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Objectives: Hamstring tendon autograft (HTA) is the most common graft source used worldwide for anterior cruciate ligament reconstruction (ACLR). The graft is comprised of a patient’s own semitendinosus tendon (ST) and gracilis tendon (GT), typically double stranded. Recent literature suggests that HTAs below 8mm in diameter are associated with higher failure rates and poorer outcome scores. Currently, surgeons do not have a reliable, user-friendly tool to estimate HTA diameter pre-operatively. The inability to do so leads to potentially harvesting an insufficient graft. There is a growing body of evidence that suggests a correlation between preoperative MRI measurements and the intraoperative measured HTA diameter. This could be used to identify patients at risk of having small HTA diameter, however, it is unknown if these patients also are at risk of smaller caliber alternative autograft tendon sources (i.e., quadriceps tendon and patellar tendon). Our hypotheses were: i) Intra-operative HTA diameter is strongly correlated with pre-operative MRI measurements of ST cross-sectional area (STCSA), GT cross-sectional area (GTCSA), and the sum of the ST and GT cross-sectional area (STGTCSA); and ii) patients with HTA diameters less than 8mm will also have smaller caliber patellar tendon and quadriceps tendon measurements on pre-operative MRI. Methods: After appropriate IRB approval was obtained, patients undergoing ACLR with HTA between the period of 01/01/2013 to 05/31/2020 were retrospectively reviewed. Inclusion criteria included the following: MRI proven ACL tear, 3-Telsa MRI available for review, surgery performed within our institution using standard quadrupled hamstring technique, intra-operative HTA diameter recorded in the operative report, and age greater than 12 years old. The MRI measurements were performed by two physicians: one orthopedic sports medicine research fellow and one orthopedic surgery resident. Each physician was blinded to the intraoperative HTA diameter. CSA of the ST and GT was measured on axial MRI sequences using the axial slice that included the widest (medial-lateral (M-L) width) portion of the distal femur. This image was magnified 4 times and CSAs of the GT and ST were measured using the elliptical region of interest tool (Figure 1). In addition, the patellar tendon length (PTL), patellar tendon thickness (PTT), patellar tendon medial-lateral width (PTW), and quadriceps tendon thickness (QT) were measured. PTL was measured at the sagittal slice showing the most distal pole of the patella and tibial tubercle. PTT was also measured on this MRI slice at the tendon’s mid-point. PTW was measured in the sagittal view and cross referenced to an axial view as previously described. A point at the center of the tendon width (M-L width) was defined, and the width was then measured from this point to the medial and lateral borders separately in order to accommodate the tendon contour. The sum of the widths was regarded as the total tendon width. QT was measured in the anterior-posterior plane on a sagittal slice located 25mm proximal to the superior pole of the patella and measured at the mid-point of the tendon (M-L plane) orthogonal to the quadriceps tendon fibers. All measurements were taken using the universal viewer image analysis software. Pearson r values were calculated for MRI measurements from both readers and the average of their measurements against intra-operative HTA diameter. Receiver operator curves (ROC) were used to calculate sensitivity and specificity values for each MRI measurement. The measurement that best correlated with HTA diameter (e.g., GTCSA) was then compared to PTL, PTT, PTW, and QT among the patients with HTA less than 8mm. Intra-class correlation coefficients (ICC) were calculated for inter-rater reliability between reader 1 and reader 2 for all MRI measurements. Results: Fifty-two patients (53 knees, 26 female and 26 male) met inclusion criteria, with a mean age of 23 years old. The mean intraoperative HTA diameter was 7.98mm, with 18 grafts (34%) measuring less than 8mm. Pearson r values for all MRI measurements and ICC values are shown in in table 1. HTA diameter was significantly correlated to all averaged MRI measurements with the exception of PTW and QT. The strongest correlation was seen with GTCSA (r=0.72, p<.01). By entering a patient’s GTCSA measurement as “x” into the line of best fit (y = 41.83x + 5.0846), the estimated HTA diameter “y” can be extrapolated (Figure 2). Using our dataset, we determined that a GTCSA cut off value of 0.0625mm can be used to identify patients who will have a HTA diameter of 8mm or greater with a sensitivity of 0.91. For our cohort of 53 knees, GTCSA significantly correlated with PTL (r=0.352, p<.01), QT (r=0.334, p<.05), and STCSA (r=0.531, p<.01). [AMT(S2] Of the 18 patients with HTA diameter less than 8mm, GTCSA showed a significant correlation with PTL (r=0.34, p<.05) and QT (r=0.33, p<.05) (Figure 3). No significant correlation was observed between GTCSA and ST, PTT, or QT. Conclusions: Pre-operative MRI measurements of STCSA and STGTCSA did not correlate with intra-operative HTA in our cohort. However, pre-operative MRI measurement of GTCSA did show a strong correlation with intra-operative HTA diameter in our cohort of patients. Among patients with HTA diameters less than 8mm, GTCSA on pre-operative MRI showed a significant correlation with PTL and PTW. GTCSA can help to estimate whether or not a patient will have a HTA greater than 8mm and may provide insight regarding alternative autograft characteristics. The methods described in this study are reproducible between observers at different levels of their orthopedic training. By knowing how likely a patient is to have a sufficient HTA, surgeons can better educate patients regarding the risks and benefits pre-operatively as well as plan for alternative graft sources as needed.

Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care.

This study evaluated the effects of the Breath–Body–Mind Workshop (BBMW) (breathing, movement, and meditation) on psychological and physical symptoms and inflammatory biomarkers in inflammatory bowel disease (IBD).MethodsTwenty-nine IBD patients from the Jill Roberts IBD Center were randomized to BBMW or an educational seminar. Beck Anxiety Inventory, Beck Depression Inventory, Brief Symptom Inventory 18, IBD Questionnaire, Perceived Disability Scale, Perceived Stress Questionnaire, Digestive Disease Acceptance Questionnaire, Brief Illness Perception Questionnaire, fecal calprotectin, C-reactive protein, and physiological measures were obtained at baseline and weeks 6 and 26.ResultsThe BBMW group significantly improved between baseline and week 6 on Brief Symptom Inventory 18 (P = 0.02), Beck Anxiety Inventory (P = 0.02), and IBD Questionnaire (P = 0.01) and between baseline and week 26 on Brief Symptom Inventory 18 (P = 0.04), Beck Anxiety Inventory (P = 0.03), Beck Depression Inventory (P = 0.01), IBD Questionnaire (P = 0.01), Perceived Disability Scale (P = 0.001), and Perceived Stress Questionnaire (P = 0.01) by paired t tests. No significant changes occurred in the educational seminar group at week 6 or 26. By week 26, median C-reactive protein values decreased significantly in the BBMW group (P = 0.01 by Wilcoxon signed-rank test) versus no significant change in the educational seminar group.ConclusionsIn patients with IBD, participation in the BBMW was associated with significant improvements in psychological and physical symptoms, quality of life, and C-reactive protein. Mind–body interventions, such as BBMW, which emphasize Voluntarily Regulated Breathing Practices, may have significant long-lasting benefits for IBD symptoms, anxiety, depression, quality of life, and inflammation. BBMW, a promising adjunctive treatment for IBD, warrants further study.

Introduction: Trochlear dysplasia is a known risk factor for patellar dislocations yet normal trochlea development is not well described. This study will define the articular cartilage and subchondral trochlear morphology development in pediatric patients using MRI evaluation. Methods: Retrospective knee MRI review including patients aged 3-16 years with non-patellofemoral related diagnoses. ICD-9/ICD-10 codes identified eligible study patients. Measurements of the trochlea were made based on previously established methods using the axial MRI image just distal to the physis at the deepest portion of the trochlear groove. Three linear (Lateral Trochlear Height (LTH), Medial Trochlear Height (MTH), Central Trochlear Height (CTH)) and three angular (Sulcus Angle (SA), Lateral Trochlear Slope (LTS), Medial Trochlear Slope (MTS)) were made at the Articular Cartilage (AC) and Subchondral Bone (SCB) (Figure 1). Twelve measurements were made independently by two study authors. Interrater reliability was assessed. Trochlea measurements were summarized across age quartiles: 1st (age 5.1 - 8.3y), 2nd (8.3 - 11.5y), 3rd (11.5 - 14.3y), 4th (14.3 - 16.9y). Associations between age and trochlea measures were assessed using linear regression with Huber-White adjusted standard errors. Results: 246 knee MRIs from 230 patients were included in this study. 113 patients (51%) were female while 117 (49%) were male. 116 MRIs (47%) were of the Left knee and 130 (53%) were Right knee. Average patient age was 11.4±3.4 years. Interrater agreement was high (ICC values >0.7). Mean values for measurements are presented by age quartiles (Table 1). LTH, MTH, and CTH showed linear increase with age (range 2 to 2.6 mm per year, p<0.001). SA, LTS, MTS measured at the AC showed no change with age (p>0.05) however LTS and MTS measured at SCB showed significant increases with age (0.6 and 0.9 degrees per year, p<0.001) while SA showed a decrease with age (-1.4 degrees per year, p<0.001). There were no significant differences found in the age associations by laterality, left vs right. There were no gender differences in the age associations for SA, LTS, MTS (p>0.05) however for MTH, LTH, and CTH, males were found to have a significantly greater growth rate (p<0.001). Conclusions: This study found an increase in articular cartilage and subchondral bone MTH, LTH, and CTH over time as well as an increase in subchondral bone LTS, MTS, and SA. However, no significant change in articular cartilage LTS, MTS, or SA was found. This normative data indicates that articular cartilage angles determine final trochlear morphology. Table 1. Descriptions of Trochlea measures across age quartiles Outcome 1st Quartile (age 5.1 - 8.3) (N) Mean ± SD 2nd Quartile (age 8.3 - 11.5) (N) Mean ± SD 3rd Quartile (age 11.5 - 14.3) (N) Mean ± SD 4th Quartile (age 14.3 - 16.9) (N) Mean ± SD Lateral Trochlear Height (AC) (62) 48.5 ± 5.0 (61) 57.7 ± 5.2 (62) 65.0 ± 5.4 (60) 66.9 ± 5.2 Lateral Trochlear Height (SCB) (62) 42.2 ± 5.2 (61) 52.6 ± 4.9 (62) 61.5 ± 5.5 (60) 63.7 ± 6.2 Medial Trochlear Height (AC) (62) 46.4 ± 5.1 (61) 59.1 ± 29.0 (62) 62.7 ± 5.0 (61) 64.3 ± 5.2 Medial Trochlear Height (SCB) (62) 42.0 ± 5.1 (61) 51.8 ± 4.9 (62) 59.9 ± 5.0 (61) 62.2 ± 5.1 Central Trochlear Height (AC) (62) 43.4 ± 4.7 (61) 51.8 ± 4.8 (62) 59.1 ± 5.1 (61) 60.8 ± 4.9 Central Trochlear Height (SCB) (62) 39.1 ± 4.6 (61) 47.2 ± 4.4 (62) 55.2 ± 5.2 (61) 57.1 ± 4.5 Sulcus Angle (AC) (62) 145 ± 7 (61) 142 ± 7 (62) 142 ± 10 (61) 145 ± 7 Sulcus Angle (SCB) (62) 151 ± 8 (61) 142 ± 6 (62) 138 ± 10 (61) 139 ± 8 Difference in Sulcus Angle (SCB - AC) (62) 5.63 ± 7.27 (61) 0.03 ± 5.79 (62) -4.2 ± 13.1 (61) -5.83 ± 5.24 Lateral Trochlear Slope (AC) (62) 19.0 ± 3.9 (61) 20.0 ± 3.4 (62) 18.9 ± 4.8 (61) 18.0 ± 4.6 Lateral Trochlear Slope (SCB) (62) 14.4 ± 4.3 (61) 18.6 ± 3.5 (62) 20.3 ± 5.6 (61) 19.3 ± 4.5 Medial Trochlear Slope (AC) (62) 15.9 ± 5.2 (61) 18.4 ± 5.1 (62) 17.9 ± 5.3 (61) 17.8 ± 5.3 Medial Trochlear Slope (SCB) (62) 15.0 ± 5.2 (61) 19.8 ± 5.0 (62) 22.2 ± 5.6 (61) 22.1 ± 5.9 Figure 1. Descriptions of MRI measurements on axial MRI

Background Preoperative valgus deformity is present in an estimated 10–20% of patients undergoing total knee replacement (TKR). Questions/Purposes The objective of this study was to compare the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after TKR in a matched cohort of patients with preoperative valgus and varus deformities. Methods This is a matched cohort study of 162 patients with varus native knees and 162 patients with valgus native knees who underwent TKR and were prospectively followed in our institutional registry. Patients matched were based on age, BMI, sex, and severity of preoperative knee deformity, which was classified as mild, moderate, severe varus or valgus, or no deformity. Outcomes were evaluated using the WOMAC preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Results No significant difference was found between the matched varus and valgus cohorts in all WOMAC subdomain scores except for a marginally worse stiffness at 1 year in patients with valgus deformity (WOMAC stiffness, 75.1 varus vs. 70.1 valgus; P = 0.049). This is below the minimal clinically important difference for WOMAC scores. There was no significant difference in postoperative varus/valgus alignment between the two groups (P = 0.092) Conclusion We found no clinically significant difference in any of the WOMAC domains in patients with preoperative varus deformity versus valgus deformity within the first year after TKR. These findings may allow surgeons to more appropriately counsel patients with osteoarthritis with valgus deformity that they can expect similar outcomes compared to patients with varus deformity.

Modularity in total hip arthroplasty allows for intraoperative adjustment of a patient’s leg length and/or offset; however, recently corrosion at the modular head–neck junction has been seen, and when it occurs, it is often associated with catastrophic consequences. The purpose of this chapter is to define corrosion, discuss potential causes/contributing factors, and suggest potential treatments.