Background: The recently developed modified Fels knee and optimized Oxford hip skeletal maturity systems (SMS) have demonstrated impressive performance compared with the Greulich and Pyle skeletal age atlas when applied to the same historical, mostly white, pediatric population. We sought to determine whether these 2 systems require modification before being used in modern children. Methods: We collected knee and hip radiographs between January 2015 and September 2020 from our electronic medical record from 4 groups of children: (1) white males, (2) black males, (3) white females, and (4) black females. Males between 9 and 17 years and females between 7 and 15 years were included. After reliability analyses, 5 nonpathologic radiographs for each age and joint were randomly selected from each group and evaluated with the appropriate SMS. The mean discrepancy between each group’s chronological age at the time of radiograph and estimated skeletal age was compared between our modern cohort and the historical Bolton-Brush children. After normality testing, paired t tests or Wilcoxon signed-rank tests were performed, as appropriate. A Bonferroni correction was applied to address multiple testing. Results: Three hundred sixty modern radiographs were evaluated (180 knees and 180 hips). All 7 modified Fels knee parameters and all 5 optimized Oxford hip parameters had inter and intrarater reliability coefficients ≥0.7, indicating good to very good reliability. For the modified Fels knee SMS, white males (Δ0.74 y, P<0.001), black males (Δ0.69 y, P<0.001), and black females (Δ0.4 y, P=0.04) had advanced skeletal age compared with their historical counterparts of the same sex. No differences were found between historical and modern patients for the optimized Oxford hip SMS. No differences were found for either SMS comparing modern patients along racial lines (P>0.05 for all). Conclusions: Discrepancies in skeletal age estimates made by the modified Fels knee SMS exist between modern pediatric white males, black males, and black females and their historic counterparts. No differences were found when using optimized Oxford hip SMS. Future studies should evaluate how these translate to clinical decision-making. Level of Evidence: Level III; retrospective chart review.

Background: Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study)

Background: The proximal humerus ossification system (PHOS), olecranon apophyseal ossification system (OAOS), and modified Fels wrist skeletal maturity system (mFWS) were recently developed or updated using a historical, mostly White, pediatric population. These upper extremity skeletal maturity systems have demonstrated skeletal age estimation performance superior or equivalent to Greulich and Pyle in historical patients. Their applicability to modern pediatric populations has not yet been evaluated. Methods: We reviewed anteroposterior shoulder, lateral elbow, and anteroposterior hand and wrist x-rays of 4 pediatric cohorts: White males, Black males, White females, and Black females. Peripubertal x-rays were evaluated: males 9 to17 years and females 7 to 15 years. Five nonpathologic radiographs for each age and joint were randomly selected from each group. Skeletal age estimates made by each of the 3 skeletal maturity systems were plotted against the chronological age associated with each radiograph and compared between cohorts, and with the historical patients. Results: Five hundred forty modern radiographs were evaluated (180 shoulders, 180 elbows, and 180 wrists). All radiographic parameters had inter- and intra-rater reliability coefficients at or above 0.79, indicating very good reliability. For PHOS, White males had delayed skeletal age compared with Black males (Δ−0.12 y, P=0.02) and historical males (Δ−0.17 y, P<0.001). Black females were skeletally advanced compared with historical females (Δ0.11 y, P=0.01). For OAOS, White males (Δ−0.31 y, P<0.001) and Black males (Δ−0.24 y, P<0.001) had delayed skeletal age compared with historical males. For mFWS, White males (Δ0.29 y, P=0.024), Black males (Δ0.58 y, P<0.001), and Black females (Δ0.44 y, P<0.001) had advanced skeletal age compared with historical counterparts of the same sex. All other comparisons were not significant (P>0.05). Conclusions: The PHOS, OAOS, and mFWS have mild discrepancies in skeletal age estimates when applied to modern pediatric populations depending on the race and sex of the patient. Level of Evidence: Level III – retrospective chart review.

Background: The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes. Methods: We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication. Results: Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%). Conclusions: Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

Background: Limited evidence suggests a positive correlation between tibial tubercle–trochlear groove (TT-TG) distance and the risk of native anterior cruciate ligament (ACL) tear. The relationship between TT-TG distance and the risk of ACL graft failure is unknown. Hypothesis: TT-TG distance is independently associated with risk of ACL graft failure. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent ACL revision surgery between 2010 and 2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006 and 2015, with no evidence of graft failure at 8.1 ± 2.5 years postoperatively. Record review included anthropometrics, graft type, and estimated Tegner activity score at ≥6 months after primary ACLR. Magnetic resonance imaging (MRI) scans after native ACL tear (controls) or graft failure (revision cohort) were assessed for (1) TT-TG distance, (2) proximal tibial slopes, (3) depth of tibial plateau concavity, and (4) tunnel position (revision cohort). Associations between ACL graft failure and MRI measurements, surgical variables, and patient characteristics were evaluated with logistic regression analyses. Sensitivity analyses, excluding patients with tunnel malposition, were performed to confirm multivariable results in patients with “ideal” tunnel placement. Results: Participants included 153 patients who underwent revisions and 144 controls. Controls were older than the patients who underwent revision (26.6 ± 8.8 vs 20.6 ± 7.3 years; P < .001). The mean TT-TG distance and lateral posterior tibial slope (PTS) were smaller for the control group than for the revision group (TT-TG: 9.3 ± 3.9 vs 11.2 ± 4.2 mm; P < .001; lateral PTS: 6.2° ± 3.3° vs 7.2° ± 3.6°; P = .01). TT-TG distance, lateral PTS, and age were associated with risk of ACL graft failure by multivariable analysis (OR, 1.15; 95% CI, 1.07-1.23; P < .001; OR, 1.13; 95% CI, 1.04-1.22; P = .004; and OR, 0.90; 95% CI, 0.87-0.94; P < .001, respectively). With sensitivity analyses, TT-TG distance, lateral PTS, and age at index surgery remained significantly and independently associated with ACL graft failure. Conclusion: Increased TT-TG distance, increased lateral PTS, and younger age are independently associated with increased odds of ACL graft failure. Patients with these characteristics may require a more comprehensive strategy to reduce the risk of ACL reinjury.