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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): e2000013?9
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
View details for DOI 10.1007/s43465-020-00233-0

View details for Web of Science ID 000561481200003
Strategies and Tools to Enhance Patient Safety: HROs, HEROs, and Safety Culture. Journal of pediatric orthopedics Shea, K. G. 2020; 40 Suppl 1: S30?S32
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
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: 2?3
View details for Web of Science ID 000590026300006
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): 572?73
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., Vasiliadis, H. S., Lindahl, C., Peterson, L. 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., Safran, M. R., Abrams, G. D., Donahue, J., 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): 3270?76
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): 2143?45
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
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)
View details for DOI 10.1177/2325967118824400

View details for Web of Science ID 000457737000001
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)
View details for DOI 10.1177/2325967118821667

View details for Web of Science ID 000456646900001
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., Richmond, C. G., Cannamela, P. C., Anderson, A. F., Ganley, T. J., Hill, A., 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

View details for PubMedCentralID PMC6600506
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 PubMedID 30775386
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 PubMedID 30839471
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., 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

View details for PubMedCentralID PMC6759752
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 PubMedID 30719479
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 5?y), and group B (aged 7 to 11?y). 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 0.30?cm (interquartile range, 0.20 to 0.50?cm) and 0.70?cm (interquartile range, 0.45 to 0.90?cm) 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 1.50?cm (interquartile range, 1.40 to 1.60?cm) and 1.80?cm (interquartile range, 1.60 to 1.85?cm), respectively. The median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20?cm (interquartile range, 1.00 to 1.20?cm) and 0.85?cm (interquartile range, 0.63 to 1.00?cm) for groups A and B, respectively. The median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05?cm (interquartile range, 2.63 to 3.30?cm) and 4.80?cm (interquartile range, 3.90 to 5.10?cm) 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., Aoyama, J., Ganley, T., Shea, K. 2019; 39 (Issue 6, Supplement 1 Suppl 1): S47?S49
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

View details for PubMedCentralID PMC6624919
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., Stavinoha, T., Troyer, S., 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

View details for PubMedCentralID PMC6624918
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): 2132?39
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
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)
View details for DOI 10.1177/2325967118815846

View details for Web of Science ID 000453828500001
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 1.9mm�1.1mm. 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 3.2mm�2.0mm. During repair on the lateral side of popliteal hiatus, the average distance from the all-inside device to the peroneal nerve was 12.4mm�3.7mm.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
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): 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
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)
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
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 PubMedID 30622996
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): 1184?85
View details for PubMedID 28973607
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 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
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
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
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
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
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
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
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
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
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
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
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: 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
View details for DOI 10.1080/00913847

Kevin Shea

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