bluuebunny/crossref_metadata_2025 huggingface dataset:
Protective effects of pterostilbene on ulcerative colitis in rats via suppressing NF-κB pathway and activating PPAR-γ
Authors: Shi Liu , Liu Qing , Tang Jian-hua , Wen Jian-jun , Li Chen
Published: March 2019

Our study aimed to investigate the protective effects and potential mechanisms of pterostilbene on rats with ulcerative colitis (UC). We established 2,4,6-trinitrobenzenesulfonic acid (TNBS) induced colitis rat model. Rats were randomly divided into three groups, including control group, model group, and pterostilbene group (30 mg/kg). Disease activity index (DAI) including body weight, stool consistency, and gross bleeding was measured. The concentration of superoxide dismutases (SODs), glutathione superoxide (GSH-px), malondialdehyde (MDA), and methylpropanediol (MPO) in serum were detected by enzyme-linked immunosorbent assay (ELISA). The levels of interleukin-1 beta (IL-1β), IL-17, IL-6, and tumor necrosis factor–alpha (TNF-α) in serum were also analyzed by ELISA kits. Histological evaluations of colons were conducted. The levels of peroxisome-proliferator-activated receptor–γ (PPAR-γ), nuclear factor-κB (NF-κB), ZO-1, and Occludin were analyzed by immunohistochemistry. Compared with model group, pterostilbene notably suppressed the production of TNF-α, IL-17, IL-1β, IL-6, MDA and MPO in serum, and markedly increased the SOD and GSH-Px activity in serum. Pterostilbene significantly attenuated macroscopic damage and histological injury, when compared with model rats. Furthermore, pterostilbene also markedly activated the expression of PPAR-γ, ZO-1, and Occludin, and suppressed the expression of NF-κB. The protective effects of pterostilbene might be associated with suppression of NF-κB and activation of PPAR-γ. Pterostilbene might be a promising therapeutic agent for colitis treatment.
Exploring changes in processing speed and intraindividual variability in youth following sports-related concussion
Authors: Green Stephanie L , Keightley Michelle L , Lobaugh Nancy J , Dawson Deirdre R , Mihailidis Alex
Published: March 2019

Background

Concussion represents a growing concern in sports participation for adults and youth alike. Studies exploring the neurocognitive sequelae of concussion, such as speed of processing typically compare mean reaction time scores to a control group. Intraindividual variability measures the consistency of reaction times between trials and has been previously explored in adults post-concussion. Some adult studies show increased variability following injury. Developmentally youth show higher intraindividual variability than adults, which may put them at higher risk of increased intraindividual variability change post-concussion. Exploring intraindividual variability may provide additional insight into fluctuating performance reported following injury. Despite preliminary findings of slowed reaction time in youth, a pre-/post-concussion comparison of intraindividual variability of reaction time has not been explored.

Objective

To describe and compare pre- and post-concussion measures of processing speed and intraindividual variability in youth.

Methods

A pre-/post-concussion design was used to compare mean reaction time and the coefficient of variation before and after sports-related concussion in 18 youth athletes aged 10–14 years using verbal and nonverbal working memory tasks. Pre-/post-concussion reaction time and coefficient of variation were compared using t-tests.

Results

The coefficient of variation for nonverbal working memory was significantly higher following concussion, but no changes in average reaction time were found.

Conclusions

Preliminary findings suggest that average response times are unchanged following concussion, but the fluctuation across response times is more variable during a nonverbal working memory task in youth. Increased variability in speed of reaction times could have implications for safe return to sports and reduced academic performance.
Group- Versus Parent-Involvement CBT for Childhood Anxiety Disorders: Treatment Specificity and Long-Term Recovery Mediation
Authors: Silverman Wendy K. , Marin Carla E. , Rey Yasmin , Kurtines William M. , Jaccard James , Pettit Jeremy W.
Published: March 2019

Treatment specificity and long-term recovery mediation of peer-involvement group cognitive behavioral therapy (GCBT) and parent-involvement CBT (PCBT) were investigated for youth anxiety disorders. Two hundred forty youths with primary anxiety diagnoses participated in a randomized controlled efficacy trial. Youth anxiety and peer variables/mediators (positive peer–youth relationships; social skills) and parent variables/mediators (psychological control; negative parent–youth relationships) were assessed. At posttreatment and 12-month follow-up, positive peer-youth relationships were significantly higher in GCBT than PCBT (specificity) according to youth and parent ratings. At posttreatment but not follow-up, parental psychological control was significantly lower in PCBT than GCBT (specificity) and findings varied by informants. Parental psychological control and positive peer–youth relationships were putative mediators. The two CBTs produced similar anxiety reductions through different mechanisms. CBT targets show specificity and mediation, providing insight into specific mechanisms through which GCBT and PCBT bring about anxiety reduction and guidance for streamlining these CBTs in practice.
Effect of Health Insurance on Hepatitis C Sustained Virologic Response Rates to Sofosbuvir-Based Treatment Regimens in a South Florida Community Hospital
Authors: Eckardt Paula , Niu Jianli , Savage Angela , Griffin Tara , Sherman Elizabeth
Published: March 2019

The high cost of direct-acting antiviral–based regimens raises concerns about the outcome of treatment in uninsured patients with chronic hepatitis C virus (HCV) infection. This study assessed the relationship between health insurance status and sustained virologic response (SVR) rates in a community hospital in South Florida. Sofosbuvir-based therapy was initiated in 82 patients, of which 73% were uninsured and 28 (34%) were HIV coinfection. The overall SVR rate for those tested was 98%. The SVR rates were similar between HCV mono- and HCV/HIV coinfected patients (96% versus 100%, P = .204). Uninsured patients, with access to patient assistance programs, had comparable SVR rates to insured patients (100% versus 95%, P = .131). However, there was a trend toward a higher rate of loss to follow-up in uninsured compared to insured patients (25% versus 9%, P = .116). Strategies specific to adherence to treatment for uninsured patients are needed to reduce rates of loss to follow-up.
PEDIATRIC PATIENTS WITH FAI AND INFLAMMATORY COMORBIDITIES HAVE A CHARACTERISTIC CAM DEFORMITY: A PILOT STUDY
Authors: Carsen Sasha
Published: March 2019

Background:

Pediatric patients with inflammatory conditions often present with single or multifocal joint pain. Assessment of these patients at our institution revealed a possible association between femoroacetabular impingement (FAI) and inflammatory comorbidities. The purpose of this study was to investigate the prevalence and unique characteristic morphology of FAI in pediatric patients with inflammatory comorbidities.

Methodology:

A retrospective review was conducted on a consecutive series of 105 patients diagnosed with FAI in our institution’s adolescent hip clinic from January 2016 to March 2018. Patients with an inflammatory comorbidity were identified. Femoral head-neck junction morphology was assessed qualitatively and with standard radiographic measures for FAI.

Results:

Seven patients (6.7% of diagnosed patients), with eight symptomatic hips, were found to have FAI and an inflammatory comorbidity. These diagnoses included Crohn’s disease, Celiac disease, juvenile idiopathic arthritis, Type 1 diabetes mellitus and hypothyroidism. All seven patients had cam deformities. Qualitative assessment revealed that most patients had a characteristic head-neck morphology that was unique to this subset of patients, with a prominent and “sharp-edged” bump at the head-neck junction (See Figure 1). Radiographic analysis of the symptomatic hips revealed a mean alpha angle of 81.3o (±8.7 o), mean LCEA of 33.1o (±8.4 o) and mean femoral offset of 0.07 (±0.05). There was no significant difference in the radiographic measurements between symptomatic and asymptomatic hips in these patients.

Conclusion:

This is the first study to identify an association between FAI and inflammatory comorbidities in pediatric patients, with a prevalence of 6.7% at our institution. Given the relative rarity of inflammatory comorbidities in the general pediatric patient, this represents an unexpectedly high association. These patients presented with a unique head-neck morphology characterized by a more prominent and “sharp-edged” cam lesion than the typical morphology seen in patients without an inflammatory comorbidity. This study raises questions regarding the possible role of physeal inflammation in the development of cam deformities and indicates a need for further studies investigating the relationship between systemic inflammatory disorders and FAI. [Figure: see text]
DO ALTERATIONS IN PELVIC ROTATION ON THE FALSE PROFILE RADIOGRAPH EFFECT THE APPARENT AIIS MORPHOLOGY?
Authors: Khan Adam Z. , Putnam Sara , Minaie Arya , Clohisy John , Nepple Jeffrey J.
Published: March 2019

Background:

Prominence of the anterior inferior iliac spine (AIIS) may contribute to femoroacetabular impingement (FAI). Identification and classification of these morphologic variants are important to evaluation and treatment of symptomatic impingement. A standard hip radiographic series including false profile radiographs are commonly used for assessment of AIIS morphology, despite 3D-CT imaging being the gold standard. Yet, obtaining the accurate degree of rotation necessary for precise false profile radiographs in the office is difficult, often leaving the clinician to interpret radiographs with non-standard pelvic rotation. The purpose of this study is to investigate the effects of pelvic rotation of false profile radiographs on perceived AIIS morphology.

Methods:

Fifteen cadaveric hips (8 pelvises: 4 male, 4 females; 68-92 years of age) without evidence of prior surgery or osteoarthritis were obtained. Samples were fixed to a custom jig in neutral pelvic tilt and rotation. An AP pelvis and radiographic images from 450 to 850 of rotation at 50 intervals were taken, with 650 designated as a true false profile view. A single grader identified the morphology of the AIIS deformities on false profile views as well as measurement of the AIIS offset of each cadaver in 5 degree increments of rotation from 45 to 85 degrees (65 degree true false profile). Interobserver and intraobserver reliability was assessed in a random subset of 20 views. Paired t-test was used to evaluate significance of AIIS offset at varying degrees of pelvic rotation.

Results:

Significant increases (p < 0.05) in measured AIIS offset were observed with each subsequent increase of 50 of pelvic rotation (greater AIIS offset seen with increased pelvic rotation towards lateral). Mean AIIS offset values for each 50 of rotation are shown in Figure 1. Figure 2 shows examples of observed differences in AIIS offset at both extremes of rotation relative to a true false profile. There was strong inter- and intra-observer reliability for AIIS offset (0.920 and 0.965), especially compared to measured femoral head diameter (0.657 and 0.779).

Conclusion:

Significant variation in measurement of AIIS offset on false profile radiographs was observed based on degree of pelvic rotation. Increased prominence of AIIS (decreased AIIS offset) was noted with decreased pelvic rotation (away from true lateral view). These findings stress the importance of clinician caution and close attention to pelvic positioning with radiographic evaluation of AIIS prominence.
MAPPING COMPRESSIVE AND TENSILE STRAINS OF THE PATELLAR TENDON IN OSGOOD-SCHLATTER DISEASE USING ULTRASOUND ELASTOGRAPHY
Authors: Rizzone Katherine , Weyand Grace E. , Richards Michael S. , Kuo Catherine K. , Buckley Mark R.
Published: March 2019

Background

Osgood-Schlatter Disease (OSD) impacts millions of young athletes every year, yet its biomechanical etiology remains unclear. It’s been postulated that increased growth velocity in children elevates tension within the patellar tendon, placing distal strain on the tibial tubercle, causing anterior knee pain, but this process has not been previously elucidated. The purpose of this study was to evaluate axial tensile and transverse compressive strains in adolescent patellar tendons during exercise to identify differences between those with and without OSD using a cumulative strain, ultrasound elastography measurement method [REF: Chimenti et al 2016].

Methods

Axial tensile and transverse compressive strains of the patellar tendon in eight adolescents with OSD and ten adolescents without OSD were quantified from ultrasound elastography images. Multiaxial strains of the patellar tendon were assessed as the participant performed two different exercises: 1) participant seated with leg fully extended, participant bends knee, followed by a return to initial extended position; (2) participant standing performs a squat and then returns to initial standing position. Participants’ disease severity was clinically assessed using the VISA-P and Cincinnati knee scale.

Results

Mean age was 13.1 years (+/- 2.7), 39% were male (63% of OSD group). There was no statistically significant difference in patellar tendon tensile strains during the seated knee flexion and squat positions between groups (p = 0.99, p = 0.83 respectively). The OSD group had significantly less tendon compression compared to the non-OSD group during both the knee flexion (p <0.01), and squat exercises (p <0.05).

Conclusions/Significance

Adolescents with OSD had lower transverse compressive strains in the patellar tendon as compared to adolescents without OSD. In contrast, tensile strains were not increased in children with OSD. These findings appear to contradict the tension hypothesis postulating that OSD is caused by increased patellar tendon axial tension associated with rapid bone growth, Instead, impingement from the tibia leading to transverse tendon compression may lead to an adaptive stiffing the patellar tendon, However, further research is needed to confirm this hypothesis. While OSD is a common cause of knee pain in growing athletes that frequently leads to loss in participation, its etiology is unclear, making development of effective treatment approaches difficult. This study highlights differences in multiaxial patellar tendon strains in adolescents with OSD which may help direct future research on management strategies.
RETURN TO SPORT PHYSICAL PERFORMANCE TESTING IN CHILDREN - BUILDING POPULATION NORMS
Authors: Myers Heather , Magill John , Esposito Valentine , Messer Michael , Lentz Trevor , Riboh Jonathan
Published: March 2019

Purpose/Hypothesis:

Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction in children is associated with a much higher risk (˜30%) of subsequent ACL injury than in adults. In adults, delaying RTS until objective physical performance test (PPT) criteria are met reduces re-injury rates. However, normative data on PPTs in children is missing, limiting their utility in this high-risk population. Designing age-specific pediatric guidelines for RTS is therefore a critical area of investigation.

Number of Subjects:

63

Materials/Methods:

We designed a prospective observational study of 130 healthy pediatric athletes (ages 6 - 18 years, 5 males and 5 females of each age). Each athlete underwent a series of 10 functional tests assessing balance (Y-Balance Test, stork test, stork test on Bosu ball), strength (single leg squat, single leg hop) and composite neuromuscular control (single leg squat on Bosu ball, clockwise and counterclockwise quadrant hop, 6 m timed hop and triple crossover hop). Demographic data including sex, chronologic age, Pubertal Maturity Observational Score (PMOS), height, weight, and body mass index (BMI). Testing order was randomized to reduce confounding from fatigue. Our primary hypothesis was that PPT results would vary predictably with chronologic age. For each PPT, multivariable linear regression was performed including age, sex, PMOS, BMI and testing order as independent variables. Standard “growth curves” for each test were then built based on age and sex.

Results:

Sixty-three athletes (29 male, 34 female) have completed testing so far (48% enrollment). Mean age was 10.7 +/- 3.2 years (range 6 - 18). Mean PMOS was 3.2 +/- 3.1 (range 0 - 9). PMOS was strongly correlated with chronologic age (Pearson’s? = 0.83), therefore PMOS was excluded as a predictor variable in regression models to avoid multicollinearity. Chronologic age was an independent predictor of all PPT results (p < 0.05 in all cases). There was a learning effect for the Bosu Stork test, with athletes doing this test later in the sequence performing better (ß = 2.47, 95% CI 0.74 - 4.19, p = 0.006). Female sex was an independent predictor of a shorter triple crossover hop distance (ß = -74.1, 95% CI -106.9 to -41.2, p < 0.0001). Balance tests showed the least linear relationships with age. The stork test had a clear ceiling effect by age 10 in females and 13 in males. The Bosu Stork test showed wide variability at all ages.

Conclusion:

Chronologic age is a strong, typically linear predictor of commonly used PPTs in children. The PMOS did not add additional predictive value.

Clinical Relevance:

The normative data generated in this study help understand normal neuromuscular development, and provide a foundation for creating age-specific RTS scores.
SLAP TEARS IN THE PEDIATRIC PATIENT: WHO IS TREATING THEM AND WHERE?
Authors: Agatstein Lauren , Brown Matthew J. , Friel Nicole , Haus Brian
Published: March 2019

BACKGROUND:

Although rare in comparison to adult cohorts, superior labral anterior to posterior (SLAP) tears do occur in children and adolescents. Previous publications have focused on the varied surgical treatments of SLAP tears in pediatric hospitals but have not stratified treatments by surgeon training or hospital setting. The objective of this study is to evaluate the demographics of patients under the age of 18 undergoing SLAP surgery as well as to evaluate the influence of hospital setting (hospital self-designation as pediatric vs. non-pediatric) and the trends of treatment choice (debridement versus repair) over a period of time.

METHODS:

The California statewide outpatient database (OSHPD) was queried for all patients under 18 years old who underwent a SLAP debridement or repair in the state of California between 2008 and 2016. The effect of age, hospital setting (pediatric versus adult hospital), gender, insurance type, race, and year of service were assessed using logistic regression.

RESULTS:

A total of 1,349 patients under age 18 years underwent surgery for a SLAP tear between 2008 and 2016. SLAP repair was performed in 83.8% of patients while SLAP debridement was performed in 16.2% of patients. 80.9% of patients were treated at non-children’s hospitals and 19.1% were treated at children’s hospitals. At non-children’s hospitals, 161 (14.7%) had SLAP debridement and 931 (85.3%) had SLAP repair. At children’s hospitals, 57 patients (22.2%) had SLAP debridement and 200 (77.8%) had SLAP repair. The odds of having a SLAP repair over SLAP debridement decreases by a factor of .58 (p < 0.01) when patients have surgery at a children’s hospital versus at a non-children’s hospital. Age, gender, race, and insurance type were not statistically significant in predicting whether patients underwent SLAP repair versus debridement. Analysis of each individual year of service over the study period from 2008 to 2016 revealed the odds of having a SLAP repair over debridement increased each year by a factor of 1.1 (p < 0.001).

CONCLUSIONS:

The majority of surgeries treating SLAP tears in patients under the age of 18 are performed in non-pediatric hospitals. However, previous literature reporting on outcomes of SLAP surgery on patients under 18 is based in tertiary care pediatric centers,, which is likely not representative of this patient population. We hypothesize that this discrepancy may be due to shoulder surgeries more often being performed by sports medicine trained orthopedic surgeons who are not tied to operating in pediatric hospitals. Further, the yearly increased rate of SLAP repair over debridement is likely due to the prevailing knowledge in the orthopedic sports literature that repair is preferable to debridement in younger patients.
SIGNIFICANT NATIONWIDE VARIATION EXISTS IN OPIOID PRESCRIPTION RATES AMONGST PEDIATRIC PATIENTS WITH ACL INJURIES: A RETROSPECTIVE COHORT STUDY
Authors: Anandarajan Dharman , Talwar Divya , Wells Lawrence
Published: March 2019

Background:

Prescription opioid rates have been found to vary on a county and state level. We aim to find if significant hospital-level and regional-level variation in opioid prescription rates exists in a pediatric orthopedic setting.

Methods:

We conducted a retrospective cohort study of children ages 10-18 who sustained an ACL injury between 2012-2016, from 39 hospitals throughout the United States, found through the Pediatric Health Information System. Patients were divided into four regions according to the regional census of hospital admission, and demographics were recorded. Primary outcomes were hospital-level variation in opioid prescription rates using a mixed effects linear regression model to compare mean differences in average opioid prescription rate.

Results:

11,452 pediatric patients were analyzed for regional-level variation in opioid prescription rates. Of those patients 7,879 were analyzed for hospital-level variation in opioid prescription rates based on if the hospital of incidence had a sample size of at least 250 patients over the five-year span (16 of the 43 hospitals fit this criteria). The most common demographics were patients ages 16-18 (n=5,613; 49.01%), white (n=6,588; 57.53%), and male (n=5,905; 51.56%). The 11,452 patients were divided into four regions: (1) Northeast (n=2,409; 21.04%), (2) Midwest (n=2,499; 21.82%), (3) South (n=3,869; 33.78%), and (4) West (n=2,675; 23.36%). After adjustment, significant variation in opioid prescription rates was found to exist at both a hospital-level using a random intercept and random slope model (-2LL=17882.381, p<.05) and at a regional-level by comparing mean differences in average opioid prescription rate (p<.05).

Conclusions:

Significant variation of opioid prescription rates exists at both a hospital-level and a regional-level over the last five years in a pediatric orthopedic setting. The findings of this study build off previous findings from the Centers for Disease Control, which found significant variation existed in opioid prescription rates on a state-wide level. Given the recent guidelines proposed by the CDC to control and limit prescription opioids (as of March 2016), future studies finding the impact of the guidelines on variation of prescription rates in a pediatric orthopedic setting could be beneficial. [Table: see text][Figure: see text]
QUADRICEP TENDON TURNDOWNS FOR MPFL RECONSTRUCTION: AN ANATOMICAL DIFFERENCE BETWEEN THE ORIGINS OF THE QUADRICEP TENDON AND MPFL ON THE PATELLA
Authors: Rustad Audrey , Anchustegui Nicolas G. , Troyer Stockton , Shea Cooper , Dingel Aleksei , Ganley Theodore J. , Shea Kevin
Published: March 2019

Background:

Quadriceps tendon (QT) turndowns are an alternative method for medial patellofemoral ligament (MPFL) reconstruction, with several distinct advantages: 1. Avoids the use of patella bone tunnels, which have been associated with patella fracture, 2. Avoids the use of separate incision for hamstring tendon harvest, and 3. Avoids the use of allograft tissue, which adds a significant cost. The disadvantage of the Quad Tendon graft is that the most distal reflection point on the patella may not duplicate the patella origin of the native MPFL. The purpose of this study was to determine whether a QT graft for MPFL reconstruction is anatomically analogous to the native MPFL origin in a skeletally immature population.

Methods:

Three skeletally immature cadaveric knee specimens (ages 10 and 11, 11) were dissected to reveal the MPFL and QT origins on the patella. The proximal and distal extent of the MPFL was marked on the medial border of the patella. The medial aspect of the quad tendon was reflected as far as possible in both a medial and distal position on the patella, to function as the MPFL graft. The distance was measured between the midpoint of the patellar origin of the MPFL in the coronal plane, and the most distal aspect of the patellar origin of the reflected quad tendon.

Results:

In the 10, 11, and 11 year-old specimens, the distance between the midpoint of MPFL patellar origin and the QT patellar origin was 3.4 cm, 4.3, and 3.7 mm. In all cases, the QT reflected origin was at least 7 mm anterior to the to native MPFL origin on the medial border of the patella.

Conclusion:

A disparity exists between the patellar origin of the MPFL and the patellar origin of the quad tendon, with the patellar origin of the MPFL being more medial, more distal, and more posterior than the reflected patellar origin of the QT graft. Surgeons performing MPFL reconstructions may find this anatomically valuable as they attempt to duplicate the normal anatomy of the patella stabilizers during surgical reconstruction. While the QT remains a good graft choice for MPFL reconstruction, attachment of the QT graft at the native origin of the MPFL may better reproduce the anatomy of the MPFL.

Figures:

[Figure: see text][Figure: see text]
SPORT SPECIALIZATION IS A RISK FACTOR FOR OVERUSE, BUT NOT ACUTE, LOWER EXTREMITY INJURIES: A PROSPECTIVE STUDY
Authors: Bell David , Biese Kevin M. , Post Eric G. , Schaefer Dan , McGuine Timothy A. , Kliethermes Stephanie , Brooks Alison , Watson Andrew
Published: March 2019

BACKGROUND:

Sport specialization is often associated with intense, high volume training, which may result in injury – especially overuse injuries. However, there is limited prospective research investigating these relationships. Additionally, previous research has focused on adolescents older than 12 years of age with no data available in younger cohorts, who may be more susceptible to repetitive stress. Therefore, the purpose of this study is to determine if sport specialization is associated with increased risk of overuse and acute lower extremity injuries in middle school aged athletes.

METHODS:

A total of 281 children (113 females (40%), age=12.1±1.2years; range 10-14 years of age) completed an online survey with their parents for 39 weeks. The study was conducted during the 2017-2018 academic year with a baseline survey conducted the first week of September. Weekly surveys were sent to respondents via Qualtrics with the final weekly survey in June of 2018. The baseline survey consisted of 1) demographic information, 2) injury history in the previous 12 months, 3) a sport specialization scale which classified individuals in low, moderate, and high levels of specialization, and 4) sport participation volume (months per year in primary sport). The weekly surveys asked participants to report and musculoskeletal injury they sustained during sport participation. Participants were included in the analysis if they completed at least 80% of the total surveys. Multivariable logistic regression analyses were utilized to examine associations between specialization category (reference category: low) and prospective injury categories, while adjusting for differences in age, sex, and previous injury history.

RESULTS:

Respondents reported 57 acute and 32 overuse lower extremity injuries during the observation period. Highly specialized athletes had significantly greater odds of reporting a prospective lower extremity overuse injury than subjects in the low specialization group (OR: 3.78, 1.02-12.90, p=0.03), even after adjusting for sex, age, and previous injury history. However, specialization was not a risk factor for acute lower extremity injuries (OR: 2.20, 0.72-6.77, p=0.17).

CONCLUSION:

Highly specialized middle school athletes are nearly 4 times greater risk of developing an overuse injury compared to low specialization athletes. Younger athletes may be more susceptible to injuries at younger ages. Thus, adolescent athletes should avoid specialization when possible.
VARIATION IN PREFERRED TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN THE SKELETALLY IMMATURE: WHERE DO WE STAND?
Authors: Patel Neeraj M. , Talathi Nakul S. , Talwar Divya , Fabricant Peter D. , Kocher Mininder S. , Ganley Theodore J. , Lawrence J. Todd
Published: March 2019

Purpose:

Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear. The goal of this study was to identify preferred techniques in skeletally immature patients of various ages and analyze differences in operative strategy based on surgeon and practice demographics.

Methods:

An electronic survey was administered to members of the Pediatric Research in Sports Medicine society, a cohort of experienced surgeons who perform a high volume of pediatric ACL reconstructions. The survey presented a scenario of a patient who had a physical exam and imaging consistent with an acute, isolated ACL tear. The respondent was asked to select their preferred reconstruction technique for females and males at consecutive skeletal ages from 8 to 15 years. Surgeon and practice demographic information was recorded. Univariate analysis was followed by stepwise multinominal logistic regression to control for confounders.

Results:

Eighty-eight of 103 surgeons (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 in females and 11 to 14 in males. The modified MacIntosh was the most frequently utilized from ages 8 to 10. An all-epiphyseal technique was preferred over a broader age range in males than females, with peak utilization at age 11 in both. A partial trans-physeal (hybrid) technique was preferred in slightly older patients, with peak utilization at age 12 in females and 13 in males. The trans-physeal technique was most widely used at age 13 and up in females and 14 and up in males. The impact of fellowship training on technique preference was statistically significant for males ages 11-13 and females 11 and 12 (p<0.05 for all). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports training preferred the modified MacIntosh.

Conclusions:

The preferred ACL reconstruction technique for skeletally immature patients varied considerably, especially in the 11-13 year-old age range, highlighting a lack of consensus among orthopedic surgeons for the optimal ACL reconstruction strategy in skeletally immature patients. Surgeon’s fellowship training was significantly associated with their preferred surgical technique.
10-MINUTE 3D MRI IN CHILDREN WITH ACUTE KNEE TRAUMA: ARTHROSCOPY-BASED DIAGNOSTIC ACCURACY FOR THE DIAGNOSIS OF INTERNAL DERANGEMENT
Authors: Klyce Walter , Fritz Jan , Ahlawat Shivani , Thawait Gaurav , Raithel Esther , Lee R. Jay
Published: March 2019

Background

Magnetic resonance imaging (MRI) is often indicated in the diagnosis of pediatric knee trauma, but using traditional MRIs in children can be time-consuming, require anaesthesia, and sometimes cause discomfort. Recently, 3D turbo spin echo (TSE) MRIs with isotropic datasets have been found to reduce acquisition times substantially, but they have been little-studied in pediatric patients. The purpose of our study was to determine the arthroscopy-based diagnostic performance of 10-minute isotropic 3D TSE MRI for the detection of internal derangement in children with acute knee trauma.

Methods

Institutional review board approval was obtained for prospective data collection, and informed consent and assent were obtained from all parents and children, respectively. The final study group consisted of 60 children (38 boys, 22 girls; 11 (2-16) years-of-age) with acute knee trauma who underwent 10-minute isotropic 3D prototype CAIPIRINHA SPACE MRI at 3 T and subsequent arthroscopic knee surgery. Two fellowship-trained musculoskeletal radiologists retrospectively evaluated the MRI studies independently and resolved discrepancies through consensus. Outcome variables included image quality, motion artifacts, meniscal abnormalities, cruciate ligament tears, and cartilage lesions. Statistical analysis included the diagnostic performance of MRI with arthroscopy as the reference standard and inter-reader agreements using kappa statistics.

Results

All studies were suitable for diagnostic interpretation with good-to-very-good image quality and little-to-no motion degradation in the majority of cases. The sensitivities/specificities/accuracies of MRI were 0.93/0.93/0.93 for 15/60 (25%) medial meniscal tears, 0.95/0.90/0.92 for 21/60 (35%) lateral meniscal tears, 0.83/1.0/0.92 for 10/60 (17%) discoid menisci, 1.0/0.95/0.98 for 16/60 (27%) anterior cruciate ligament tears, 1.0/0.95/0.98 for 2/60 (3%) posterior cruciate ligament tears, 1.0/1.0/1.0 for 5/60 (8%) osteochondritis dissecans lesions, and 0.71/0.97/0.84 for 48 (13%) defects in 360 cartilage segments. The inter-reader agreements were overall good-to-very-good (kappa, 0.730 -1.00).

Conclusion

10-minute isotropic 3D TSE MRI of the knee is feasible in children with acute knee trauma and yields high diagnostic accuracies for the diagnosis of internal knee derangement. Accuracies for the detection of meniscal tears, discoid menisci, anterior and posterior cruciate ligament tears, osteochondritis dissecans lesions, and cartilage defects ranged from 84-100%. Using previously published protocols for pediatric 2D MRI knee exams with total acquisition times of 25 minutes as a benchmark for traditional MRI, a 10-minute protocol could increase the efficiency by a factor of two or more, and thus substantially improve the availability of MRI and timely care for children with acute knee trauma. [Table: see text]
OUTCOMES OF SURGICAL TREATMENT OF OSTEOCHONDRAL LESIONS OF THE ELBOW IN PEDIATRIC AND ADOLESCENT ATHLETES
Authors: Pandya Nirav K. , Bryant Jessica
Published: March 2019

BACKGROUND

Osteochondral lesions of the elbow are a difficult entity to treat in high-demand individuals. Pediatric and adolescent patients who typically present with these lesions are upper extremity athletes involved in high demand sports. There has been relatively limited examination in the literature of these patients’ ability to return to sport at midterm follow-up; particularly after non-osteochondral grafting procedures such as fixation and micro-fracture. The purpose of this study was to determine the mid-term outcomes of lesion treatment in a cohort of pediatric and adolescent patients.

METHODS

This was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent surgical treatment for osteochondral lesions of the elbow. Patients were treated arthroscopically by a single surgeon from 2012 to 2017. All patients had confirmed osteochondral lesions of their elbow confirmed via MRI and underwent surgical intervention after failure of conservative treatment. Data including age, hand dominance, sporting activity, physeal status, imaging, intra-operative findings, procedure performed, post-operative complications, and return to sport were analyzed.

RESULTS

Twenty patients (twenty-two elbows) underwent surgical treatment with a mean age of 13.05 (±1.89) years with a mean follow-up 1.9 years. Fifteen males and 5 females were involved in the following sports: baseball (10), gymnastics (3), football (2), lacrosse (1), softball (2), and multi-sport (2). Sixty-three percent of the elbows had open physes at the time of surgical intervention. There were 19 capitellar lesions, 2 trochlear lesions, and 1 radial head lesion. The mean lesion size was 8.5 (±3.7) mm X 8.9 (±3.0) mm. Three patients underwent fixation, and the remainder underwent loose body removal and microfracture. No patients had any post-operative complications and all healed radiographically. One patient (4.5%) underwent a re operation due to repeat injury after gymnastics, and underwent an osteochondral autograft procedure. Thirty-percent of patients did not return to the same sport; forty-percent of baseball players and sixty-six percent of gymnasts.

CONCLUSIONS / SIGNIFICANCE

Osteochondral lesions of the elbow are a challenging entity to treat. Although arthroscopic intervention can be performed safely and result in radiographic healing, there is a high rate of inability to return to sport in patients involved in high impact upper extremity activity such as baseball and gymnastics with either fixation or lesion debridement /microfracture. Further treatment strategies in these patients including cartilage restoration procedures (i.e. OATS) may be warranted in this population.
REASONS PEDIATRIC ATHLETES CONTINUE TO PLAY AFTER CONCUSSION
Authors: Zynda Aaron J. , Sabatino Meagan J. , Chung Jane , Cullum Munro , Miller Shane M.
Published: March 2019

Introduction:

As sport-related concussion incidence has increased in the pediatric population, the risks of continuing to play while injured have become apparent. These risks include subsequent injury, prolonged recovery, and Second Impact Syndrome. The purpose of this study was to determine why pediatric athletes continue to play following a concussion.

Methods:

Prospectively collected data of subjects enrolled in the North Texas Concussion Network Registry (ConTex) between December 2015 and April 2018 was reviewed. Subjects were included in this analysis if they were diagnosed with a sport-related concussion, less than 19 years old at time of injury, reported they continued to play, and provided a reason for continuing play.

Results:

258 subjects met inclusion criteria. Mean age was 13.9 years (range: 7-18 years) and 130 (50.4%) subjects were female. 142 (55%) subjects reported they continued to play following their concussion. Of those subjects who continued to play, 45 (31.7%) reported they “felt okay at the time”, 41 (28.9%) reported they wanted to “play through the injury or tough it out”, 36 (25.4%) reported they “did not realize it was a concussion”, 17 (11.9%) reported they “felt pressured to play from their coach or teammates”, and 3 (2.1%) reported they “were allowed to continue to play by an athletic trainer”. No significant differences were noted in age, gender, or sport of the pediatric athletes amongst the reasons for continuing to play.

Conclusions:

More than half of pediatric athletes continued to play following their concussion. Pediatric athletes most frequently continued to play because they were not experiencing symptoms at the time of the injury, wanted to play through it, and did not think their injury was a concussion. Future educational programs should take these reasons into consideration to prevent pediatric athletes from continuing to play following a concussion.
PREVENTING INJURY IN YOUTH ATHLETES (PRIYA)
Authors: Jayanthi Neeru
Published: March 2019

Affiliation:

Emory Sports Medicine Center & Emory University School of Medicine, Atlanta, GA

Background:

To compare the incidence of re-injury after lower extremity (LE) injury and the days missed following LE injury in high school athletes who use a criteria-based single leg hop test (SLHT) to determine return-to-play (RTP) versus those that do not utilize a criteria-based method.

Methods:

Prospective cohort analysis of athletic exposures (AE), injuries, re-injuries, and RTP duration between two high schools during the 2017-2018 fall season. One school (SLHT school) utilized the SLHT to determine RTP after LE injuries. The other school (control school) did not utilize a criteria-based method. Athletes were excluded if they sustained a fracture, high-grade ligament tear, or injury requiring surgery. Incidence rates (IR) of LE injuries, re-injuries, and average RTP duration after LE injury were calculated for each school.

Results:

At the time of submission, there were 66,100 AEs with 41 LE injuries (LE injury IR = 6.2 per 10,000 AEs, 95% CI 4.6-8.4) at the SLHT school and 45,342 AEs with 34 LE injuries (7.7 per 10,000 AEs, 95% CI 5.5-10.8) at the control school (p=0.34). The average RTP duration after LE injury was 12.3 days at the SLHT school and 12.7 days at the control school (p=0.12). There were no re-injuries after LE injury at the SLHT school, and 1 at the control school.

Conclusions:

There was no statistically significant difference between LE injury rates or RTP duration between the control and intervention schools. There was only 1 re-injury after LE injury that occurred at the control school.

Significance:

The SLHT does not appear to influence reinjury risk in RTP progression, however it does not add any additional days missed on RTP compared to control school with no criteria-based progression. We will continue to monitor for differences prospectively for another year of exposures.

Acknowledgements

This study was supported by a grant from the AMSSM Foundation and a grant from the Emory University Department of Orthopaedics.
FLEXOR HALLUCIS LONGUS TENOLYSIS/TENOSYNOVECTOMY IN DANCERS
Authors: Barchi Elizabeth I. , Rose Donald , Swensen Stephanie , Espiritu-McKay Tracy
Published: March 2019

Purpose:

The purpose of this study was to report on a series of dancers who had undergone Flexor Hallucis Longus (FHL) tenolysis/tenosynovectomy after having failed conservative management.

Methods:

Institutional human subjects committee approval was obtained prior to initiating this study. This study is a retrospective case series of 58 dancers and 63 ankles who underwent FHL tenolysis/tenosynovectomy via an open posteromedial approach by a single surgeon between 1993-2017. All patients were interviewed and charts reviewed retrospectively. Collected variables included: pre-operative and post-operative pain levels, time to return to dance, and subjective satisfaction with the procedure. Average age, primary dance form, level of dance were determined.

Results:

Average pre-operative pain level decreased significantly post-operatively. Average time to return to dance was 7.1 weeks. There was a 98% return to dance at some level while 97% of patients returned to dance symptom-free. There were no neurovascular or other major complications. Minor complications included superficial wound infection (3.1%) and hypertrophic scar (4.8%). Over 97% of dancers considered the procedure a success and 98% of dancers would repeat the procedure.

Conclusions:

This is one of the largest series reported of isolated FHL tenolysis/tenosynovectomy in dancers who have failed non-operative management. Satisfactory pain relief and return to dance with a low complication rate may be expected from this surgical procedure. The results of this study can be used to help dancers and their providers make informed decisions about treatment in isolated FHL tendinitis.
USE OF A WASHER DOES NOT AFFECT THE RATE OF IMPLANT REMOVAL OR ELBOW MOTION AFTER FIXATION OF MEDIAL EPICONDYLE FRACTURES
Authors: Patel Neeraj M. , Gajewski Christopher R. , Ascoli Anthony M. , Lawrence J. Todd
Published: March 2019

Background:

The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM).

Methods:

All surgically-treated pediatric medial epicondyle fractures over a 7-year period were queried for this retrospective case-control study. Patients were only included if their fracture was fixed with a single screw with or without a washer. Per institutional protocol, implants were not routinely removed after fracture healing. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Full ROM was considered flexion beyond 130 degrees and less than a 10-degree loss of extension. Univariate analysis was followed by creation of Kaplan-Meier (one minus survival) curves in order to analyze the time until full ROM was regained after surgery. Curves between patients with and without a washer were compared with a log rank test.

Results:

Of the 137 patients included in the study, the mean age was 12.2±2.3 years and 85 (62%) were male. A total of 31 (23%) patients ultimately underwent hardware removal. A washer was utilized in 90 (66%) cases overall. There was not an increased need for subsequent implant removal in these patients compared to those that underwent screw fixation alone (p=0.11). The mean BMI of patients that underwent hardware removal (19.1±2.5) was similar to that of children who did not (20.4±3.5, p=0.06). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (p=0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9±9.7 weeks after surgery (Figure 1). There was no statistically significant difference in the proportions of patients with and without a washer that achieved full ROM (p=0.46). Full ROM was achieved at a mean of 14.1±11.0 weeks in those with a washer compared to 13.6±6.2 weeks in those without one (p=0.21).

Conclusions:

Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of pediatric medial epicondyle fractures, even in thinner patients or competitive athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.