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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.

OBJECTIVE Pelvic fixation with S2-alar-iliac (S2AI) screws is an established technique in adult deformity surgery. The authors’ objective was to report the incidence and risk factors for an underreported acute failure mechanism of S2AI screws. METHODS The authors retrospectively reviewed a consecutive series of ambulatory adults with fusions extending 3 or more levels, and which included S2AI screws. Acute failure of S2AI screws was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS Failure occurred in 6 of 125 patients (5%) and consisted of either slippage of the rods or displacement of the set screws from the S2AI tulip head, with resultant kyphotic fracture. All failures occurred within 6 weeks postoperatively. Revision with a minimum of 4 rods connecting to 4 pelvic fixation points was successful. Two of 3 (66%) patients whose revision had less fixation sustained a second failure. Patients who experienced failure were younger (56.5 years vs 65 years, p = 0.03). The magnitude of surgical correction was higher in the failure cohort (number of levels fused, change in lumbar lordosis, change in T1–pelvic angle, and change in coronal C7 vertical axis, each p < 0.05). In the multivariate analysis, younger patient age and change in lumbar lordosis were independently associated with increased failure risk (p < 0.05 for each). There was a trend toward the presence of a transitional S1–2 disc being a risk factor (OR 8.8, 95% CI 0.93–82.6). Failure incidence was the same across implant manufacturers (p = 0.3). CONCLUSIONS All failures involved large-magnitude correction and resulted from stresses that exceeded the failure loads of the set plugs in the S2AI tulip, with resultant rod displacement and kyphotic fractures. Patients with large corrections may benefit from 4 total S2AI screws at the time of the index surgery, particularly if a transitional segment is present. Salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Introduction: The relative indications for removing symptomatic implants after osseous healing are not fully agreed on. The purpose of this study was to (1) determine whether patients showed improvement in functional outcomes after the removal of symptomatic orthopaedic implants, (2) compare the outcomes between upper and lower extremity implant removal, and (3) determine the rate of implant removal complications. Methods: A prospective study was conducted between 2013 and 2016. Patients completed a Short Musculoskeletal Function Assessment outcome questionnaire before implant removal and at the 6-month follow-up. Demographic data were stratified and compared between upper and lower extremity groups and between preimplant removal and 6-month postremoval. Results: Of the 119 patients included in the study, 85 (71.4%) were lower extremity and 34 (28.6%) were upper extremity. Significant improvement after implant removal was seen in the dysfunction index ( P ≤ 0.001), bother index ( P ≤ 0.001), and daily activities domain ( P ≤ 0.001). Depression or anxiety ( P = 0.016) were statistically significant predictors for an improved Short Musculoskeletal Function Assessment dysfunction index score at 6 months. The complication rate was 10.1% (n=12) for the cohort. Discussion: Implant removal in both the upper and lower extremity presented notable improvement in dysfunction. Complications that require surgical intervention are extremely rare.

Objectives: With value-based payment models on the horizon, this study was designed to examine the perceptions of value-based care among orthopaedic traumatologists and how they influence their practice. Design: Systems-based survey study. Setting: Orthopaedic Trauma Association (OTA) research surveys. Participants: OTA members. Main Outcome Measure: Thirty-eight–question surveys focusing on 5 areas related to value-based care: understanding value, assessing interest, barriers, perceptions around implementing value-based strategies, and policy. Results: Of 1106 OTA members, 252 members responded for a response rate of 22.7%. Consideration around cost was not different between hospital, academic, and private practice settings (P = 0.47). Previous reported experience in finance increased the amount surgical decision-making was influenced by cost (P < 0.01), along with reported understanding of implant costs (P < 0.01). Over half of the respondents (59.4%) believed value-based payments are coming to orthopaedic trauma. The vast majority (88.5%) believed bundled payments would be unsuccessful or only partially successful. With respect to barriers, a third of respondents (34.7%) indicated accurate cost data prevented the implementation of programs that track and maximize value, another third (31.5%) attributed it to a limited ability to collect patient-reported outcomes, and the rest (33.8%) were split between lack of institutional interest and access to funding. Conclusion: Our study indicated the understanding of value in orthopaedic trauma is limited and practice integration is rare. Reported experience in finance was the only factor associated with increased consideration of value-based care in practice. Our results highlight the need for increased exposure and resources to changing health care policy, specifically for orthopaedic traumatologists. Level of Evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.