bluuebunny/crossref_metadata_2025 huggingface dataset:
Home ovulation test use and stress during subfertility evaluation: Subarm of a randomized controlled trial
Authors: Weddell Sarah , Jones Georgina L , Duffy Sheila , Hogg Cameron , Johnson Sarah , Ledger William
Published: March 2019

Objectives:

A prospective, randomized controlled trial in women seeking to conceive examined the impact of using ovulation tests on self-reported levels of stress, psychological well-being, and quality of life in women with unexplained infertility.

Method:

The test group used a home ovulation test to detect the day of ovulation, whereas the control group were provided with a predicted day of ovulation based on the average length of menstrual cycle reported during study recruitment. Volunteers collected their first morning urine samples to evaluate biochemical levels of stress (urinary cortisol and estrone-3-glucouronide) and completed questionnaires over two complete menstrual cycles.

Results:

Overall, the use of digital ovulation tests by sub-fertile women under medical care had negligible negative effects and no detectable positive benefit on psychological well-being, according to multiple measurements of stress by questionnaire and biochemical markers. No significant differences were found between groups for all stress measures at the various study time points, except in relation to “couple concordance” where the test group scored much higher than the control group (mean difference at end of study was 21.25 (95% confidence interval: 9.25, 33.25; P = 0.0015)). The maximum difference in log cortisol: creatinine ratio between the test and control groups was −0.28 (95% confidence interval: −0.69, 0.13).

Conclusions:

These results do not support propositions that using digital ovulation tests can cause stress in women trying to conceive.
Optimal design of an electrical connector intermittent fault–accelerated reproduction test based on a genetic algorithm
Authors: Zhu Zunqing , Li Qian , Zhang Yong , Liu Guanjun , Qiu Jing , Lyu Kehong
Published: March 2019

The intermittent fault of an electrical connector is a latent threat to the reliability of an electromechanical system. For electrical connector intermittent fault diagnosis, an intermittent fault must be reproduced. Reproducing an intermittent fault by a traditional test has a low efficiency and adds some damage to the product, which is not conducive to intermittent fault diagnosis. To further improve the reproduction efficiency of an intermittent fault and reduce the damage, optimal design of a step-stress-accelerated intermittent fault reproduction test is carried out. First, the number of intermittent faults and the degree of damage in the reproduction test are estimated, and reproduction and damage models of an intermittent fault during the step-stress reproduction test are constructed. Then, based on the intermittent fault and damage models, an optimized method based on a genetic algorithm is established. Finally, the validity and applicability of the theoretical model and the optimized method of the step-stress-accelerated test based on a genetic algorithm are verified by comparing data from a contrast test.
Cardiac rehabilitation in the elderly patient in eight rehabilitation units in Western Europe: Baseline data from the EU-CaRE multicentre observational study
Authors: Prescott Eva , Mikkelsen Nicolai , Holdgaard Annette , Eser Prisca , Marcin Thimo , Wilhelm Matthias , Gil Carlos Peña , González-Juanatey José R , Moatemri Feriel , Iliou Marie Christine , Schneider Steffen , Schromm Eike , Zeymer Uwe , Meindersma Esther P , Ardissino Diego , Kolkman Evelien K , Prins Leonie F , van der Velde Astrid E , Van 't Hof Arnoud WJ , de Kluiver Ed P
Published: March 2019

Background

Due to the progressive deconditioning, comorbidities and higher complication rates, elderly patients are in particular need of cardiac rehabilitation. We compared elderly patients (65+ years old) participating in cardiac rehabilitation, focusing on baseline characteristics, risk factor control and functional assessment.

Methods

The EU-CaRE study is a prospective study comparing cardiac rehabilitation in eight centres across Western Europe. Consecutive patients with acute coronary syndrome, stable coronary artery disease and heart valve replacement undergoing cardiac rehabilitation were included.

Results

Of 1633 patients (median age 72 years) participating, 54% had acute coronary syndrome, 33% had stable coronary artery disease and 13% followed valve replacement. Fifty-five per cent had undergone percutaneous coronary intervention and 29% coronary artery bypass grafting. Characteristics varied across centres: 23% (17–27%) were women, 4% (0–12%) were of non-European origin and 16% (4–32%) were living alone. Median time from index event to start of cardiac rehabilitation varied from 11 to 49 days ( p < 0.001). Mean VO2peak was relatively low (16 mL/kg per min) and varied significantly between the participating centres, largely unaffected by multivariable adjustment. Overall patients received guideline recommended treatment: 93% (87–97%) were on a statin and 70% (55–85%) an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. However, risk factor control was inadequate: 58% had three or more risk factors not controlled.

Conclusion

EU-CaRE provides a snapshot of the elderly population with heart disease participating in cardiac rehabilitation across countries in Western Europe. Risk factors and exercise capacity indicate the continued need for cardiac rehabilitation in these patients. Of concern, the lag-time to start of cardiac rehabilitation needs improvement in many centres.
Professionalizing and Profiting: The Rise of Intermediaries in the Social Media Influencer Industry
Authors: Stoldt Ryan , Wellman Mariah , Ekdale Brian , Tully Melissa
Published: March 2019

This study examines the relationship between travel influencers (e.g., bloggers and social media personalities) and destination marketers within the changing travel and tourism industry. Through in-depth interviews, observations, and document analysis, we explore the tensions between travel influencers and destination marketers that shape the way travel is promoted, labor is compensated, and professional structures are negotiated. We examine a new breed of travel and tourism worker—intermediaries who seek to professionalize and formalize the relationship between influencers and destination marketers while simultaneously solidifying their own role within the industry. Intermediaries promote and facilitate relationships based on structured flexibility—formalized agreements designed to satisfy a brand’s campaign goals yet open enough for influencers to pursue their unique needs. By examining the relationships between digital content creators, destination marketers, and third-party intermediaries, this article provides insight into how digital media industries negotiate the tension between participation and control.
Integrating Content Analysis Into Urban Research: Compatibility With Sociotope Method and Multimodal Graph
Authors: Zaleckis Kestutis , Grazuleviciute Vileniske Indre , Vitkuviene Jurga , Tranaviciutė Brigita , Dogan Huriye Armagan , Sinkiene Jolita , Grunskis Tomas
Published: March 2019

The content analysis approach is well-established and acknowledged sociological research technique, although it is constantly evolving and its field of application is expanding. The aim of the article is to demonstrate the possibilities to use the content analysis method in urban studies. It includes the analysis of literature and the example of methodology design in the frame of case of the study of modernization of Lithuanian cities during the Soviet period. It can be concluded that the content analysis method is a flexible tool that can be integrated both with sociospatial (sociotope methodology) and spatial (Space Syntax, multimodal graph) research methods and reinforce social dimension in spatial analysis of cities.
ISCHIOFEMORAL IMPINGEMENT IN ADOLESCENTS: FROM CLINICAL PRESENTATION TO RETURN TO SPORTS
Authors: Besomi Javier , Garin Alan , Herrera Cristhian , Salgado Pedro , Abara Selim , Tobar Carlos , Lara Joaquin
Published: March 2019

Background:

Ischiofemoral impingement is an often unrecognized cause of hip pain in adolescents. It is caused by abnormal contact between the proximal femur and the ischium. The aim of our work is to describe clinical presentation, imaging findings and functional outcomes of ischiofemoral impingement in adolescents.

Methods:

We performed a retrospective study. Clinical files were reviewed (age, sex, type and duration of symptoms and hip physical examination). Imaging findings were evaluated in pelvis radiographs (presence of coxa profunda, acetabular protrusio, Wiberg angle, femoral neck shaft angle and acetabular retroversion) and in MRI (quadratus femoris edema, measurement of ischiofemoral and quadratus femoris space). Lower extremity functional scale (LEFS) were used to measured response to a physiotherapy protocol. Also relapse and time to sports return were recorded.

Results:

24 hips, two bilateral in 20 female patients and 2 male patients, with 13 years-old on average (9-18) were obtained. Main symptom was hip pain with latency to consultant of 9 days on average (2-14). All patients practiced school sports, the most frequent was gymnastics. Positive FADIR test, ischiofemoral impingement test and pain on palpation of the ischium and gluteus medius were found in everyone. The median of Wiberg angle was 37º (25-48), femoral shaft angle 138º (128-144), and coxa profunda was present in 5 hips. MRI showed 13 hips with quadratus femoris edema, one with muscle atrophy, ischiofemoral space was 20 mm on average (16-25) and quadratus femoris space 17 mm on average (13-21). Our physiotherapy protocol was followed for all patients with a median of 18 sessions (10-30). LEFS improved from 56.4% (30-93) to 92% (80-100) (p=0,02). Time to turn asymptomatic was 6 months on average (3-13). With 2 years follow up, 2 hips had recurrence of symptoms. Time to sports return was 5 months on average (3-7).

Conclusions:

Ischiofemoral impingement is cause of hip pain in active female adolescents. X-rays are inespecific and MRI shows typically quadratus femoris edema. Conservative treatment with physiotherapy is an effective method that allows sports return in few months. This is the first report in the literature regards ischiofemoral impingement in pediatric population including results of treatment and return to sports.
ARE SELF-REPORTED PAIN SCALES IN PEDIATRICS VALID?
Authors: Sabatino Meagan J. , Jo Chan-Hee , Wilson Philip L. , Ellis Henry B.
Published: March 2019

Background:

Pain is the most common symptom for presentation to an orthopaedic practice and orthopedists rank 4th among top prescribers of opiates. Pain acuity, etiology and severity have been published as guiding factors for pain assessment and management. In an attempt to address the underassessment and undertreatment of pain, pain was even considered the 5th vital sign for a period of time. Assessment of pain using validated severity assessment instruments including the Visual Analogue Scale and the Wong-Baker FACES® Scale, is common in orthopaedic practices. The purpose of this study is to evaluate the validity and sensitivity of self-reported pain assessment tools administered to pediatric and adolescent patients presenting with a primary complaint of knee pain.

Methods:

A retrospective review of 211 patients with a primary complaint of knee pain in a single practice over a nine-month period was completed. Medical records were reviewed for demographics, sport, laterality, symptoms, and factors described as influencing the pain. Prior to orthopaedic evaluation, patients were given an electronic tablet to complete patient reported outcomes measures and the visual analog scale (VAS). Patients were asked, electronically, “Do you have pain today?” and to verbally rate the pain using a Wong-Baker FACES® Pain Rating Scale (FACES). The FACES scale, typically a 0-5 rating, was normalized to a 0-10 scale for comparison to both the VAS and the pain component of the pedi-IKDC (Pain-pIKDC). A Pearson’s correlation was used to compare the VAS and the Pain-pIKDC with the FACES scores to determine validity. A paired t-test was used to identify differences between the three measures.

Results:

Of the 211 subjects, 112 were females and 99 were males, with a mean age of 13.9 years (range 7-18). 82% of patients reported presenting for pain due to a specific injury and not of spontaneous origin. The mean FACES score was 1.26 (normalized to 2.52) with a median score of 0. Compared to the FACES, the mean VAS was 4.22 (p<0.001) and Pain-pIKDC was 3.66 (p<0.001) noted to be both a statistically and clinically significant difference. When comparing the FACES to VAS, a weak correlation was noted (0.360, p<0.001). A stronger correlation was noted between the VAS and the Pain-pIKDC (0.752, p<0.001). 66.4% of patients reported no pain on the FACES but reported pain >1 on the Pedi-IKDC. 80.5% of patients reported no pain on FACES but pain of >1 on the VAS. Only 12.2% on VAS and 16.2% on Pain-pIKDC reported no pain . For both the VAS and Pain-pIKDC, the sensitivity of detecting “no pain” is low at 19.2% and 30.2% respectively.

Conclusion:

Though pain is widely accepted as an important factor for patient care management, clinicians should be aware that self-reported pain assessment tools in pediatrics and adolescents, without verbal confirmation, may inflate reported pain intensity and lead to possible overtreatment.
INCREASED LIKELIHOOD OF PEDIATRIC RECURRENT PATELLAR DISLOCATIONS BASED ON SEVERITY OF RADIOGRAPHIC MEASURES
Authors: Albiero William , Morscher Melanie A. , Elias John , Riley Pat , Adamczyk Mark , Jones Kerwyn
Published: March 2019

Background:

The etiology for recurrent patellar dislocations in children with patellofemoral instability (PFI) is not always apparent. Radiographic and other imaging measures help guide the clinician. However, the imaging parameters for pathologic pediatric PFI and the significance of these measures based on severity are not clearly defined. This study compares common imaging measures for PFI in a non-pathologic and known patellar dislocation pediatric population and determines the likelihood of symptoms based on the severity of each individual measure.

Methods:

An IRB-approved retrospective review of knee MRIs and radiographs at a single pediatric institution identified 108 limbs (102 patients) meeting inclusion criteria. Sixty-nine limbs had no known patellar pathology (control group) and 39 had surgery for recurrent patellar dislocations (surgical group). MRI measures included tibial tuberosity-trochlear groove distance (TT-TG), tibial tuberosity-posterior cruciate ligament distance (TT-PCL), and lateral trochlear inclination (LTI). Radiographic measures included the Caton-Deschamps Index (CDI) and Insall-Salvati Index (ISI). These measures are representative of PFI risk factors, specifically patellar tendon malalignment, trochlear dysplasia, and patella alta. Binomial logistic regression was used to relate the anatomical parameters to the probability of PFI.

Results:

The surgical and control groups were similar in terms of age, height and weight. The logistic regression analysis indicated that the TT-TG (p=0.001) and LTI (p<0.001) were correlated with PFI. The odds ratio (95% confidence interval) was 1.19 (1.07 -1.31) for TT-TG, giving the increased probability of a knee to experience PFI for each 1 mm increase. The odds ratio was 0.85 (0.77-0.93) for LTI, showing a decrease in the probability of instability with each 1° increase. Neither CDI nor ISI measures significantly correlated with probability of PFI (p=0.30 and p=0.18, respectively). The two parameters of TT-TG and LTI accounted for 42% (Nagelkerke R2) of the variance between the control and surgical groups.

Conclusion/Significance:

Comparing pediatric patients with recurrent patellar dislocations to controls, logistic regression analysis suggests the likelihood of PFI correlates with the severity of specific radiographic measures, specifically those representing the degree of patellar tendon alignment (TT-TG) and trochlear dysplasia (LTI). Knowing this correlation can help guide the treatment of PFI in pediatric patients by providing physicians and families with a continuum on which to base their decisions.
PATELLAR FACET MORPHOLOGY IN EARLY PEDIATRIC DEVELOPMENT
Authors: Wilson Philip L. , Ellis Henry B. , Ganley Theodore J. , Green Daniel W. , Fabricant Peter D. , Yen Yi-Meng , Tompkins Marc , Mayer Stephanie W. , Shea Kevin
Published: March 2019

Background:

The relative influence of patella and trochlear shape on the development of each structure is poorly understood. Articular morphology is felt to be an important factor influencing patellar instability. The purpose of this study was to evaluate the development of patellar facets in relation to age and sulcus depth in the pediatric knee.

Methods:

Dissection of 57 immature knees (1 month – 11 years; 36 male) was performed by fellowship-trained orthopaedic surgeons. A coordinated laser scanner, and analysis software (Hexagon Romer V3 CMM; Polyworks) were used to record cartilage anatomy. Patellar facets were identified as distinct regions of surface contour. In a subset of 30 specimens (2 years – 11 years; 22 male) trochlear cartilage sulcus angles were analyzed at points on the trochlea in relation to orientation angle from the femoral axis [F90° (perpendicular to the femoral axis, correlated to the posterior condylar axial slice), F120° (30° flexion), and F150° (60° flexion)]. Spearman’s correlations and nonparametric Mann-Whitney tests were evaluated for specimen age, patellar articular surface lengths, and trochlear sulcus angles.

Results:

There was strong correlation of patellar facet development with the angle of the cartilaginous femoral sulcus at 30° of flexion (p<0.001, rs=-0.696). With deepening femoral sulcus angles (range 137°-163°), there was an increase in the number of patellar facets present. Additionally, the presence of multiple medial facets was correlated with the sulcus angle at 30° (p<0.01) (Fig. 1). In the 13 specimens with a sulcus angle < 150°, all demonstrated well-formed patella with 5-7 facets identified. Within the group including those specimens younger than 2 years old, age (p<0.001) and width of the patellar articular surface (p<0.001) were correlated with the number of facets present. Multiple facet development on the lateral side of the patella was most strongly correlated with patellar articular surface width (p<0.001). Gender and the superior-most sulcus angle (F90°) didn’t correlate with patellar morphological development. The average number of facets identified was 3.8 (+/- 1.6), and the median number present was 4 (range 0-7). The most common patellar shape was 5 facets (n=16, age range 3 months – 11 years); medial, inferior-medial, lateral, inferior-lateral, and odd.

Conclusion:

Complex patellar morphology with multiple facets present is not uncommon in early pediatric development, with patellar width and the femoral sulcus angle at 30° as correlates.

Significance:

Patellar maturation may occur early and further investigation of the relationship of patellofemoral dysplasia on the early development of the corresponding structures is warranted. [Figure: see text]
A COMPARISON OF EMERGENCY PREPAREDNESS AND MEDICAL COVERAGE BETWEEN HIGH SCHOOL AND CLUB SPORT COACHES
Authors: Post Eric G. , Schaefer Dan , Biese Kevin M. , Cadmus-Bertram Lisa , Watson Andrew , McGuine Timothy A. , Brooks Alison , Bell David
Published: March 2019

BACKGROUND:

Recent studies have demonstrated that a large population of high-school aged athletes participate on club sport teams. Studies have documented emergency preparedness and medical coverage standards in the high school athletic setting. However, similar examinations do not exist for youth club sport teams. PURPOSE: To determine if differences in emergency preparedness and medical coverage exist between high school team coaches and high school-aged club team coaches. A secondary purpose was to compare emergency training characteristics between high school and club coaches.

METHODS:

A total of 769 coaches (female N=266, 34.6%, age: 41.0±11.5 years) completed an anonymous online questionnaire regarding their emergency preparedness and training. Coaches from 3 sports were surveyed (basketball N=290, volleyball N=256, soccer N=223). The questionnaire consisted of 1) demographics and information regarding the teams that the respondent coaches, 2) emergency preparedness factors such as automated external defibrillator (AED) availability, emergency action plan (EAP) awareness, and medical coverage, and 3) emergency care training requirements (CPR, AED, first aid). Chi-square tests were used to compare response frequencies to various emergency preparedness questions between high school and club coaches.

RESULTS:

Overall, 64.6% (N=497) respondents were coaches of a high school team, and 35.4% (N=272) were coaches of a club team with high school-aged athletes. High school coaches were more likely than club coaches to be aware of the EAP for their practice venue (83.9% vs. 54.4%, p<.001), but most coaches in both categories had not practiced their EAP in the past 12 months (70.0% vs. 68.9%, p=.54). During competitions, high school coaches were more likely than club coaches to be aware of the EAP (47.5% vs. 37.1%, p=.02). However, the majority of coaches in each category reported that they were never aware of EAPs during competition. High school coaches were more likely than club coaches to 1) have an AED available at practice (87.9% vs. 58.8%, p<.001), 2), to report that athletic trainers were responsible for medical care at practices (31.2% vs. 8.8%, p<.001) and competitions (57.9% vs. 31.2%, p<.001), and 3) to be required to have CPR, AED, or first aid training (p<.001). Nearly all (98.8%) high school coaches were required to have CPR training, and overall, 58.6% of high school coaches were required to have training in all 3 categories (CPR, AED, first aid) compared to 23.9% of club coaches (p<.001).

CONCLUSIONS:

High school sport coaches displayed greater levels of emergency preparedness and training compared to coaches of high school-aged club teams. Significant attention and effort is needed to improve emergency preparedness and medical coverage at the club sports level among basketball, soccer, and volleyball coaches.
HOW DO IMAGING PRACTICES VARY ACROSS THE UNITED STATES WHEN DIAGNOSING A MEDIAL EPICONDYLE FRACTURE?
Authors: Patel Neeraj M. , Talwar Divya , Lawrence J. Todd
Published: March 2019

Background:

A number of controversies surround the evaluation of medial epicondyle fractures, including the use of advanced imaging at the time of diagnosis. In an era of increased focus on resource utilization, an analysis of diagnostic testing for this injury is timely. The purpose of this study is to evaluate national variation in diagnostic imaging for pediatric medial epicondyle fractures.

Methods:

The Pediatric Health Information System, a national database consisting of 49 children’s hospitals, was queried for all patients with a medial epicondyle fracture between 2004 and 2015. Demographic information was collected as well as data regarding diagnostic imaging at initial presentation. United States Census guidelines were used to categorize hospitals geographically into regions and divisions. Univariate analysis was followed by purposeful entry multivariate regression to control for confounders.

Results:

A total of 7799 patients underwent 9961 imaging procedures at initial presentation, of which 9627 were plain radiographs (1.2 x-rays per patient). Additionally, 286 patients (3.7%) obtained a computed tomography (CT) scan and 46 (0.6%) received magnetic resonance imaging (MRI). After controlling for confounders in a multivariate model, patients in cities with a pediatric population below 300,000 were 2.5 times more likely to undergo CT scan than in a city with over 1 million children (95% CI 1.7, 3.9; p<0.001). Geography was also predictive, with children in the Northeast at 3.1 times higher odds of receiving a CT scan (95% CI 2.2, 4.3; p<0.001). When region was further stratified into Census division, those in New England had 4.6 times higher odds of undergoing CT (95% CI 2.5, 8.7; p<0.001). Patients treated at a hospital with 300 or fewer beds were 2.6 times more likely to receive MRI than in larger hospitals (95% CI 1.2, 5.4; p=0.01). Older age was associated with higher odds of receiving a CT (p<0.001) while younger age was associated with higher likelihood of MRI (p=0.006).

Conclusions:

There is substantial variation in imaging practices across the United States when diagnosing a medial epicondyle fracture. CT scans are more likely to be ordered in smaller cities and in older children, while MRI is more likely to be obtained in smaller hospitals and in younger children. CT is ordered most frequently in the Northeast, especially in New England. Improved evidence relating to the initial evaluation of medial epicondyle fractures may help reduce the current variation in resource utilization.
MAGNETIC RESONANCE IMAGING FINDINGS ASSOCIATED WITH ULNAR COLLATERAL LIGAMENT TEARS IN ADOLESCENT BASEBALL PITCHERS
Authors: Cox Ben , Plummer Hillary , Goodrich Eric , Andrews James , Saper Michael
Published: March 2019

BACKGROUND:

The number of ulnar collateral ligament (UCL) injuries in adolescent baseball pitchers has risen over the past 2 decades with the incidence of UCL reconstructions also increasing dramatically over that time period. The Joyner-Andrews magnetic resonance imaging (MRI) classification of UCL tears has previously been described to describe the grade and location of tears, which can aid in surgical decision-making. However, the classification of UCL tears in the at-risk adolescent population has yet to fully investigated. Improving our knowledge of these injuries is crucial to help drive targeted evidence-based treatment strategies. The purpose of this study was to examine the grade and location UCL tears using the Joyner-Andrews MRI classification in a large group of adolescent baseball pitchers.

METHODS:

We reviewed 225 symptomatic adolescent (aged =19 years) male baseball pitchers with UCL injuries treated by the senior author from 2007-2016. All patients had failed conservative treatment prior to evaluation. Pitchers with a prior history of elbow surgery were excluded. Plain radiographs and MRI arthrograms were evaluated for each patient to categorize the UCL injury and associated pathology. The images were reviewed by a sports medicine-trained orthopedic surgeon. UCL tear grade and location were classified using the Joyner-Andrews classification.

RESULTS:

The mean age at the time of evaluation was 17.2 ± 1.5 years. 56% of the patients were high school athletes. The majority (59.1%) of UCL tears were high-grade partial tears (Type II). Of those 53.4% were on the humeral side (Type II H). The least common tear types were low-grade partial tears (I) and tears in more than one location (Type IV) in 1.3% and 0.9% of patients, respectively. Plain radiographs revealed 31.4% of patients had abnormal findings; calcifications and olecranon osteophytes were present in 10% and 13% of patients, respectively and more commonly occurred in patients with Type II tears.

CONCLUSIONS:

The results of this study showed that the majority of adolescent baseball pitchers (59%) sustain high-grade partial tears of the UCL. These findings suggest that effective non-reconstruction options such as platelet-rich plasma and UCL repair with internal brace augmentation could be ideal alternatives to UCL reconstruction for these young patients. The high percentage of radiographic abnormalities in these patients highlights the adaptive changes about the elbow in response to the repetitive stresses experienced by the young elbow during throwing.
IS EARLY EXCELLENT ISOKINETIC AND FUNCTIONAL TESTING FOLLOWING ACL RECONSTRUCTION IN PATIENTS WITH OPEN-PHYSES PREDICTIVE OF SUBSEQUENT ACL DISRUPTION?
Authors: Melugin Heath P. , Samuelsen Brian T. , Hevesi Mario , Levy Bruce A. , Dahm Diane L. , Hewett Timothy E. , Larson Annalise , Stuart Michael J. , Krych Aaron J. , Milbrandt Todd A.
Published: March 2019

Introduction:

It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not.

Methods:

Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively.

Results:

Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p < 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p < 0.02).

Conclusion:

Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group).

Significance:

Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.
THE EVALUATION OF SUPRATROCHLEAR OSSEOUS MORPHOLOGY: AN EPIDEMIOLOGIC STUDY
Authors: Onor Gabriel , Mason Bonnie , Farrow Lutul
Published: March 2019

Introduction:

Patellar instability can impede activities of daily life. The morphology of the femoral trochlea has significant involvement in maintaining patellofemoral joint stability. Trochlear dysplasia, or a shallow trochlear groove, has been implicated as a risk factor for recurrent patellar dislocation. A supratrochlear spur in the setting of existing trochlear dysplasia can generate further patellar instability. Trochleoplasty has been popularized by some surgeons for the treatment of recurrent patellar instability in the setting of significant trochlear dysplasia. Despite recommendation of trochleoplasty in treatment of patellar instability in the setting of trochlear dysplasia, much is unknown about the prevalence of trochlear dysplasia and supratrochlear spurs in the general population. The purpose of this study is to investigate the prevalence of supratrochlear spurs and trochlear dysplasia in the population and investigate the relationship between supratrochlear spurs and dysplastic femoral trochleae.

Methods:

This study was performed at the Cleveland Museum of Natural History, the Hamann Todd Human Osteological Collection. With over 4,000 complete human skeletons, the Hamann Todd osteological collection at the Cleveland Museum of Natural History is the largest collection of osteological specimens with documented demographic data in the Western Hemisphere. We evaluated femora from over 1,000 individuals aged 16-40 years. Each specimen was evaluated for the presence of trochlear dysplasia and supratrochlear spurs. We excluded skeletally immature specimens as well as specimens with visible signs of osteoarthritis or abnormal, bony deformity. The presence or absence of supratrochlear spurs was documented. Abnormal femoral trochleae were photographed in A/P, axial, and lateral views. The width and length of supratrochlear spurs were measured using digital calipers.

Results:

Of the 1,148 specimens studied, 135 femora from 93 individuals were found to be dysplastic. Amongst these, 9 femora with trochlear dysplasia had supratrochlear spurs. The average age of individuals with dysplastic trochleae in this study was 32.86. Of the 93 specimens identified, 24 were female (25.8%). Additionally, 52% of individuals with dysplastic trochleae were white while 48% were black.

Conclusions:

There may be an association of supratrochlear spurs with trochlear dysplasia. Though 25.8% of individuals with dysplastic trochleae were female, it is important to note that the Hamann Todd Collection as a whole is 19% female.
INCONSISTENT 6-MONTH FUNCTION AND ISOKINETIC TEST RESULTS FOLLOWING ACL RECONSTRUCTION IN A GROUP OF SKELETALLY IMMATURE PEDIATRIC PATIENTS
Authors: Samuelsen Brian T. , Melugin Heath P. , Hevesi Mario , Levy Bruce A. , Dahm Diane L. , Hewett Timothy E. , Larson Annalise , Stuart Michael J. , Krych Aaron J. , Milbrandt Todd A.
Published: March 2019

Purpose:

The goal of this study was to evaluate patient and surgical factors predictive of excellent functional and isokinetic test results 6-months following anterior cruciate ligament (ACL) reconstruction in a group of pediatric patients with open physes.

Methods:

We retrospectively reviewed the records of all patients 14 years of age or younger that underwent ACL reconstruction from 2000 to 2015. An excellent 6-month outcome was defined as greater than 85% in isokinetic strength and greater than 90% in functional tests when compared to the non-operative extremity. We then utilized univariate and multivariate statistical models to identify patient and/or surgical factors associated with excellent 6-month outcomes.

Results:

Eighty-six patients (46 male, 42 female) with open physes on preoperative radiographs were included in the study, with a mean age of 13.6 (range, 8.4-14.9), body mass index (BMI) of 22.1 (range, 15.6-36.0), Tegner activity score of 8.8 (6.0-9.0). Thirty-four patients (40%) met the criteria for the excellent 6-month group, which left 52 (60%) in the delayed 6-month group. In univariate analysis, no single preoperative factor correlated with excellent 6-month outcome. The two groups were statistically similar in terms of age, BMI, time to surgery, preoperative arc of motion, presence of concomitant meniscal tear, cartilage damage, graft size, use of a nerve block or tourniquet, operative time, and tourniquet time. Use of a nerve block trended towards delayed outcomes (p = 0.051).

Conclusion:

Children undergoing ACL reconstruction only have a 40% chance of achieving an excellent rehabilitation result at 6 months. We found no statistically significant patient or surgical characteristics that could predict this outcome. Utilizing a nerve block is a factor which will need to be further evaluated.

Significance:

Studies in the adult population have identified preoperative patient and surgical factors associated with excellent 6-month isokinetic and functional test results. This pediatric cohort did not find similar results as many of these children were young, healthy and fit. However, the variability of the outcome casts doubts on applying adult rehabilitation protocols to children.
A BIOMECHANICAL COMPARISON OF SUTURE ANCHOR VS. INTERFERENCE SCREW TECHNIQUE FOR PATELLAR FIXATION FOR MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION
Authors: Mijic Dragomi , Yokhana Sanar , Kalra Kunal
Published: March 2019

Background:

There are numerous techniques for MPFL reconstruction, however, one single technique has not been proven to be superior to another. Suture anchor reconstruction has been shown to provide stable fixation while decreasing the risk of patellar fracture. The aim of the study was to compare the stiffness and clinical load to failure of two common MPFL reconstruction techniques. Our hypothesis was that there would be no significant difference in the stiffness and the clinical load to failure between the suture anchor and interference screw reconstructions.

Methods:

Eight pairs of fresh frozen cadaveric knees were randomized into two groups undergoing MPFL reconstruction using either a suture anchor technique (n=8) or an interference screw technique (n=8). Testing was performed at 0, 30, 60, and 90 degrees of flexion for the native knee, transected medial structures, and reconstructed MPFL. Next, the reconstructed MPFL specimens were tested until failure in 0 degrees of flexion. T test, One-Way ANOVA, and repeated measures of ANOVA were used for statistical analysis, P values less than 0.05 were considered significant.

Results:

The average stiffness for the suture anchor and interference screw reconstructions was 12.02 ± 3.96 N/mm and 14.21 ± 4.20 N/mm, respectively (t test, p = 0.27), while average clinical load to failure was 256.57 ± 54.1 N and 237.81 ± 23.82 N, respectively (t test, p = 0.38). There was no significant difference in stiffness between the suture anchor and interference screw techniques at 0, 30, and 60 degrees of flexion.

Conclusions:

The suture anchor and interference screw reconstruction techniques produce comparable stiffness for sub-failure testing at 0 and 30 degrees of flexion. For testing to failure, the initial stiffness for both reconstruction techniques have been shown to be concordant with previously published values for the native MPFL. Both reconstruction techniques provide greater ultimate failure loads than those reported for the native MPFL in previous studies.

Clinical Relevance:

Suture anchor reconstruction described in our study provides another reliable option for the reconstruction of the medial patellofemoral ligament. [Figure: see text]
DIFFERENCE IN RECOVERY TIME BETWEEN GENDERS AFTER CONCUSSION
Authors: Sarkisova Natalya , Herrera-Hamilton Anita , Edison Bianca , Zaslow Tracy
Published: March 2019

Background:

Recent literature has shown that between the two sexes, females sustain concussions at a higher rate than males. However, other studies have shown that males take a longer time recover after a concussion than females. Currently, there is limited research done on gender and recovery time in adolescents. Sex is defined as a biological concept that is assigned at birth whereas gender is defined as somebody’s internal self-identification. This study aims to determine if there is a difference in recovery time between genders.

Methods:

Patients diagnosed with a concussion in our sports medicine clinic were prospectively enrolled into a mild traumatic brain injury (mTBI) repository. 300 patient charts were reviewed. Age, non-binary gender identification, date of injury, first appointment date, and clearance date (Level V) were identified. Post-concussive syndrome (PCS) was also noted. Patients were also recognized if they were lost to follow up. Level of clearance was determined by the 4th International Conference on Concussion in Sports (Zurich 2012) with the following supervised protocol: Level 4: Non-contact training drills, Level 5: Full contact training after medical clearance.

Results:

60% (180/300) of patients were cleared for return to play. 57% (171/180) of patients were cleared for a Level V and 5% (9/180) patients were cleared for a Level IV with gradual return to play. 120 (40%) patients were lost to follow up and not cleared, 60% (73/120) identified as male and 40% (47/120) identified as female. For the patients that were cleared, 67% (121/180) of patients identified as male (mean age=13 years) (range 5 to 18 years) and 33% (59/180) of patients identified as female (mean age=14 years) (range 5 to 20 years). From date of injury to recovery time, male patients were cleared on average after 62 days and female patients were cleared on average after 82 days. There was no significant difference between the two genders identified in this specific population (p=0.17). 14% of females and 15% of males were diagnosed with PCS. From date of injury to first appointment with a physician, male and female patients reported going an average 17 days post injury, with no significant difference (p=0.53).

Conclusion:

Rate of recovery time for patients that sustained a concussion showed no significant difference among genders. Further research is necessary for a comprehensive review of all genders to identify recovery time and appropriate treatment management.
PHYSEAL-SPARING DISTAL FEMORAL TROCHLEOPLASTY: A TECHNIQUE ANALYSIS IN A PEDIATRIC CADAVERIC MODEL
Authors: Wilson Philip L. , Ellis Henry B. , Tompkins Marc , Stavinoha Tyler J. , Wyatt Charles W. , Zynda Aaron J. , Mitchell Parker , Jo Chan-Hee , Shea Kevin
Published: March 2019

Background:

To describe the results and extra-physeal position of a pediatric distal femoral trochleoplasty in a pediatric cadaveric model.

Methods:

Eight pediatric cadaveric specimens (mean maturity: 7.75 years, range 4-11) were used to model a distal femoral anterolateral metaphyseal osteotomy immediately proximal to the physis. A standardized 4 mm wedge was placed at the distal end of an anterior cortical shingle; created by an osteotomy 3.25 mm below the anterior cortex (range 2.5 – 4.4), with a transverse corticotomy just proximal to the physis, and hinged 25.5 mm proximally (range 21.9-28.1). The specimens were evaluated with multi-planar micro-CT scans (0.67 mm) pre and post-osteotomy. Lateral cortical elevation, the pre and post sulcus angle of the anterior supra-trochlear metaphysis, distance from distal elevated margin of the osteotomy to the superior edge of the trochlear cartilage, and distance from the distal margin of the osteotomy to the superior edge of the physis were evaluated.

Results:

The supra-physeal trochleoplasty elevated the lateral cortex an average of 3.26 mm (range 2.8-3.9). The resultant mean angle of the supra-trochlear metaphyseal sulcus was changed by 15.25° (range 8° -21°) (p<0.001); with the central to lateral cortical angle along the anterior femoral surface changing from 173° (range 166°-178°) pre-trochleoplasty, to 157° (range 146°-166°) following the osteotomy. The magnitude of the change in angle was associated with age; with larger corrections in the younger specimens (p<0.05). The distal margin of the trochleoplasty was on average 9.56 mm (range 2.73-13.24) from the superior margin of the trochlear articular cartilage. The distance from the distal extent of the osteotomy to the superior margin of the physis was 5.54 mm (range 1.95-9.55). No fracture into the physis, or physeal deformity was demonstrated.

Conclusion:

A technique for an extra-physeal, metaphyseal, distal femoral trochleoplasty resulted in alterations to the anterior femoral cortex that may serve as deterrents to lateral patellar translation. Lateral cortical elevation immediately superior to the trochlea may serve as a guide for centralizing patellar motion during early flexion in the setting of patella alta and trochlear dysplasia that is not uncommon in pediatric lateral patellar instability. A pediatric cadaveric model demonstrated changes in close proximity to the superior entrance of the femoral trochlea, while avoiding injury to the distal femoral physis.

Significance:

A supra-trochlear, lateral metaphyseal elevating osteotomy may be feasible and merit further study as an option for the treatment of lateral patellar instability in the skeletally immature.
HEALTH-RELATED QUALITY OF LIFE FOLLOWING ADOLESCENT SPORTS-RELATED CONCUSSION OR FRACTURE: A PROSPECTIVE COHORT STUDY
Authors: Russell Kelly F. , Selci Erin , Black Brian , Ellis Michael
Published: March 2019

Background:

Sport-related concussion is a form of traumatic brain injury that often presents with a combination of symptoms that reflect disturbances in physical, cognitive, sleep, and emotional functioning. The longitudinal effects of adolescent sports-related concussion (SRC) on health-related quality of life (HRQOL) remain poorly understood. The objectives of this study were to 1) compare HRQOL outcomes among adolescents with an acute SRC or sports-related extremity fracture (SRF) who were followed until physician-documented clinical recovery and 2) to identify the clinical variables associated with worse HRQOL among adolescent SRC patients.

Methods:

We conducted a prospective cohort study of adolescents with acute isolated SRC or SRF who underwent clinical assessment within 30 days post injury and follow-up at tertiary sub-specialty clinics. Longitudinal patient-reported HRQOL was measured at initial assessment and at each follow-up appointment using the adolescent version (age 13-18) Pediatric Quality of Life Inventory generic core scale and Cognitive Functioning scale. Demographic characteristics were collected from the medical charts.

Results:

Participants in this study included 135 patients with SRC (60.0% male; mean age 14.7 years; time from injury to initial assessment 6 days) and 96 with SRF (59.4% male, mean age 14.1 years; time from injury to initial assessment 8 days). At initial assessment, SRC patients reported significantly worse cognitive, school and overall HRQOL compared to SRF patients with no differences in physical, emotional and social HRQOL. Clinical variables associated with worse HRQOL among SRC patients differed by domain but were significantly impacted by initial symptom burden and the development of delayed physician-documented clinical recovery (> 28 days post-injury). Overall, 132 (97.8%) SRC patients and all SRF patients achieved physician-documented clinical recovery during the study period. The median days until physician-documented clinical recovery for the SRC patients was 26 days (IQR: 17, 49) and this was not significantly different than SRF patients (31 days, IQR: 23, 42; p=0.12). At the time of physician-documented clinical recovery, patients with SRC did not have persistent impairments in HRQOL.

Conclusions:

Adolescent SRC is associated with temporary impairments in HRQOL that resolve in patients followed until physician-documented clinical recovery. Compared to SRF, adolescent SRC patients experience significantly greater impairments in cognitive, school, and overall HRQOL. The degree of impairment experienced by adolescent SRC patients across HRQOL domains is impacted by initial symptom burden and length of clinical recovery. Future studies are needed to identify the clinico-pathological features associated with impaired HRQOL and assess whether the initiation of multi-disciplinary targeted rehabilitation strategies lead to an improvement in HRQOL in acute SRC patients.