bluuebunny/crossref_metadata_2025 huggingface dataset:
High School Student-Athletes’ Awareness of Concussion Education May Differ by Age
Authors: Kostyun Regina , Wang David , Solomito Matthew
Published: April 2020

Background:

A tremendous amount of resources and education have been directed towards those involved in high school athletics to help recognize the signs and symptoms of a concussion and ensure removal from play of potentially concussed athletes. Concussion education policies have been broadly implemented across the country; however, the success of these educational methods at encouraging adolescents to disclose their symptoms has yet to be determined.

Purpose:

The purpose of this study was to (1) identify how many student-athletes recognized they had been provided concussion education and (2) document disclosure and non-disclosure patterns.

Methods:

An anonymous survey was distributed to student-athletes at four Connecticut high schools. The survey contained demographic questions (sex, age, primary sport, and prior history of concussion) along with a question asking if the individual had received formal concussion education. The survey then asked in which of six provided situations the athlete would disclose their symptoms and which of eight provided reasons would prevent the athlete from disclosing their symptoms. Respondents were grouped by education status (received or not) and the difference in response frequency was evaluated using Chi-Square tests.

Results:

A total of 872 athletes (average age 15.8±1.3 years, 410 Males, 462 Females) completed the survey (61.2% response rate). A total of 583 (66.9%) athletes reported having received concussion education. Athletes who reported that they had not received concussion education were significantly younger than athletes that reported that they had received concussion education (p=<0.001). Both the education and non-education groups identified an important game as the least likely situation to disclose symptoms, and practice as the most likely situation. The most common reason for non-disclosure was “Don’t want to miss game” in the education group and “Don’t think I have a concussion” in the non-education group. Significant differences in response rates between groups were found for ‘Don’t think I have a concussion’ (p=0.038) and ‘Others played with concussions’ (p=0.005).

Conclusion:

Current educational efforts may not be successfully educating younger student-athletes about the importance of recognizing and reporting concussion symptoms. Within our small cohort of Connecticut high schools, approximately 1/3 of individuals reported not receiving education, and more than half of student-athletes report that they would not disclose concussion symptoms during important games despite receiving education. Further work is required to re-evaluate the efficacy of current educational programs available to high school athletes, focusing on non-disclosure reasons reported by varying ages of student-athletes.

[Table: see text]
Presence and Perceptions of Menstrual Dysfunction Among High School Female Athletes
Authors: Armento Aubrey , VanBaak Karin , Sweeney Emily A. , Wilson Julie C. , Howell David R.
Published: April 2020

Background:

Previous studies have reported a high prevalence of menstrual dysfunction (MD) among adolescent female athletes. Little is known about the characteristics of adolescent athletes with MD, as well as their awareness of MD.

Purpose:

Our primary study purpose was to determine the prevalence and characteristics of female athletes who believe that MD is a normal response to high training demands. The secondary purpose was to explore the relationship between MD and patient-reported quality of life.

Methods:

We conducted a cross-sectional study of adolescent athletes undergoing pre-participation evaluation. Participants completed health history, family affluence, and Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires. Those who reported menarche within the past year were excluded. We categorized participants into groups based on their response to, “Do you think it is normal to lose your period during high levels of athletic training?” (yes/no). We compared groups using Mann-Whitney U and Fisher’s exact tests. We also grouped patients into MD (yes/no) if they exhibited one or more of the following: 1) age of menarche >15 years; 2) ≤9 periods in the last year; or 3) a period of three consecutive months without a menstrual cycle. We constructed a series of linear multivariable regression models assessing the effect of MD on PROMIS outcomes adjusting for age and BMI.

Results:

44% (n=40/90) answered that period loss was a normal response to a high level of training, and this group had lower body mass index (BMI), were less likely to report being worried about current weight, and had a higher family affluence level than those who answered period loss was not a normal response to training (Table 1). The overall prevalence of MD was 28% and was not significantly different between those who did and did not answer that period loss was a normal response to training (Table 1). Those with MD reported higher fatigue and pain interference scores than those without MD (Table 2). After adjusting for age and BMI, MD was significantly associated with higher levels of anxiety, fatigue, and pain interference (Table 3).

Conclusion:

Nearly half of our sample of adolescent female athletes perceive MD as a normal response to high training demands. Females with MD reported higher levels of anxiety and fatigue than those without MD. Understanding adolescent perceptions of MD and the characteristics of those with MD can guide future educational interventions aimed at high risk athletes for the female athlete triad.

[Table: see text][Table: see text][Table: see text]
WHAT ARE THE PREDICTORS OF POOR PATIENT-REPORTED OUTCOMES FOLLOWING SHOULDER INSTABILITY SURGERY?
Authors: Bayomy Ahmad F. , Briskin Isaac , Grobaty Lauren E. , Sosic Elizabeth , Strnad Greg J. , Farrow Lutul D. , Rosneck James T. , McCoy Brett W. , Schickendantz Mark S. , Miniaci Anthony , Jones Morgan H. , Spindler Kurt P. , Saluan Paul M.
Published: April 2020

Background:

Prospectively-collected patient-reported outcomes (PROs) following shoulder instability surgery are limited. Attention has been drawn to standardizing these outcome measures in the adolescent literature.

Hypothesis/Purpose:

The purpose of this study was to evaluate which factors predict unfavorable PROs following shoulder instability surgery, including a “No” response to the Patient Acceptable Symptom State (PASS) question. We hypothesized that poor outcomes are associated with adolescent males, bone loss, larger labral tears, and articular cartilage injury.

Methods:

A cohort of patients age 13 years and older undergoing shoulder instability surgery were prospectively enrolled in point-of-care data collection at a single institution across 12 surgeons from 2015-2017. Demographics, ASES and SANE responses, and surgical findings were obtained at baseline. ASES, SANE, and PASS responses as well as revision surgery were queried at least one year post-operatively. Patients with isolated posterior labral tears and prior ipsilateral shoulder surgery were excluded. Regression analyses were performed.

Results:

A total 268 patients met inclusion criteria of which 201 completed follow-up responses (75%). Non-responders had a greater BMI, smaller proportion of glenoid bone loss, fewer Hill-Sachs lesions, and lower baseline ASES scores by 7.5 points (p < 0.05). Responders’ mean age was 25.5 years and 23% were female. Revision surgery occurred in 2.5% of these patients, and 81% responded “Yes” to PASS. A “Yes” response correlated to mean 31-point improvement in ASES and 34-point improvement in SANE scores. On univariate analysis, “No” responders were more likely to have a smoking history, a larger proportion of glenoid bone loss, and revision surgery (p < 0.05). However, on multivariate analysis, only combined labral tears (anterior/inferior plus superior or posterior tears) and injured capsules were associated with greater odds of responding “No” to PASS and with lower ASES and SANE scores (p ≤ 0.05) (Table 1). Age, sex, Hill-Sachs lesions, and grade III/IV articular cartilage injuries were not associated with variation in any PROs.

Conclusion:

In this prospective cohort, patients largely approve of their symptom state at one year or greater following shoulder instability surgery. A PASS “Yes” response occurred in 81% of patients and correlated to a clinically and statistically significant improvement in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across PROs, whereas age, sex, and Hill-Sachs lesions were not.

Table: [Table: see text]
DEFINING TROCHLEAR DYSPLASIA VIA THE LATERAL TROCHLEAR INCLINATION ANGLE
Authors: Cheng Christopher , Hedgecock Jon , Solomito Matthew , Joseph Sheeba , Pace J. Lee
Published: April 2020

Background:

Trochlear dysplasia (TD) is the principle anatomic risk factor for patellar instability (PI). The lateral trochlear inclination (LTI) is a quantitative measure of trochlear morphology on axial magnetic resonance imaging (MRI). Threshold values for patients at risk for PI via LTI measurement have ranged from 11o to 17o. Our group recently described a new technique for characterizing LTI by referencing the fully-formed posterior femoral condyles. This novel measurement technique revealed that the historically-used method was comparable in reliability but significantly underestimated TD.

Purpose:

The purpose of this study was to define, with high specificity, a LTI value cutoff value consistent with patellar instability using the new LTI measurement technique.

Methods:

MRI scans of 95 patients aged 9 to 18 years treated for PI at our tertiary referral center were compared with a control cohort of 98 age- and gender- matched patients with knee imaging but no clinical evidence of PI. LTI was measured as the angle formed between a line subtended from the cartilaginous surface of the lateral trochlea at its most proximal extent and a line parallel to the fully-formed posterior condyles. Receiver operator characteristic (ROC) curve analysis was conducted to establish a cutoff value with optimal specificity and sensitivity.

Results:

Average LTI was significantly lower in the study group (5.9±10.4o) than control (18.9±5.8o) (p<0.001). Area under the ROC curve was 0.86. A proposed 8.9o LTI threshold angle achieves good discrimination between the two groups, with specificity of 0.904 and sensitivity of 0.684.

Conclusion:

Re-examination of previously described threshold values using ROC curve analysis of LTI measured in reference to the posterior condyles found 8.9o as the optimal threshold value to achieve good discrimination between patients with and without PI. The novel technique has previously been established to have excellent intra- and inter-observer reliability and produced significantly lower LTI values than the historically-used technique. Taken in concert, this new cutoff is valuable to improve future clinical decision making in regards to risk stratification, treatment algorithms and research purposes.
HOW DO LEARNING DISORDERS IMPACT CLINICAL MEASURES FOLLOWING CONCUSSION?
Authors: Zynda Aaron J. , Stokes Mathew A. , Chung Jane S. , Cullum C. Munro , Miller Shane M.
Published: April 2020

Background:

There is limited evidence examining the impact of learning disorders on testing and screening scores used in evaluation following concussion in adolescents.

Purpose:

To examine differences in clinical measures between adolescents with a history of dyslexia or ADD/ADHD and those without a history of learning disorder (LD) following concussion.

Methods:

Data were collected from participants enrolled in the North Texas Concussion Network Prospective Registry (ConTex). Participants ages 10-18 who had been diagnosed with a concussion sustained within 30 days of enrollment were included. Participants were separated into three groups based on self-reported prior diagnosis: dyslexia, ADD/ADHD, and no history of LD. Clinical measures from initial presentation were examined, including ImPACT®, King-Devick (KD), SCAT-5 symptom log, Patient Health Questionnaire (PHQ-8), and Generalized Anxiety Disorder (GAD-7) scale. Independent t-test analysis was performed to compare scores between groups.

Results:

A total of 993 participants were included; 68 with dyslexia, 141 with ADD/ADHD, and 784 with no history of LD. There was no difference in age, sex, time since injury, or history of concussion between the dyslexia group and no LD group. In the ADD/ADHD group, there were significantly more male participants (64.5% and 50.3% respectively, p=0.002). Participants with a history of dyslexia had a significant increase in KD time (63.7 sec vs 56.5 sec, p=0.019). Additionally, ImPACT® testing showed a decrease in visual motor speed (28.87 vs 32.99, p= 0.010). Total symptom score was higher in this group as well (36.22 vs 28.27, p=0.013). In those with a history of ADD/ADHD, multiple domains were found to be significantly different on ImPACT® testing including visual motor speed (30.05), reaction time (0.75), and cognitive efficiency (0.23) when compared to those with no LD (32.99, 0.71, and 0.27 respectively, p=0.004, 0.047, 0.027). KD time was also significantly higher in this group (62.1 sec vs 56.5 sec, p=0.008), as was the total symptom score (32.99 vs 28.27, p=0.043). PHQ-8 and GAD-7 were both significantly higher in the group with ADD/ADHD (5.79 and 5.06 respectively, p=0.001) than those with no LD (4.32 and 3.56, p=0.001).

Conclusion:

Differences were seen in participants with a history of dyslexia and ADD/ADHD on clinical concussion measures, including ImPACT® and KD testing, SCAT-5 symptom log, and screenings for depression and anxiety. A better understanding of the unique profiles seen in these patients will aid providers in their evaluation and assist as they counsel families regarding their child’s injury.
Relationships Between Sport Specialization and Running-Related Injury Among Competitive High School Cross-Country Runners
Authors: Rauh Mitchell J. , Tutino Alexandra K. , Post Eric G. , Prescher Kelly , Rosenthal Michael D.
Published: April 2020

BACKGROUND:

During the past few decades, the number of participants in high school cross-country has increased. Simultaneously with its popularity has been an increased incidence of running-related injury (RRI). Limited risk factors have been examined in their relationship to RRI in this population. Of these, few studies have reported on the prevalence of sport specialization and its association with RRI among competitive high school cross-country runners.

PURPOSE:

The purpose of this study was to assess the prevalence of sport specialization and examine its risk association with RRI in competitive high school cross-country runners.

METHODS:

We prospectively followed 93 runners (35 females, 15.7±1.1y) who competed in the 2018 interscholastic cross-country season in Southern California. At baseline, all runners were injury-free and completed the study questionnaire, which included questions on whether cross-country was their primary sport, the number of months/year spent running-related training, and if they quit another sport(s) to focus on cross-country/track distance running during the past year. High (all 3 factors), moderate (2 of 3 factors) and low (0 or 1 factors) sport specialization was then determined using a widely-utilized scale. Injury occurrence data for all runners was recorded throughout the cross-country season using a standardized injury reporting system. Odds Ratio (OR) estimates and 95% confidence intervals (CIs) were used to determine the association between sport specialization and likelihood of RRI.

RESULTS:

Of the 93 runners, 15 (16.1%) met criteria for high sport specialization, 49 (52.7%) were classified as moderately specialized, and 29 (31.2%) runners were classified as low sport specializers. The prevalence of high sport specialization was similar between female (17.1%) and male (15.5%) runners (p=0.38). Twenty-six runners (28%) experienced a time loss RRI, with a higher percentage among female runners (37.1%) than males (22.4%) (p=0.16). Although the incidence of injury was greater among high sport specializers (40.0%) than low sport specializers (24.1%), the likelihood of RRI was not statistically significant (OR=2.10, 95% CI: 0.6-8.0; p=0.28). Similar risk associations between high sport specialization and RRI were found between female and male runners.

CONCLUSIONS:

Based on the existing classification method for sport specialization, these findings indicated that high sports specialization was not common among competitive high school cross-country runners in this study sample. As the incidence of RRI was almost twice as great among high sport specializers, studies assessing larger populations of high school cross-country runners are needed to better evaluate this relationship.
ISOKINETIC PERFORMANCE AND LIMB ASYMMETRY DIFFERENCES BETWEEN ADOLESCENT MALES AND FEMALES FOLLOWING QUADRICEPS TENDON – PATELLAR BONE AUTOGRAFT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Authors: Gagliardi Alexia G. , Howell David R. , Kanai Susan K. , Rhodes Jason T. , Tagawa Alex , Albright Jay C.
Published: April 2020

Background:

Accurate measurement of limb strength asymmetry differences between sexes may be important to consider when determining readiness to return to sport among adolescents following ACL reconstruction.

Hypothesis/Purpose:

The purpose was to compare isokinetic performance between females and males after ACL reconstruction but before return to sport clearance on isokinetic measures of limb strength asymmetry and flexor/extensor strength ratio. We hypothesized there would be no difference in limb strength asymmetry or flexor/extensor strength ratio between sexes measured by isokinetic testing.

Methods:

We retrospectively collected demographic, surgical, and injury information on patients aged 10 – 18 years at time of surgery. Patients completed isokinetic testing within 5-10 months after primary quadriceps tendon ACL reconstruction, and before return to sport clearance. Isokinetic testing assessed maximum torque at three speeds, 60, 180, and 300 degrees per second, through a limited range of knee extension and flexion. Maximum torque percent deficit of the involved leg compared to the uninvolved leg and flexor/extensor strength ratios were calculated. We compared peak torque extensor deficits and flexor deficits (the % difference between operative and non-operative sides) and flexor/extensor ratios at the three isokinetic test speeds within sexes and between sexes.

Results:

80 subjects were tested during the study period, of which 44 subjects met inclusion criteria (female: n=29, 66%). Injury characteristics and time since surgery were similar between sexes (Table 1). Greater extensor deficits among males and females were observed at 60 degrees/s compared to 180 degree/s (p=0.003) and 300 degree/s (p<0.001), and at 180 degrees/s compared to 300 degrees/s (p=0.001) (Figure 1). Females demonstrated significantly greater peak torque flexor deficits at 300 degrees/s, compared to males (p=0.04, Figure 2). Within males, greater flexor deficits were observed at 60 degrees/s compared to 180 degrees/s (p<0.001) and 300 degrees/s (p=0.001) (Figure 2). Within females, greater flexor deficits were observed at 60 degrees/s compared to 180 degrees/s (p=0.02, Figure 2). There were no significant interactions or main effects of sex or speed for either the operative or the non-operative limb peak torque flexor/extensor ratio.

Conclusion:

The results demonstrate greater peak torque flexor deficits among females compared to males at the fastest testing speed in our protocol. Currently, our results indicate variability both within and between sex isokinetic performance at different speeds and suggest that isokinetic testing at slower speeds may be most effective in determining strength deficits between limbs.

Tables and Figures: [Table: see text][Figure: see text][Figure: see text]
THE EFFECTIVENESS OF ONLINE ACL INJURY PREVENTION EDUCATION FOR SPORTS COACHES
Authors: Russomano James , Ologhobo Titilayo , Janosky Joseph J. , Goldsmith Sandra , Marx Robert G. , Kinderknecht James , Robbins Laura
Published: April 2020

Background:

The efficacy of ACL injury prevention programs (IPP) have been well-defined by sports medicine researchers over the past decade, but the adoption and implementation of effective ACL IPP is noticeably deficient in real-world situations. One barrier to the widespread implementation of ACL IPP by sports coaches is the limited understanding of how to effectively deliver these programs to young athletes. The ability to effectively identify and correct high-risk movements during the performance of neuromuscular training and athletic activities has been reported as a key factor in the effectiveness of an ACL IPP. Educational opportunities to train sports coaches to effectively deliver ACL IPP programs are not common, but those that do exist are often delivered in live settings. Live educational workshops are resource-intensive and limit the number of participants that can be trained over time. Educational workshops offered online can deliver information efficiently to large numbers of individuals but have not yet demonstrated education outcomes that are equivalent to live education events.

Hypothesis/Purpose:

The purpose of this study is to investigate the association between participation in an online educational workshop for coaches and knowledge of how to effectively employ an ACL IPP with young athletes. We hypothesize that participation in an online educational workshop is associated with increased knowledge of how to effectively employ an ACL IPP with young athletes and high levels of program satisfaction.

Methods:

An online educational workshop was developed to teach sports coaches how to effectively employ an ACL IPP program with young athletes. Coaches from throughout the United States were recruited to access the workshop through a computer-based learning management system. A series of instructional videos were used to deliver educational content to participants. Pre- and post-workshop surveys were utilized to determine program effectiveness and participant satisfaction.

Results:

468 coaches (77% male) participated in the pilot phase of the program. Nearly two-thirds of all participants demonstrated an increase in knowledge immediately post-intervention. Mean knowledge scores increased by 33% (56.5 to 74.9, p < 0.001). 89% of participants rated the workshop favorably and 90% of participants reported that they would recommend the workshop to other coaches.

Conclusion:

Results indicate that an online workshop for sports coaches improved the knowledge needed to effectively deliver an ACL IPP to young athletes. These findings support the continued evaluation of computer-based learning management systems to deliver online ACL IPP workshops to sports coaches. [Table: see text][Table: see text][Table: see text]
ENERGY BALANCE AND VITAL SIGNS IN PEDIATRIC PATIENTS
Authors: Young Julie A. , Napolitano Jessica , Rauh Mitchell J. , Nichols Jeanne , Fischer Anastasia N.
Published: April 2020

BACKGROUND:

Prior studies have shown that vital signs such as heart rate, blood pressure and body temperature are depressed in patients with an eating disorder who have experienced a negative energy balance for a significant amount of time. More recently, a negative energy balance has been the focus of Relative Energy Deficiency in Sport (RED-S), which links energy availability to the health of multiple body systems in adults in as little as 5 days with a negative energy balance. High rates of disordered eating patterns have been reported in high school athletes. As adolescents grow, the consequences of a negative energy balance can be significant and potentially irreversible. Thus, vital signs may help clinicians quickly evaluate a patient’s energy status or highlight them for further evaluation.

PURPOSE:

The purpose of this study was to examine energy balance and vital signs in a cohort of adolescents who were seen by a sports dietitian to gain weight or optimize sports performance.

METHODS:

We evaluated 240 subjects, 83% female, average age 15.0±2.3 years. Heart rate and blood pressure were measured with a dynamometer in a seated position. Body temperature was measured orally. Height and weight were recorded. BMI was then calculated and evaluated by percentile. Energy intake was assessed using a 3-day food recall log. Energy expenditure was calculated using Harris Benedict Equation and combined with estimated exercise energy expenditure. Energy balance was estimated as energy intake minus energy expenditure.

RESULTS:

Average age was 15.03±2.71. 85% were female. 30% were below the 15th percentile for BMI. There were no differences in BMI percentiles between males and females (p=0.99). The average heart rate was 71.62±13.4 bpm and 19% were below the 10th percentile for heart rate. Average systolic blood pressure was 110±11 mm Hg and average diastolic blood pressure was 62±7 mmHg. Average temperature was 98.1±.4 degrees F. 88%were in a negative energy balance with an average energy deficit of 552±511 calories. There were no statistically significant differences in energy balance between males and females (p=0.08).

CONCLUSIONS:

A disproportional number of children with low BMI and heart rate percentiles was observed, which may indicate a long-standing energy deficiency. We also found a high proportion of adolescents who experienced a standalone negative energy balance itself or vital signs consistent with a negative energy balance. Additional studies are needed to study the relationships between energy deficit magnitude and duration in adolescents and children.
OUTCOME OF SURGICAL TREATMENT IN PATIENTS WITH BORDERLINE ACETABULAR DYSPLASIA: A COMPARATIVE ANALYSIS OF HIP ARTHROSCOPY AND PERIACETABULAR OSTEOTOMY
Authors: Nepple Jeffrey J , Schwabe Maria , Graesser Elizabeth , Pascual-Garrido Cecilia , Clohisy John C
Published: April 2020

Background:

Optimal treatments of patients with borderline hip dysplasia, defined as LCEA 20°-25°, is controversial. These patients can have symptomatic impingement and/or instability. The optimal treatment of either hip arthroscopy (HA) alone or periacetabular osteotomy (PAO) (with/without hip arthroscopy) has not been established.

Purpose:

The purpose of this study was to evaluate surgical outcomes of patients with borderline hip dysplasia at a minimum of 2-year follow-up.

Methods:

A longitudinal cohort was utilized to identify patients with borderline acetabular dysplasia defined via prospective radiographic measurements. Demographics and radiographic measurements were recorded. Patient evaluation, diagnosis and treatment decisions (PAO v HA) were made by one treating surgeon. Outcome were assessed at baseline and a minimum 2 years postoperative. Descriptive and comparative statistics were performed. Failure was defined as reoperation, or failure to reach mHHS MCID (8 points) or PASS (mHHS <74).

Results:

Total of 113 hips were included at 4.7 years postoperatively (range 2.0-11.2 years). Overall, 76% were female and 42% of hips had PAO (65% combined with hip arthroscopy), while 58% had isolated hip arthroscopy (HA). For PAO group, mHHS improved from 57.9 to 82.8 postoperatively, compared to 62.6 to 84.0 for the HA group. Similarly, HOOS pain (PAO 48.2 to 79.1, HA 61.2 to 82.0) and HOOS Sports (PAO 36.5 to 73.0, HA 47.8 to 74.4) demonstrated similar improvements. Comparing the PAO and HA groups, the change in PRO was significantly greater for the PAO group for HOOS Pain (10.5 ±23.2, p=0.02) and HOOS ADL (9.4 ±20.5, p=0.04) which was primarily due to a lower baseline score (similar final score). No significant difference was detected for other PROs. Reoperations in the PAO group were 2% (1 hip arthroscopy) and 6% for hip arthroscopy group (3 hip arthroscopies, 1 PAO). The failure rate was 17% for PAO and 15% for HA (p=0.86).

Discussion:

Surgical outcomes at minimum of 2 years in patients with borderline hip dysplasia in selected patients undergoing PAO or hip arthroscopy were good. Significant differences in patient characteristics and radiographic parameters were present between hips indicated for PAO vs. HA emphasizing the need for careful diagnosis and treatment decision-making.
HIP ARTHROSCOPY VS. PHYSICAL THERAPY IN PATIENTS WITH FEMOROACETABULAR IMPINGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
Authors: Schwabe Maria , Cheng Abby L , Pascual-Garrido Cecilia , Harris-Hayes Marcie , Harris Michael , Hunt Devyani , Prather Heidi , Clohisy John C , Nepple Jeffrey J
Published: April 2020

Introduction:

Both physical therapy (PT) and surgery appear to have some efficacy in treating femoroacetabular impingement (FAI). Only recently have high-level evidence studies compared these two options, though results of these randomized controlled trials (RCTs) are contradictory. The purpose of this study was to perform a systematic review and meta-analysis of RCTs comparing PT and surgery in patients with FAI.

Methods:

A systematic review was performed to identify randomized trials comparing FAI and PT. Data was extracted for demographics, study design, patient reported outcomes (PROs), and study quality/bias. In total, 819 abstracts were reviewed, with three RCTs identified (Griffin 2018, Mansell 2018, and Palmer 2019). All three RCTs reported iHOT-33, while two studies reported HOS ADL and Sport (Mansell 2019 and Palmer 2019). In a random effects meta-analysis, between-group differences in post-intervention scores were assessed using intention-to-treat analysis in each study.

Results:

All 3 RCTs reported PROs improvement from baseline to follow-up for both PT and surgery. The meta-analysis demonstrated greater improved iHOT-33 outcomes with surgery compared to PT with a mean relative difference of 11.3 (95% CI 1.86-20.73, p=0.014). The meta-analysis for HOS ADL and Sports (two RCTs) similarly demonstrated higher scores with surgery with a mean difference of 3.9 (95% CI -9.6-17.3, p=0.571) and 6.2 (95% CI -6.8-19.2, p=0.347), respectively, though without statistical significance. The quality of two RCTs was assessed as good with minimal bias (Griffin and Palmer). In the third RCT, an extremely high crossover rate may affect its validity (Mansell 2018, 70% crossover from PT to surgery). For instance, HOS ADL outcome based on treatment received, adjusting for Mansell’s crossover rate, favored surgery with a larger mean difference of 12.0 (95% CI 7.5-16.5, p<0.001) (compared to intention-to-treat difference of 3.9).

Discussion:

In patients with FAI, combined results of three RCTs demonstrate superior outcomes of surgery compared to PT. However, PT can result in improvements in some patients and does not appear to compromise surgical outcomes. Provided that the studies adjusted for certain patient characteristics, further research needs to identify patient characteristics that predict success of non-operative and operative treatment of FAI in specific patient subgroups.

[Figure: see text]
SPORT SPECIALIZATION AND COLLEGE SCHOLARSHIP BELIEFS AND FINANCIAL INVESTMENT AMONG HIGH SCHOOL BASEBALL PARENTS
Authors: Post Eric G. , Rosenthal Michael D. , Rauh Mitchell J.
Published: April 2020

BACKGROUND:

Youth athletes are increasingly encouraged to specialize in a single sport and participate on club teams year-round to be offered a college scholarship. For collegiate baseball, only 11.7 scholarships are available for a 35-player team. Presently, the beliefs of parents of baseball athletes towards sport specialization are unknown along with whether they have an accurate understanding of college baseball scholarship availability.

PURPOSE:

To describe the beliefs of parents of high school baseball players regarding sport specialization and college scholarships. A secondary purpose was to compare child baseball participation characteristics by parent median household income (MHI) categories.

METHODS:

During the 2019 spring baseball season, 155 parents (female N=82 (52.9%), age: 49.45.5 years) of high school baseball players from six San Diego county high schools completed an anonymous questionnaire concerning parent and child demographics, child baseball participation information (e.g., club baseball team participation), money spent on their child’s baseball participation, sport specialization status, and parent beliefs regarding sport specialization and college scholarships. Sport specialization status was determined using a validated 3-point specialization scale. Parent MHI was estimated using residence zip code and categorized into MHI tertiles (low, middle, high).

RESULTS:

Seventy-three parents (47.7%) classified their children as highly specialized and 110 parents (71.0%) reported their child played club baseball in addition to their high school team. Parents reported spending a median of $3000 [$1500-6000] on their child’s baseball participation during the previous year. Only 44 parents (28.4%) reported being concerned about sport specialization. Most parents (69.9%) believed that specialization would increase their child’s chances of making a college team. Parents underestimated the number of college baseball scholarships available per team (median [IQR]: 5 [0-5]), but 55 parents (35.9%) believed it was “somewhat” or “very likely” their child would receive a college baseball scholarship. Compared to low MHI parents, high MHI parents were more likely to classify their child as highly specialized (65.8% vs. 31.7%, p=0.02), and have a child participating in club baseball (82.1% vs. 58.3%, p=0.02).

CONCLUSIONS:

Parents who reported a greater financial investment in their child’s baseball participation believed it would improve their child’s sport performance to play college baseball. Despite having a realistic understanding of the limited college scholarships available, parents were optimistic that their child would receive a baseball scholarship. The current year-round, highly specialized environment of youth sports in the United States may favor families with more financial resources.
INCREASED PREVALENCE OF JUVENILE OSTEOCHONDRITIS DISSECANS IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Authors: Hinkle Andrew , Dickason Celeste Quitiquit , Jinguji Thomas , Shenoi Susan , Thapa Mahesh , Thapa Mahesh , Saper Michael G. , Bompadre Viviana , Schmale Gregory A.
Published: April 2020

Background:

Juvenile Idiopathic Arthritis (JIA) is an autoimmune disorder presenting with chronic arthritis with prevalence of 5-20/100,000. Juvenile osteochondritis dissecans (OCD) is an idiopathic disease of articular cartilage and subchondral bone, has onset at 10-16 years, often affects the knee and ankle with prevalence of 5-30/100,000.

Hypothesis/Purpose:

We hypothesize that OCD is more prevalent in JIA, and when diagnosed in JIA, OCD is advanced, often requiring surgery.

Methods:

This was a retrospective review of patients with JIA and OCD treated between January 2008 and March 2019 at one children’s hospital. We queried Department of Rheumatology records for JIA patients treated during this interval as well as Departments of Orthopedics and Radiology records for patients with OCD. Demographic information, classification of the stability of OCD lesions by review of magnetic resonance imaging, and clinical details of treatment were recorded.

Results:

2,021 JIA patients were identified, 20 of whom (19 girls, 1 boy) had OCD of the knee and/or talus for a prevalence of 1/100 or 1000/100,000, or approximately 30-200x that of the general population. These 20 patients had a total of 28 OCD lesions: 43% (9 femur, 3 talus) were radiographically stable over time, 50% (10 femur, 2 patella, and 2 talus) were unstable at initial diagnosis, and 7% (femur) were initially stable but progressed to unstable lesions despite drilling. Eleven patients (55%) underwent surgery: 5 with stable femoral lesions for persistent symptoms despite prolonged non-operative treatment, and 6 for treatment of their unstable lesions (femur and patella). Of these 11 patients, 3 underwent two or more surgeries for OCDs, and 3 were treated with hemiepiphysiodesis for concomitant genu valgum.

Conclusion:

OCD lesions are 30-200x more prevalent in JIA compared to the general population. In JIA, OCD often presents at an advanced stage requiring surgery for stabilization. Patients with JIA may benefit by early screening, to potentially allow for treatment of an OCD lesion prior to the progression to instability.
ADOLESCENTS REPORT SLEEP QUALITY IMPAIRMENTS ACUTELY POST-CONCUSSION
Authors: Wilson Julie C. , Kirkwood Michael W. , Provance Aaron J. , Walker Gregory A. , Wilson Pamela E. , Howell David R.
Published: April 2020

Background:

Recently, the association between concussion and sleep has been explored. Few studies have used validated patient-reported outcome measures to examine how sleep quality differs between adolescents who have recently sustained a concussion compared to healthy adolescents.

Hypothesis/Purpose:

Our purpose was to evaluate the effect of acute concussion on sleep quality using the Pittsburgh Sleep Quality Index (PSQI). We hypothesized that adolescents with acute concussion symptoms would report worse sleep quality compared to healthy adolescent athletes undergoing a pre-participation evaluation.

Methods:

Patients seen for initial evaluation at a sports medicine clinic within 14 days of sustaining a concussion were matched with healthy control subjects undergoing a pre-participation evaluation based on age, sex and concussion history at a 3:1 control:concussion subject ratio. Controls with history of concussion were included if fully recovered at their evaluation. Both groups completed the PSQI and Post-Concussion Symptom Inventory (PCSI). Those with concussion reported sleep quality since their injury, while controls reported sleep quality over the past month. The primary outcome was global PSQI score, where higher scores indicate worse sleep quality. We compared sleep quality ratings between groups using independent samples t-test, and proportion of poor sleep ratings using Chi-square analysis. We then constructed a multivariable regression model to assess the effect of acute concussion on global PSQI scores while adjusting for sex, age and concussion history.

Results:

We evaluated 17 patients with concussion (mean 8±3 days post-injury) who were matched with 51 controls. Demographic variables did not differ significantly between concussion and control groups (Table 1). The concussion group reported higher PCSI symptom rating (Table 1), and worse overall sleep quality (Table 2). Specifically, the concussion group reported longer time to fall asleep, later morning awakening, longer sleep duration and longer time in bed, compared to controls. The concussion group was also less likely to rate their sleep as “very good” compared to controls (Table 2). After adjusting for the independent effect of sex, age, and concussion history, concussion was significantly associated with higher PSQI scores (β=2.01, 95% CI= 0.35, 3.68; p= 0.019).

Conclusion:

Adolescents assessed within 14 days of concussion reported worse overall sleep quality, longer sleep duration, and decreased sleep efficiency compared to healthy adolescents. These results, obtained utilizing a validated measure, highlight the negative impact of acute concussion on sleep quality and provide additional support that assessment of sleep characteristics is an important component of acute concussion management.

[Table: see text][Table: see text]
PATIENT REPORTED OUTCOMES ARE ASSOCIATED WITH ISOMETRIC STRENGTH DEFICITS EARLY AFTER ACL RECONSTRUCTION IN ADOLESCENTS
Authors: Weaver Adam , Macmillan Lauren , Suprenant Danielle , Giampetruzzi Nicholas
Published: April 2020

Background:

Quadriceps Femoris (QF) strength has been identified to impact patient reported function following ACL reconstruction (ACLR) at time of return to sport. Patients with higher subjective reports of knee function displayed greater QF symmetry. To our knowledge the relationship between patient reported outcomes and strength measurements have not been studied during the rehabilitation process in adolescent patients post ACLR.

Hypothesis/Purpose:

The purpose of this study was to examine the relationship of International Knee Documentation Committee subjective form (IKDC) and the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scores to isometric QF strength at three months status post ACLR.

Methods:

A retrospective chart review was conducted on patients treated with ACLR between July 2017 and April 2019 at a single institution. Patients between 12 and 20 years of age that underwent ACLR and completed a three-month functional tests assessment were included in the study. Data was collected for IKDC and ACL-RSI scores, and isometric strength testing at 60° of knee flexion on the HUMAC isokinetic dynamometer (CSMI USA, Stoughton, MA). Pearson correlation was used to determine if there is an association between IKDC and isometric strength, and Spearman Correlation to determine if there is an association between ACL-RSI and isometric strength.

Results:

The cohort included 138 patients (68 females; 16.16±1.88) (97.31±16.12 post-op days) status post ACLR, with an average IKDC score of 69.73±13.19 and average ACL-RSI score of 60.08±24.19. Hamstring autografts were the most common reconstruction (n=80, 58%). The average QF peak torque was 71.30±28.98 ft-lbs and average isometric QF strength deficit was 31.07±23.85 percent. IKDC scores were positively associated with QF peak torque isometric strength (r=0.437, P=<.0001). ACL-RSI scores were also positively associated with peak torque QF isometric strength (r=0.284, P=.001) and negatively associated with QF strength deficit (r= -.279, P=<.002).

Conclusion:

IKDC and RSI were positively associated with QF isometric strength in adolescent patients three months status post ACLR. These finding suggest that QF strength impacts patients’ reported function and psychological readiness to return to sport at this time point. Possible impact on rehabilitation includes implementing strategies to progress QF strength from three months status post to time of return to sport.
MICROENVIRONMENTAL INFLUENCES ON ARTICULAR CHONDROCYTE DIFFERENTIATION
Authors: Chau Michael , Toth Ferenc , Bendre Ameya , Armstrong Alexandra , Macalena Jeffrey , Tompkins Marc , Clohisy Denis , Nilsson Ola , Carlson Cathy
Published: April 2020

Background:

Immature articular cartilage (a.k.a. articular epiphyseal cartilage complex, AECC), serves dual functions as an articulating layer and surface growth plate. The AECC originates from an uninterrupted cartilaginous template during embryogenesis, presumably stemming from the same pool of progenitors, but it is unclear how the articulating layer is maintained throughout life, while the surface growth plate undergoes endochondral ossification.

Hypothesis:

The function and fate of chondrocytes in the AECC are not predetermined in the embryo, but instead can be influenced during development by biochemical and/or biomechanical stimuli in the cellular microenvironment.

Methods:

Microenvironments of the articulating layer and surface growth plate were switched in an in vivo goat model. Twelve 3-week-old goats were used. Osteochondral autografts were harvested from medial and lateral condyles and trochlea of the distal femur. Subchondral bone was removed (Figures 1A and 1B). Grafts were inverted and press-fit into select sites, which were full (condyles) or low (trochlea) weightbearing (Figures 1C through 1E). Animals were allowed ambulation and range of motion as tolerated. Two goats each were euthanized at 1, 2, 3, 6, 12, and 24 weeks postoperatively. Distal femurs were harvested and grafts were analyzed with trichrome staining and in situ hybridization for Col10, Col2, and Prg4.

Results:

All animals survived surgery, ambulated within 24 hours, and none exhibited signs of surgical site infection. Macroscopically, grafts at the trochlea and lateral condyle maintained a more cartilaginous appearance than those at the medial condyle, but all eventually developed an osseous appearance. Histologically, there was healing over time, with early grafts often containing areas of hemorrhage and occasionally necrosis, followed by formation of granulation tissue and subjacent myelofibrosis, with eventual invasion and ossification. At later timepoints, there was better graft incorporation at the articular surface without replacement by fibrosis at the medial condyle (Figure 2). In situ hybridization demonstrated some Prg4 positive cells and a decrease in Col10 expression at the articular surface (Figure 3).

Conclusions:

The synovial microenvironment may play a protective role against endochondral ossification. Some incorporation of epiphyseal cartilage into articular cartilage occurred at sites subjected to both compressive and shear forces. Data suggest the existence of local cytokines and/or matrix effects on chondrocytes that stimulate different cell functions and fates. A limitation of this study is its observational nature. Further understanding of articular chondrocyte differentiation and identification of key biochemical and/or biomechanical stimuli hold therapeutic promise for articular cartilage regeneration, repair, and replacement.

[Figure: see text][Figure: see text][Figure: see text]
INCREASED TIBIOFEMORAL ROTATION WITH INCREASING SEVERITY OF PATELLAR INSTABILITY
Authors: Lin Kenneth M. , James Evan W. , Schlichte Lindsay , Wang Grace , Green Daniel
Published: April 2020

Background:

Tibiofemoral rotation (TFR), specifically external tibial rotation, has been recently identified as a potential contributing factor to patellar instability. However, no previous studies have explored the clinical effects of differing degrees of TFR in relation to patellar instability.

Purpose and Hypothesis:

The purpose of this study is to investigate the relationship between severity of instability with degree of TFR. Our hypothesis is that fixed or obligatory dislocators (FOD) are more likely to have increased external TFR (tibial external rotation compared to femur) than standard patellar instability (SPI) patients requiring medial patellofemoral ligament (MPFL) reconstruction, who will have similar or slightly increased external TFR compared to normal controls.

Methods:

A retrospective study was performed with patients from 3 cohorts from April 2009 to February 2019: FOD, SPI, and controls with normal magnetic resonance imaging (MRI) of the knee. All FOD patients from the study time frame were analyzed, while controls and SPI patients were randomly selected. Patients were included for age under 18 years and diagnosis corresponding to one of the three cohorts, and excluded for outside institution MRI, and previous MPFL reconstruction or tibial tubercle osteotomy. TFR was measured on preoperative axial MRI using the posterior femoral and tibial condylar lines (Figure 1). Tibial tubercle to trochlear groove distance (TT-TG) was measured. Intraclass correlation coefficient (ICC) was calculated among 3 measurers. Statistical analysis using ANOVA and t-test was performed with significance set at α=0.05.

Results:

A total of 57 patients were included, 19 in each cohort. Average age was 13.2 years (range 10-17 years), with 31 females (54%). ICC for TT-TG and TFR were 0.90 and 0.72, respectively. TT-TG differed between the controls and SPI patients (both P<0.001), and controls and FOD patients (P<0.001), but not between SPI and FOD patients (P=0.12). TFR differed among the three groups: 8.4° (SD 16.7°) external TFR in FOD, 1.6° (SD 5.4°) external TFR in SPI, and 2.5° (SD 5.8°) internal TFR in controls (P=0.0089). FOD patients had significantly greater external tibial rotation than the SPI group (P=0.047).

Conclusions:

The degree of TFR is correlated with severity of patellar instability, with greater external tibial rotation seen in FOD than SPI patients, while TT-TG was not different. Further information on the relationship of TFR and patellar instability will not only improve understanding of pathogenesis and prognosis, but may also direct surgical treatment strategies in refractory or severe cases.

[Figure: see text][Figure: see text]