt in the face of evolving challenges.

View details for DOI 10.2106/JBJS.19.01006

View details for PubMedID 31895237

Age-Appropriate Pediatric Sports Patient-Reported Outcome Measures and Their Psychometric Properties: A Systematic Review AMERICAN JOURNAL OF SPORTS MEDICINE Suryavanshi, J. R., Goto, R., Jivanelli, B., Fabricant, P. D., Aberdeen, J., Duer, T., Lam, K. C., Franklin, C. C., MacDonald, J., Shea, K. G., PRiSM Outcomes Measures Res Intere 2019; 47 (13): 327076

Abstract

Phenomena including early sport specialization and year-round training and competition have contributed to an increase in pediatric sports injuries. There has been a concomitant increase in clinical studies focusing on physically active children and adolescents. These studies include investigations of patient-reported outcome measures (PROMs). While the use of PROMs in pediatric orthopaedics has been increasing, PROMs are often inappropriately applied to study populations for whom they are not specifically validated.The purpose of this study was to establish a comprehensive list of pediatric- and adolescent-validated PROMs and catalog their psychometric properties as a resource for clinicians and researchers.Systematic review; Level of evidence, 4.A systematic review of articles in PubMed, Embase, and the Cochrane library was performed to identify articles developing and validating PROMs appropriate for use in pediatric sports medicine research. The inclusion criteria were as follows: age <18 years, the use of surveys and questionnaires, and the presence of sports-related injuries. The psychometric properties of included PROMs were entered into an electronic database.Our search strategy identified 14,708 unique articles, among which 139 studies (0.9%) were included in the final data analysis. Forty-seven distinct PROMs were identified, as well as 160 cross-cultural adaptations. While all identified PROMs were validated in physically active young participants, only 12 (26%) were specifically created initially for active children. Thirty (64%) PROMs were health-related quality-of-life measures; 13 (28%) were psychosocial measures; and 4 (9%) were activity scales. No studies validated PROMs for use with wrist/hand injuries, and only 1 PROM each was valid for hip, back/spinal, and foot/ankle injuries in pediatric sports.This systematic review yielded 47 unique PROMs reliable and valid for use in pediatric and adolescent sports medicine. This list will unify clinicians and researchers in using these age-appropriate measures while identifying areas that are still in need of appropriate PROMs for young athletes.

View details for DOI 10.1177/0363546518818822

View details for Web of Science ID 000493776100030

View details for PubMedID 30649907

Three-Dimensional Quantitative Magnetic Resonance Imaging of Epiphyseal Cartilage Vascularity Using Vessel Image Features: New Insights into Juvenile Osteochondritis Dissecans. JB & JS open access Ellermann, J. M., Ludwig, K. D., Nissi, M. J., Johnson, C. P., Strupp, J. P., Wang, L., Zbyn, S., Toth, F., Arendt, E., Tompkins, M., Shea, K., Carlson, C. S. 2019; 4 (4)

Abstract

We introduce a quantitative measure of epiphyseal cartilage vascularity and examine vessel networks during human skeletal maturation. Understanding early morphological changes in the distal femoral condyle is expected to provide information on the pathogenesis of developmental diseases such as juvenile osteochondritis dissecans.Methods: Twenty-two cadaveric knees from donors ranging from 1 month to 10 years of age were included in the study. Images of bone, cartilage, and vascularity were acquired simultaneously with a 3-dimensional gradient-recalled-echo magnetic resonance imaging (MRI) sequence. The secondary ossification center volume and total epiphysis cartilage volume ratio and articular-epiphyseal cartilage complex and epiphyseal cartilage widths were measured. Epiphyseal cartilage vascularity was visualized for 9 data sets with quantitative susceptibility mapping and vessel filtering, resulting in 3-dimensional data to inform vessel network segmentation and to calculate vascular density.Results: Three distinct, non-anastomosing vascular networks (2 peripheral and 1 central) supply the distal femoral epiphyseal cartilage. The central network begins regression as early as 3 months and is absent by 4 years. From 1 month to 3 years, the ratio of central to peripheral vascular area density decreased from 1.0 to 0.5, and the ratio of central to peripheral vascular skeletal density decreased from 0.9 to 0.6. A narrow, peripheral vascular rim was present at 8 years but had disappeared by 10 years. The secondary ossification center progressively acquires the shape of the articular-epiphyseal cartilage complex by 8 years of age, and the central areas of the medial and lateral femoral condyles are the last to ossify.Conclusions: Using cadaveric pediatric knees, we provide quantitative, 3-dimensional measures of epiphyseal cartilage vascular regression during skeletal development using vessel image features. Central areas with both early vascular regression and delayed ossification correspond to predilection sites of juvenile osteochondritis dissecans in this limited case series. Our findings highlight specific vascular vulnerabilities that may lead to improved understanding of the pathogenesis and better-informed clinical management decisions in developmental skeletal diseases.Clinical Relevance: This paradigm shift in understanding of juvenile osteochondritis dissecans etiology and disease progression may critically impact future patient management. Our findings highlight specific vascular vulnerabilities during skeletal maturation in a group of active young patients seen primarily by orthopaedic surgeons and sports medicine professionals.

View details for DOI 10.2106/JBJS.OA.19.00031

View details for PubMedID 32043049

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Adams, A. J., O'Hara, N. N., Abzug, J. M., Aoyama, J. T., Ganley, T. J., Carey, J. L., Cruz, A. I., Ellis, H. B., Fabricant, P. D., Green, D. W., Heyworth, B. E., Janicki, J. A., Kocher, M. S., Lawrence, J. R., Lee, R., McKay, S. D., Mistovich, R., Patel, N. M., Polousky, J. D., Rhodes, J. T., Sachleben, B. C., Sargent, M., Schmale, G. A., Shea, K. G., Yen, Y., Tibial Spine Res Grp 2019; 7 (8): 2325967119866162

Abstract

Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative.To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures.Cross-sectional study.A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient's sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon's decision, as well as surgeon training background, years in practice, and risk-taking behavior.The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by 3.5 mm. Significant variation in surgeon's propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent's preference for surgical treatment.There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

View details for DOI 10.1177/2325967119866162

View details for Web of Science ID 000483466800001

View details for PubMedID 31489334

View details for PubMedCentralID PMC6713965

Editorial Commentary: Anterolateral Ligament-Anatomy, Evaluation, and Future Applications to Knee Stability. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Shea, K. G., Musahl, V., Stavinoha, T. J. 2019; 35 (7): 214345

Abstract

Magnetic resonance imaging evaluation of anterolateral ligament injury may be reliable for individuals experienced and trained to identify it, but it does not reference a diagnostic gold standard. The structural anatomy and radiographic diagnosis may differ from those of more traditional ligaments, which should influence concepts of reconstruction.

View details for DOI 10.1016/j.arthro.2019.04.007

View details for PubMedID 31272634

Patellar-Trochlear Morphology in Pediatric Patients From 2 to 11 Years of Age: A Descriptive Analysis Based on Computed Tomography Scanning. Journal of pediatric orthopedics Richmond, C. G., Shea, K. G., Burlile, J. F., Heyer, A. M., Ellis, H. B., Wilson, P. L., Arendt, E. A., Tompkins, M. A. 2019

Abstract

BACKGROUND: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development.METHODS: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex.RESULTS: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued.CONCLUSIONS: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients.LEVELS OF EVIDENCE: Level IV.

View details for DOI 10.1097/BPO.0000000000001405

View details for PubMedID 31107711

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter. Journal of pediatric orthopedics Goldberg, M. J., Shea, K. G., Weiss, J. M., Carter, C. W., Talwalkar, V. R., Schwend, R. M. 2019; 39 (4): e241-e244

Abstract

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

View details for DOI 10.1097/BPO.0000000000001295

View details for PubMedID 30839471

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter JOURNAL OF PEDIATRIC ORTHOPAEDICS Goldberg, M. J., Shea, K. G., Weiss, J. M., Carter, C. W., Talwalkar, V. R., Schwend, R. M. 2019; 39 (4): E241-E244
Mechanical and Microstructural Properties of Native Pediatric Posterior Cruciate and Collateral Ligaments ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Schmidt, E. C., Chin, M., Aoyama, J. T., Ganley, T. J., Shea, K. G., Hast, M. W. 2019; 7 (2)
Mechanical and Microstructural Properties of Native Pediatric Posterior Cruciate and Collateral Ligaments. Orthopaedic journal of sports medicine Schmidt, E. C., Chin, M., Aoyama, J. T., Ganley, T. J., Shea, K. G., Hast, M. W. 2019; 7 (2): 2325967118824400

Abstract

Although anterior cruciate ligament (ACL) tears have received the most attention, the medial collateral ligament (MCL) is thought to be the most commonly injured knee ligament overall. The lateral collateral ligament (LCL) and posterior collateral ligament (PCL) are less frequently compromised but can be involved in severe multiligament injuries. The paucity of information on the native properties of these ligaments in the pediatric population hinders the overall optimization of treatment for these injuries.To characterize the mechanical and microstructural properties of pediatric MCLs, LCLs, and PCLs using a rare cadaveric cohort (mean age, 9.2 years).Descriptive laboratory study.MCLs, LCLs, and PCLs were harvested from 5 fresh-frozen pediatric knee specimens (3 male, 2 female) and were subjected to a tensile loading protocol. A subset of contralateral tissues from a single donor was analyzed using bright-field, polarized light, and transmission electron microscopy to measure collagen fiber morphology.The pediatric MCL exhibited values for ultimate stress (11.7 6.7 MPa), ultimate strain (18.2% 6.8%), and the Young modulus (93.7 56.5 MPa) that were similar to values for the LCL (11.4 11.5 MPa, 27.7% 12.9%, and 64.4 76.6 MPa, respectively). The PCL demonstrated decreased ultimate stress (4.2 1.8 MPa), increased ultimate strain (28.8% 11.9%), and a decreased Young modulus (19.8 10.4 MPa) when compared with the MCL and LCL. All 3 ligaments had similar mean crimp wavelengths (MCL, 32.8 3.6 m; LCL, 27.2 3.5 m; PCL, 25.8 3.5 m) and collagen fibril diameters (MCL, 88.0 26.0 nm; LCL, 93.3 34.6 nm; PCL, 90.9 34.0 nm); however, the fibril distribution profiles exhibited different modalities.The pediatric MCL and LCL possessed similar mechanical properties, while the pediatric PCL was weaker but capable of withstanding higher amounts of strain. All 3 of these pediatric structures were weaker than what has been reported in studies with adult cohorts.Results from this study can be considered preliminary mechanical and microstructural data for healthy pediatric collateral and posterior cruciate ligaments that can be used to guide further laboratory and clinical research.

View details for DOI 10.1177/2325967118824400

View details for PubMedID 30775386

View details for PubMedCentralID PMC6362518

Mechanical and Microstructural Properties of Pediatric Anterior Cruciate Ligaments and Autograft Tendons Used for Reconstruction ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Schmidt, E. C., Chin, M., Aoyama, J. T., Ganley, T. J., Shea, K. G., Hast, M. W. 2019; 7 (1)
The Position of the Popliteal Artery and Peroneal Nerve Relative to the Menisci in Children: A Cadaveric Study. Orthopaedic journal of sports medicine Shea, K. G., Dingel, A. B., Styhl, A. n., Richmond, C. G., Cannamela, P. C., Anderson, A. F., Ganley, T. J., Hill, A. n., Yen, Y. M. 2019; 7 (6): 2325967119842843

Abstract

Meniscal injury in skeletally immature patients is increasingly reported. During meniscal repair, all-inside devices may protrude beyond the posterior limits of the meniscus, putting the neurovascular structures at risk.The purposes of this study were (1) to examine the relationship between the popliteal artery and the posterolateral and posteromedial aspects of the menisci, (2) to examine the relationship of the peroneal nerve to the posterolateral meniscus, and (3) to develop recommendations for avoiding neurovascular injury during posterior meniscal repair in pediatric patients.Descriptive laboratory study.A total of 26 skeletally immature knee cadaveric specimens (7 females and 19 males) were included. Specimens were divided into age groups: 2-4, 5-8, and 9-11 years. The most posterior extent of the lateral and medial menisci was identified via sagittal and axial views on computed tomography (CT) scans. The shortest distance from the most posterior aspect of the lateral and medial menisci to the popliteal artery and the shortest distance from the posterior aspect of the lateral menisci to the anterior rim of the peroneal nerve were measured, and 3-dimensional models of representative specimens were re-created through use of CT scans.For the age groups 2-4, 5-8, and 9-11 years, the mean minimum distance from the posterolateral meniscus to the popliteal artery was 5.2, 6.7, and 8.2 mm, respectively, and the mean minimum distance from the posteromedial meniscus to the popliteal artery was 12.7, 15.4, and 20.3 mm, respectively. In all groups, the distance between the posteromedial meniscus and the popliteal artery was greater than that between the posterolateral meniscus and the popliteal artery. The mean distance from the peroneal nerve to the lateral meniscus was 13.3, 15.0, and 17.9 mm for the respective groups.Many all-inside meniscal repair devices have sharp tips that penetrate posterior to the meniscus and capsule. This study demonstrated that the distance between the posterior meniscus and popliteal artery is relatively small in pediatric patients, especially for the lateral meniscus region.Because of the higher potential for meniscal healing, meniscal repair is more likely to be performed in pediatric patients. The data in this study regarding the proximity of the lateral meniscus and neurovascular structures may be used to guide safe surgical repair of posterior meniscal tears during the use of all-inside meniscal repair devices in these patients.

View details for DOI 10.1177/2325967119842843

View details for PubMedID 31286001

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Trends in Concomitant Meniscal Surgery Among Pediatric Patients Undergoing ACL Reconstruction: An Analysis of ABOS Part II Candidates From 2000 to 2016. Orthopaedic journal of sports medicine Cruz, A. I., Gao, B. n., Ganley, T. J., Pennock, A. T., Shea, K. G., Beck, J. J., Ellis, H. B. 2019; 7 (9): 2325967119869848

Abstract

Rates of anterior cruciate ligament (ACL) reconstruction among pediatric and adolescent patients are increasing. Limited knowledge exists about population-level rates of concomitant meniscal surgery in this age group.This study sought to examine trends in concomitant meniscal procedures and describe short-term complications in pediatric and adolescent patients undergoing ACL reconstruction. We hypothesized that overall meniscal surgery rates are increasing and that the likelihood of performing meniscal repair or meniscectomy is associated with patient- and surgeon-specific factors.Cross-sectional study.We queried ACL procedures in patients younger than 19 years reported by American Board of Orthopaedic Surgery (ABOS) part II examination candidates from 2000 to 2016. Regression models examined associations between patient and surgeon characteristics, year of surgery, follow-up time, meniscal procedure type, and number and type of complications.A total of 9766 cases were identified. Females represented 46% (n = 4468) of included cases. Mean patient age was 16.1 years (SD, 1.62 years; range, 0-18 years). The rate of concomitant ACL-meniscal procedures increased from the years 2000 to 2016 (49%-60%; P = .005). Surgeons with sports medicine (+7.0%) or pediatric orthopaedic fellowship (+6.6%) training had a higher likelihood of reporting a concomitant ACL-meniscal procedure (P = .003 and .006, respectively). Sports medicine-trained surgeons were more likely to perform meniscal repair compared with meniscectomy (+3.0%; P = .016). Younger patient age was associated with increased likelihood of undergoing meniscal repair compared with meniscectomy. Overall reported complication rate was 12.8%. Notable reported complications included infection (1.61%), arthrofibrosis (1.14%), and deep venous thrombosis or pulmonary embolism (0.11%). Sports medicine and pediatric orthopaedic fellowship training was associated with higher rates of reporting postoperative stiffness and/or arthrofibrosis.Among ABOS part II candidates, concomitant ACL-meniscal surgery has become more common than isolated ACL procedures. Procedures involving sports medicine fellowship-trained surgeons and younger patients were associated with increased rates of meniscal repair compared with meniscectomy. Pediatric orthopaedic and sports medicine training was associated with a greater likelihood of being involved in a concomitant ACL-meniscal procedure of any kind, and surgeons with such training also reported a higher incidence of postoperative stiffness and/or arthrofibrosis in patients.

View details for DOI 10.1177/2325967119869848

View details for PubMedID 31579682

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Mechanical and Microstructural Properties of Pediatric Anterior Cruciate Ligaments and Autograft Tendons Used for Reconstruction. Orthopaedic journal of sports medicine Schmidt, E. C., Chin, M., Aoyama, J. T., Ganley, T. J., Shea, K. G., Hast, M. W. 2019; 7 (1): 2325967118821667

Abstract

Over the past several decades, there has been a steady increase in pediatric anterior cruciate ligament (ACL) tears, particularly in young female basketball and soccer players. Because allograft tissue for pediatric ACL reconstruction (ACLR) has shown high rates of failure, autograft tissue may be the best option for ACLR in this population. However, differences in the structure and mechanical behavior of these tissues are not clear.To characterize the mechanical and microstructural properties in pediatric ACLs and autograft tissues using a rare cadaveric cohort (mean age, 9.2 years).Descriptive laboratory study.ACLs, patellar tendons, quadriceps tendons, semitendinosus tendons, and iliotibial bands (ITBs) were harvested from 5 fresh-frozen pediatric knee specimens (3 male, 2 female) and subjected to a tensile loading protocol. A subset of contralateral tissues was analyzed using bright-field, polarized light, and transmission electron microscopy.Patellar tendons exhibited values for ultimate stress (5.2 3.1 MPa), ultimate strain (35.3% 12.5%), and the Young modulus (27.0 8.8 MPa) that were most similar to the ACLs (5.2 2.2 MPa, 31.4% 9.9%, and 23.6 15.5 MPa, respectively). Semitendinosus tendons and ITBs were stronger but less compliant than the quadriceps or patellar tendons. ITBs exhibited crimp wavelengths (27.0 2.9 m) and collagen fibril diameters (67.5 19.5 nm) that were most similar to the ACLs (24.4 3.2 m and 65.3 19.9 nm, respectively).The mechanical properties of the patellar tendon were almost identical to those of the ACL. The ITB exhibited increased strength and a similar microstructure to the native ACL. These findings are not entirely congruent with studies examining adult tissues.These results can be used to inform further clinical research. In particular, they justify a further examination of the biomechanical and microstructural properties of the ITB in the context of its role as an autograft tissue in pediatric ACL reconstruction.

View details for DOI 10.1177/2325967118821667

View details for PubMedID 30719479

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Anatomic Dissection and CT Imaging of the Anterior Cruciate and Medial Collateral Ligament Footprint Anatomy in Skeletally Immature Cadaver Knees. Journal of pediatric orthopedics Shea, K. G., Cannamela, P. C., Dingel, A. B., Fabricant, P. D., Polousky, J. D., Anderson, A. F., Ganley, T. J. 2019

Abstract

Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in skeletally immature patients are increasingly recognized and surgically treated. However, the relationship between the footprint anatomy and the physes are not clearly defined. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and define the footprint anatomy in relation to the physes in skeletally immature knees.Twenty-nine skeletally immature knees from 16 human cadaver specimens were dissected and divided into 2 groups: group A (aged 2 to 5y), and group B (aged 7 to 11y). Metallic markers were placed to mark the femoral and tibial attachments of the ACL and MCL. Computed tomography scans were obtained for each specimen used to measure the distance from the center of the ligament footprints to the respective distal femoral and proximal tibial physes.The median distance from the ACL femoral epiphyseal origin to the distal femoral physis was 0.30cm (interquartile range, 0.20 to 0.50cm) and 0.70cm (interquartile range, 0.45 to 0.90cm) for groups A and B, respectively. The median distance from the ACL epiphyseal tibial insertion to the proximal tibial physis for groups A and B were 1.50cm (interquartile range, 1.40 to 1.60cm) and 1.80cm (interquartile range, 1.60 to 1.85cm), respectively. The median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20cm (interquartile range, 1.00 to 1.20cm) and 0.85cm (interquartile range, 0.63 to 1.00cm) for groups A and B, respectively. The median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05cm (interquartile range, 2.63 to 3.30cm) and 4.80cm (interquartile range, 3.90 to 5.10cm) for groups A and B, respectively.Surgical reconstruction is a common treatment for ACL injury. Computed tomography scanning of pediatric tissue clearly defines the location of the ACL and MCL with respect to the femoral and tibial physes, and may guide surgeons for physeal respecting procedures.In addition to ACL reconstruction, recent basic science and clinical research suggest that ACL repair may be more commonly performed in the future. MCL repair and reconstruction is also occasionally required in skeletally immature patients. This information may be useful to help surgeons avoid or minimize physeal injury during ACL/MCL reconstructions and/or repair in skeletally immature patients.

View details for DOI 10.1097/BPO.0000000000001398

View details for PubMedID 31166245

Pediatric ACL Tears: Natural History. Journal of pediatric orthopedics Dingel, A. n., Aoyama, J. n., Ganley, T. n., Shea, K. n. 2019; 39 (Issue 6, Supplement 1 Suppl 1): S47S49

Abstract

Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury.The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature.A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms "anterior cruciate ligament," "pediatric" and/or "adolescent," and "conservative" and/or "nonoperative treatment." A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format.Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event.The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.

View details for DOI 10.1097/BPO.0000000000001367

View details for PubMedID 31169648

The Safe Distance to the Popliteal Neurovascular Bundle in Pediatric Knee Arthroscopic Surgery: An Age-Based Magnetic Resonance Imaging Anatomic Study. Orthopaedic journal of sports medicine Schachne, J. M., Heath, M. R., Yen, Y. M., Shea, K. G., Green, D. W., Fabricant, P. D. 2019; 7 (7): 2325967119855027

Abstract

The close proximity of the popliteal neurovascular bundle to the posterior horn of the lateral meniscus puts it at risk of compromise during lateral meniscal repair. This is particularly important in smaller pediatric patients, who are commonly treated for lateral meniscal abnormalities in isolation (discoid meniscus) or concomitantly with anterior cruciate ligament reconstruction.To quantify the distance between the posterior horn of the lateral meniscus and the popliteal neurovascular bundle along the path of meniscal repair and to investigate for associations with age, sex, height, weight, body mass index (BMI), and skeletal maturity.Cross-sectional study; Level of evidence, 3.A total of 144 magnetic resonance imaging scans were evaluated in a cohort of patients aged 10 to 18 years without meniscal or ligament abnormalities. Measurements were made along a line from the anterolateral portal between the popliteal neurovascular bundle and the free edge, midpoint, and meniscocapsular junctions of the posterior horn of the lateral meniscus. In addition to descriptive statistics of these distances by age and sex, analyses of variance and linear regression analyses were performed to investigate for associations with age, sex, height, weight, BMI, and skeletal maturity.Male participants had a significantly larger mean free edge distance (14.4 2.5 vs 13.1 2.5 mm, respectively; P = .005) and midpoint distance (9.6 2.2 vs 8.9 1.8 mm, respectively; P = .011) than female participants but not a significantly larger meniscocapsular distance (5.2 1.6 vs 4.6 1.4 mm, respectively; P = .096). Linear regression analyses revealed significant associations between these distances and age, height, weight, and BMI (P < .001 for all). There were statistically significant pairwise differences for free edge and midpoint distances to the neurovascular bundle between patients with open and closed physes.The distance between the posterior horn of the lateral meniscus and the popliteal vasculature along a trajectory from the standard anterolateral arthroscopic portal increases linearly throughout development between the ages of 10 and 18 years. There were also significant associations between height, weight, BMI, and skeletal maturity and these anatomic distances. Knowing the safe distance to the popliteal vasculature will increase the safety of arthroscopic lateral meniscal repair in children, especially with all-inside devices that require setting the penetration depth for the advancement of a sharp delivery device beyond the posterior capsule.

View details for DOI 10.1177/2325967119855027

View details for PubMedID 31321247

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Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient. Orthopaedic journal of sports medicine Shea, K. G., Burlile, J. F., Richmond, C. G., Ellis, H. B., Wilson, P. L., Fabricant, P. D., Mayer, S. n., Stavinoha, T. n., Troyer, S. n., Dingel, A. B., Ganley, T. J. 2019; 7 (7): 2325967119856578

Abstract

The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest.To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest.Descriptive epidemiology study.Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT.The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella.The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex.

View details for DOI 10.1177/2325967119856578

View details for PubMedID 31321249

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Identification of Areas of Epiphyseal Cartilage Necrosis at Predilection Sites of Juvenile Osteochondritis Dissecans in Pediatric Cadavers. The Journal of bone and joint surgery. American volume Toth, F., Tompkins, M. A., Shea, K. G., Ellermann, J. M., Carlson, C. S. 2018; 100 (24): 213239

Abstract

BACKGROUND: The pathogenesis of human juvenile osteochondritis dissecans (JOCD) remains poorly understood, with multiple factors implicated, including ischemia, repetitive trauma, and genetic predisposition. Similarities in the predilection site and the diagnostic and clinical features of JOCD to the well-characterized veterinary counterpart, osteochondrosis dissecans, suggest that, similar to the animal disease, the pathogenesis JOCD may also be initiated in the first few years of life, when disruption of blood supply to the epiphyseal growth cartilage leads to failure of endochondral ossification. To gather data in support of the hypothesis that JOCD and osteochondrosis dissecans have a shared pathogenesis, biopsy specimens obtained from predilection sites of JOCD in juvenile human cadavers were histologically examined to determine whether they contained lesions similar to those found in animals diagnosed with subclinical osteochondrosis dissecans.METHODS: In this descriptive laboratory study, 59 biopsy specimens (6 mm in diameter) were harvested from the central aspect (i.e., the notch side) of the femoral condyles of 26 human cadavers (1 month to 11 years old). Specimens were histologically evaluated for the presence of areas of cartilage necrosis and the morphology of cartilage canal blood vessels.RESULTS: Locally extensive areas of necrotic epiphyseal cartilage were identified in 4 specimens obtained from 3 donors (ages 2 to 4 years). Areas of cartilage necrosis accompanied by focal failure of endochondral ossification or surrounded by subchondral bone were identified in biopsy specimens from 4 donors (ages 4 to 9 years).CONCLUSIONS: The identification of epiphyseal cartilage necrosis identical to that described in animals with subclinical osteochondrosis, found in biopsy specimens obtained from femoral predilection sites of JOCD in pediatric cadavers, suggests a shared pathogenesis of JOCD in humans and osteochondrosis dissecans in animals.CLINICAL RELEVANCE: These findings imply that the pathogenesis of human JOCD likely starts 5 to 10 years prior to the development of clinical symptoms. Enhanced understanding of the temporal features of JOCD pathogenesis provides an opportunity for earlier diagnosis and treatment, likely resulting in improved outcomes for this condition in the future.

View details for PubMedID 30562294

Identification of Areas of Epiphyseal Cartilage Necrosis at Predilection Sites of Juvenile Osteochondritis Dissecans in Pediatric Cadavers JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Toth, F., Tompkins, M. A., Shea, K. G., Ellermann, J. M., Carlson, C. S. 2018; 100 (24): 2132-2139
Demographics and Epidemiology of Osteochondritis Dissecans of the Elbow Among Children and Adolescents ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Kessler, J. I., Jacobs, J. C., Cannamela, P. C., Weiss, J. M., Shea, K. G. 2018; 6 (12)
Proximity of the neurovascular structures during all-inside lateral meniscal repair in children: a cadaveric study. Journal of experimental orthopaedics Yen, Y., Fabricant, P. D., Richmond, C. G., Dingel, A. B., Milewski, M. D., Ellis, H. B., Wilson, P. L., Mayer, S. W., Ganley, T. J., Shea, K. G. 2018; 5 (1): 50

Abstract

PURPOSE: Meniscal repair has become increasingly common in a pediatric and adolescent population. All-inside repair techniques are utilized more often given their ease of insertion and decreased operative time required. However, there are possible risks including damage to adjacent neurovascular structures. The purpose of this study to was examine the proximity of the neurovascular structures during lateral meniscus repairs in pediatric specimens simulating a worst-case scenario.METHODS: Ten pediatric cadaveric knees (age 4-11) were utilized and simulated lateral meniscal repair through the posterior horn of the lateral meniscus and both medial and lateral to the popliteal hiatus through the body of the lateral meniscus was performed with an all-inside meniscal repair device. The distance to the popliteal artery or peroneal nerve was measured.RESULTS: During posterior horn repair, the average distance from the all-inside device to the popliteal artery was 1.9mm1.1mm. There was penetration of the artery in one specimen. During repair on the medial side of popliteal hiatus, the average distance from the all-inside device to the peroneal nerve was 3.2mm2.0mm. During repair on the lateral side of popliteal hiatus, the average distance from the all-inside device to the peroneal nerve was 12.4mm3.7mm.CONCLUSIONS: This study demonstrates that the proximity of the neurovascular structures to the lateral meniscus in children is extremely close and at high risk during meniscal repair with all-inside devices. This study gives important data for the proximity of these structures during these repair techniques.LEVEL OF EVIDENCE: Level 5 Cadaveric Study.

View details for PubMedID 30564981

Demographics and Epidemiology of Osteochondritis Dissecans of the Elbow Among Children and Adolescents. Orthopaedic journal of sports medicine Kessler, J. I., Jacobs, J. C., Cannamela, P. C., Weiss, J. M., Shea, K. G. 2018; 6 (12): 2325967118815846

Abstract

Osteochondritis dissecans (OCD) of the elbow is a disorder of subchondral bone and articular cartilage, of which the incidence among children is not clearly known.To assess the demographics and epidemiology of OCD of the elbow among children.Cross-sectional study; Level of evidence, 3.A retrospective chart review of an integrated health system for the years 2007 through 2011 was performed for patients with elbow OCD aged 2 to 19 years. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole as well as by sex and age group (2-5, 6-11, 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and multivariable logistic regression models were used to assess the risk of elbow OCD by group.A total of 37 patients with 40 OCD lesions fit the inclusion criteria. No lesion was found among 2- to 5-year-olds. A majority of lesions (n = 39, 97.5%) were in the capitellum, and 1 (2.5%) was in the trochlea. Twenty-five patients (67.6%) had right-sided lesions; 9 (24.3%), left-sided; and 3 (8.1%), bilateral. The incidence of elbow OCD for patients aged 6 to 19 years was 2.2 per 100,000 overall and 3.8 and 0.6 per 100,000 for males and females, respectively. The majority of OCD cases were seen in those aged 12 to 19 years, with an incidence of 3.4 per 100,000 versus 0.38 among 6- to 11-year-olds. Multivariable logistic regression analysis revealed a 21.7-times increased odds ratio of elbow OCD among patients aged 12 to 19 years versus 6 to 11 years, and males had a 6.8-times greater odds ratio of elbow OCD than females (P < .0001 for both). Based on race and ethnicity, non-Hispanic whites had the highest incidence of elbow OCD as compared with all other ethnic groups.In this population-based cohort study of pediatric elbow OCD, males had almost 7 times the risk of elbow OCD as compared with females, and 12- to 19-year-olds had nearly 22 times the risk of elbow OCD versus 6- to 11-year-olds. In keeping with many prior studies, the majority of patients had right-sided lesions.

View details for DOI 10.1177/2325967118815846

View details for PubMedID 30622996

View details for PubMedCentralID PMC6302285

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter. Journal of pediatric orthopedics Goldberg, M. J., Shea, K. G., Weiss, J. M., Carter, C. W., Talwalkar, V. R., Schwend, R. M. 2018

Abstract

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

View details for PubMedID 30418384

MANAGEMENT OF OSTEOCHONDRITIS DISSECANS OF THE FEMORAL CONDYLE A Critical Analysis Review JBJS REVIEWS Chan, C., Richmond, C., Shea, K. G., Frick, S. L. 2018; 6 (3)
Management of Osteochondritis Dissecans of the Femoral Condyle: A Critical Analysis Review. JBJS reviews Chan, C. n., Richmond, C. n., Shea, K. G., Frick, S. L. 2018; 6 (3): e5

View details for PubMedID 29557795

Incidence of Meniscal Entrapment and Associated Knee Injuries in Tibial Spine Avulsions Journal of Pediatric Orthopaedics Rhodes, J. T., Cannamela, P. C., Cruz, A. I., Mayo, M., Styhl, A. C., Richmond, C. G., Ganley, T. J., Shea, K. G. 2018; 38 (2): e38-42

View details for PubMedID 28973607

All-Epiphyseal Double Bundle PCL Reconstruction- Femoral Tunnel Drilling J ISAKOS Richmond, C. G., Cannamela, P. C., Polousky, J. D., Ganley, T. J., Shea, K. G. 2018
Avoiding Tibial Physeal Injury During Double Bundle Posterior Cruciate Ligament Recontruction J ISAKOS Troyer, S., Anchustegui, N., Richmond, C. G., Cannamela, P., Dingel, A., Stavinoha, T., Ganley, T., Anderson, A., Shea, K. G. 2018; 3 (1)

View details for DOI 10.1080/00913847

Appropriate Use Criteria for the Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists AAOS Board of Directors, A. AAOS. American Academy of Orthopaedic Surgeon's Website. 2018
Management of Osteochondritis Dissecans of the Femoral Condyle: A Critical Analysis Review Journal of Bone and Joint Surgery Chan, C., Richmond, C. G., Shea, K. G., Frick, S. L. 2018; 6 (3): e5
The Incidence of Osteochondritis Dissecans in Adults American Journal of Sports Medicine Weiss, J. M., Shea, K. G., Jacobs, J. C., Becker, I., Portman, M., Cannamela, P. C., Kessler, J. I. 2018; 46 (7): 1592-95
Risk Factors and Predictors of Significant Chondral Surface Change from Primary to Revision Anterior Cruciate Ligament Reconstruction: A MOON and MARS Cohort Study American Journal of Sports Medicine The MARS, G. 2018; 46 (3): 557-64
All-Epiphyseal ACL Femoral Tunnel Drilling- Avoiding Injury to the Physis, LCL, ALL, and Popliteus- A 3-Dimensional Study Arthroscopy Shea, K. G., Cannamela, P. C., Fabricant, P. D., Milewski, M. D., Terhune, B., Polousky, J. D., Anderson, A. F., Ganley, T. J. 2018; 34 (5): 1570-78
Childhood Obesity is Associated with Osteochondritis Dissecans of the Knee, Ankle, and Elbow in Children and Adolescents. Journal of Pediatric Orthopaedics Kessler, J., Jacobs, J. C., Cannamela, P. C., Shea, K. G., Weiss, J. M. 2018; 38 (5): e296-299
Pediatric and adolescent clavicle non-unions: Potential risk factors and surgical management. Journal of Shoulder and Elbow Surgery Pennock, A. T., Edmonds, E. W., Kocher, M. S., Bae, D. S., Farley, F. A., Ying Li, G., Ellis, H. B., Wilson, P. L., Nepple, J., Gordon, E., Willimon, S. C., Busch, M. T., Spence, D. D., Kelly, D. M., Pandya, N. K., Sabatini, C. S., Shea, K. G., Heyworth, B. E. 2018; 27 (1): 29-35
Long-term Intra-articular Steroid Injections and Knee Cartilage JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Maloney, W. J., Jevsevar, D. S., Shea, K. G. 2017; 318 (12): 118485
Surgical Predictors of Clinical Outcomes After Revision of Anterior Cruciate Ligament Reconstruction American Journal of Sports Medicine The Mars, G. 2017; 45 (11): 2586-2594
The Impact of Complications of Total Health Care Spending and Resource Utilization during a 2-3 Vertebra Lumbar Spinal Fusion and the 90-Day Follow-Up Period among Medicare Beneficiaries The Spine Journal Schlosser, M., Little, K., Shea, K. G., Hickey, E., Simon, A. 2017; 17 (10): s194
Avoiding Anterior Meniscus Root Injury During All-Epiphyseal ACL-R Tunnel Drilling in Skeletally Immature Knees J ISAKOS Shea, K. G., Cannamela, P. C., Fabricant, P. D., Anderson, A. F., Polousky, J. D., Fabricant, E. B., Milewski, M., Ganley, T. 2017; 3 (3): 7
Variation in the MPFL Origin in the Skeletally Immature- An Anatomic Study American Journal of Sports Medicine Shea, K. G., Martinson, W. D., Cannamela, P. C., Richmond, C. G., Fabricant, P. D., Anderson, A. F., Ganley, T. J., Polousky, J. D. 2017; 46 (2): 363-369
The Incremental Hospital Cost and Length-of-Stay Associated with Treating Adverse Events Among Medicare Beneficiaries Undergoing Cervical Spinal Fusion during Fiscal Year 2013-2014 Spine Culler, S. D., McGuire, K. J., Little, K. M., Jevsevar, D., Shea, K. G., Schlosser, M., Ambrose, K., Simon, A. 2017; 42 (20): 1578-1586
Anatomic Variation of the Anterolateral Ligament of the Knee in Pediatric Specimens Clinical Orthopaedics and Related Research Shea, K. G., Ganley, T., Fabricant, P., Terhune, B., Styhl, A., Cannamela, P., Jacobs, J. C., Milewski, M., Anderson, A., Polousky, J. 2017; 475 (6): 1583-91
Lateral Radiographic Landmarks for ACL and LCL Footprint Origins During All-Epiphyseal Femoral Drilling in Skeletally Immature Knees Journal of Bone and Joint Surgery Shea, K. G., Cannamela, P. C., Fabricant, P. D., Terhune, B., Polousky, J. D., Milewski, M. D., Ganley, T. J., Anderson, A. F. 2017; 99: 506-11
The Reliability of Assessing Radiographic Healing of Osteochondritis Dissecans of the Knee American Journal of Sports Medicine Wall, E. J., Milewski, M. D., Carey, J. L., Shea, K. G., Ganley, T. D., Polousky, J. D., Grimm, N. L., Eismann, E. A., Jacobs, J. C., Murnaghan, L. M., Nissen, C. W., Weiss, J. M., Myer, G. D. 2017; 45 (6): 1370-1375
Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risky Factors From a Multicenter Cohort American Journal of Sports Medicine The Mars, G. 2017; 45 (9): 2068-2076
Research in Osteochondritis Dissecans of the Knee Journal of Joint and Knee Surgery Nepple, J., Milewski, M., Shea, K. G. 2016; 29 (7): 533-538
Surgeon Directed Cost Variation in Isolated Rotator Cuff Repair Orthopaedic Journal of Sports Medicine Terhune, B., Johnson, J., Cannamela, P., Sadd, C., Silbernagel, J., Faciszewski, T., Shea, K. G. 2016; 4 (12)
Management of Osteochondritis Dissecans of the Femoral Condyle Journal of American Academy of Orthopaedic Surgeons Shea, K. G., Carey, J. L., Brown, G., Murray, J., Pezold, R., Sevarino, K. 2016; 24 (9): e102-4
The American Academy of Orthpaedic Surgeons Evidence-Based Clinical Practice Guideline on: Management of Carpal Tunnel Syndrome The Journal of Bone and Joint Surgery Graham, B., Peljovich, E., Shea, K. G., ., e. 2016; 98 (20): 1750-54
Pediatric Knee Osteochondritis Dissecans (OCD) Lesions. Orthopaedic Clinics of North America Aristides, C., Shea, K. G., Ganley, T. 2016; 47 (4): 763-775
Ankle Injury Prevention Meta-Analysis for Soccer Athletes Journal of Bone and Joint Surgery Grimm, N., Jacobs, J., Kim, J., Amendola, N., Shea, K. G. 2016; 98 (17): 1436-43
AAOS appropriate use criteria: Management of osteochondritis dissecans of the femoral condyle Journal of American Academy of Orthopaedic Surgery Carey, J., Shea, K. G. 2016; 24 (9): 105-111
Management of Osteochondritis of the Femoral Condyle JAAOS Shea, K. G., Carey, J. L., Brown, G. A., Murray, J., Pezold, R., Sevarino, K. 2016; 24 (9): 102-4
The Relationship of the Femoral Physis and the Medial Patellofemoral Ligament in Children- A Cadaveric Study American Journal of Sports Medicine Shea, K. G., Styhl, A. C., Jacobs, J., Ganley, T., Milewski, M., Cannamela, P. C., Anderson, A. F., Polousky, J. 2016
Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction American Journal of Sports Medicine ., T. 2016; 44 (7): 1671-1679
The Incremental Hospital Cost and Length-of-Stay Associated with Treating Adverse Events Among Medicare Beneficiaries Undergoing Lumber Spinal Fusion during Fiscal Year 2013 Spine Culler, S., Jevsevar, D., Shea, K. G., Little, K., McGuire, K. J., Write, K., Simon, A. 2016
The American Academy of Orthpaedic Surgeons Evidence-Based Clinical Practice Guideline on Surgical Management of Osteoarthritis of the Knee The Journal of Bone and Joint Surgery McGrory, B., Weber, K., ., e. 2016; 98 (8): 688-92
Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study American Journal of Sports Medicine Carey, J. L., Wall, E., Grimm, N., Ganley, T., Edmonds, E., Anderson, A. F., Polousky, J., Murnaghan, M. L., Nissen, C., Weiss, J., Lyon, R., Chambers, H., Wright, R., Heyworth, B., Peterson, L., Myer, G., Shea, K. G. 2016
The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents Orthopaedic Journal of Sports Medicine Weiss, J., Nikizad, H., Shea, K., Gyurdzhyan, S., Jacobs, J. C., Cannamela, P. C., Kessler, J. I. 2016
The Anterolateral Ligament of the Knee: An Inconsistent Finding in Pediatric Cadaveric Specimens Journal of Pediatric Orthopaedics Shea, K. G., Polousky, J., Jacobs, J. C., Yen, Y., Ganley, T. 2015
The Patellar Insertion of the Medial Patellofemoral Ligament in Children: a cadaveric study Journal of Pediatric Orthopaedics Shea, K. G., Polousky, J. D., Jacobs, J. C., Ganley, T., Aoki, S. K., Grimm, N., Parikh, S. N. 2015; 35 (4): e31-5
Guideline Developmental Dysplasia of the Hip in Infants up to Six Months of Age Journal of Bone and Joint Surgery Mulpuri , K., ., e. 2015; 97 (20): 1717-8
SHIFTING INTO WRIST PAIN - DEQUERVAINS DISEASE AND OFF-ROAD MOUNTAIN BIKING PHYSICIAN AND SPORTSMEDICINE SHEA, K. G., SHUMSKY, I. B., SHEA, C. F. 1991; 19 (9): 59-&
Shifting into Wrist Pain: De Quervain's Disease and off-road mountain biking The Physician . and Sports Medicine Shea, K. G., Shea, O. F., Shumsky, I. B. 1991; 19 (9): 59-63