Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non–English language manuscripts, multiligamentous injuries, and nonclinical studies. Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences ( P = .413) or proportion with difference ≥3 mm ( P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

Background: We sought to investigate the relationship between the time from an anterior cruciate ligament (ACL) tear to the surgical procedure and meniscal tears in the pediatric and adolescent population.Methods: Patients who were £18 years of age and had undergone an ACL reconstruction from 2006 to 2018 were identified in a retrospective, multicenter cohort. The primary outcomes were arthroscopically confirmed medial meniscal or lateral meniscal tears specifically and, in general, if any meniscal tear was present (medial and/or lateral). A multivariable Poisson regression model was used to determine whether the time from the injury to the surgical procedure was a risk factor for subsequent meniscal injury, after controlling for sex, age, and body mass index (BMI). Multivariable Poisson regression was also used to characterize associations of age, sex, and BMI with meniscal injury.Results: In this study, 546 patients with a mean age (and standard deviation) of 15.3 ± 1.6 years were identified. For each week that the surgical procedure was delayed, there was a 2% increased risk of a medial meniscal tear (adjusted relative risk [ARR], 1.02 [95% confidence interval (CI), 1.01 to 1.03]). The weekly increase in risk of a medial meniscal injury was significant for male patients (ARR, 1.03 [95% CI, 1.01 to 1.05]), but not for female patients (ARR, 1.00 [95% CI, 0.97 to 1.04]), even though the effect modification was not significant (p = 0.24). Obese male patients had a 77.9% increased risk of medial meniscal tear for each 10-week delay (p < 0.001). The use of crutches was associated with a decreased risk of medial meniscal tears (ARR, 0.47 [95% CI, 0.34 to 0.64]).Conclusions: In pediatric and adolescent patients, the risk of meniscal injury is substantial after an ACL tear. A delay Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G568).

Congenital knee dislocation is a rare disorder and the published literature largely consists of small case series. Congenital knee dislocation represents a broad spectrum of severity from hyperextension to frank dislocation. It can be isolated or be present in syndromic infants with concomitant joint disorders such as clubfoot or developmental dysplasia of the hip. Hyperextended knees can be reduced with serial casting alone in the neonatal period and do not require further treatment. Surgical treatment of the congenital knee dislocation results in satisfactory outcomes in the majority of reported cases, although outcomes are highly dependent on the degree of concomitant joint involvement. Treatment decisions are often based on radiographic findings and passive range of motion of the knee. Described procedures include percutaneous or mini-open quadriceps tenotomy, VY quadricepsplasty, and femoral shortening. The current review summarizes the most up-to-date literature on the surgical management of congenital knee dislocation.

Objectives. A free-standing emergency department (FSED) is a facility that provides comprehensive emergency medical care similar to a traditional emergency department but is not attached to a hospital campus. Medical scribes are increasingly likely to work in free-standing emergency departments. The purpose of this study was to retrospectively investigate the benefits of a scribe program in an FSED.Methods. A retrospective, Institutional Review Board-approved analysis from December 1, 2013, to February 1, 2015, of free-standing emergency department medical data was extracted to determine if scribed charts resulted in increased revenue and improved throughput.Results. When scribes are present in the FSED there is a small, but statistically significant, decrease in time from patient arrival to provider by 2.74 minutes. Scribed charts collected $4.69 more per chart and resulted in an increase in productivity. Incremental cost effectiveness ratios resulted in proven cost-utility with a net-positive effect.Conclusion. While there are some gains in terms of operational metrics and provider productivity with the addition of scribes to a free-standing emergency department, there is a net-positive financial impact of scribes. Implementing a scribe program at a FSED is cost-effective and justified from both an operational and a financial analysis.

Background: Preoperative diagnosis of concomitant meniscal tears in pediatric and adolescent patients with acute anterior cruciate ligament (ACL) deficiency is challenging. Purpose: To investigate the diagnostic performance of magnetic resonance imaging (MRI) in detecting meniscal injuries for pediatric and adolescent patients with acute ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The authors retrospectively identified patients aged ≤18 years who underwent acute ACL reconstruction between 2006 and 2018 at 2 tertiary academic hospitals. The primary outcomes were arthroscopically confirmed medial, lateral, or any (defined as medial and/or lateral) meniscal tears. To control for chronically deficient knees, patients must have received their MRI study within 4 weeks of injury and must have undergone surgery no more than 8 weeks after their MRI study. Preoperative MRI reports were compared with the gold standard of arthroscopically confirmed tears to calculate sensitivity, specificity, positive predictive value, and negative predictive value. In a secondary analysis, patients were stratified by age into 2 groups (≤13 or ≥14 years), body mass index-for-age data from the Centers for Disease Control were used to classify patients as obese or nonobese, and differences between sensitivity and specificity proportions were analyzed using chi-square test for homogeneity. Results: Overall, 406 patients with a mean age of 15.4 years (range, 10-18 years) were identified. The sensitivity, specificity, positive predictive value, and negative predictive value were as follows: for lateral meniscal (LM) tears, 51.0%, 86.5%, 78.3%, and 65.0%; for medial meniscal tears, 83.2%, 80.6%, 62.3%, and 92.5%; and for any meniscal tear, 75.0%, 72.1%, 81.5%, and 63.8%, respectively. In the stratified analysis, MRI was less specific for the following diagnoses: any meniscal tear in patients aged ≤13 years ( P = .048) and LM tears in obese patients ( P = .020). Conclusion: The diagnostic ability of MRI to predict meniscal injuries present at acute ACL reconstruction was moderate. Performance was poorest at the lateral meniscus, where MRI failed to detect 97 tears that were found arthroscopically. Specificity was significantly lower in younger patients for any meniscal tear and in obese patients for LM tears.