bluuebunny/crossref_metadata_2025 huggingface dataset:
Ethnographies and/of violence
Authors: Jones Gareth A. , Rodgers Dennis
Published: March 2019

This paper examines ethnography as both a methodological practice and a form of writing, and specifically how ethnography as a textual product may shape and be shaped by the methodological process. We argue that a critical discussion of this relationship is especially important in relation to the ethnography/ethnographies of violence. Examining a range of recent texts, we consider whether different forms of violence necessitate, or have prompted, different styles of ethnographic writing. The paper raises questions about how decisions to adopt particular styles of writing can affect the substance of empirical material, and we reflect on the use of testimonio, biography and quasi-novel, as well as issues of anonymity and composite characterisation. Finally, the paper introduces the special issue contributions from five authors, who were invited to contribute reflections on the multiple ways in which their field method has intersected with representation, textually and intellectually.
Deep learning-based automated underground cavity detection using three-dimensional ground penetrating radar
Authors: Kang Man-Sung , Kim Namgyu , Lee Jong Jae , An Yun-Kyu
Published: March 2019

Three-dimensional ground penetrating radar data are often ambiguous and complex to interpret when attempting to detect only underground cavities because ground penetrating radar reflections from various underground objects can appear like those from cavities. In this study, we tackle the issue of ambiguity by proposing a system based on deep convolutional neural networks, which is capable of autonomous underground cavity detection beneath urban roads using three-dimensional ground penetrating radar data. First, a basis pursuit-based background filtering algorithm is developed to enhance the visibility of underground objects. The deep convolutional neural network is then established and applied to automatically classify underground objects using the filtered three-dimensional ground penetrating radar data as represented by three types of images: A-, B-, and C-scans. In this study, we utilize a novel two-dimensional grid image consisting of several B- and C-scan images. Cavity, pipe, manhole, and intact features extracted from in situ three-dimensional ground penetrating radar data are used to train the convolutional neural network. The proposed technique is experimentally validated using real three-dimensional ground penetrating radar data obtained from urban roads in Seoul, South Korea.
Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis
Authors: de Cordova Pamela B. , Rogowski Jeannette , Riman Kathryn A. , McHugh Matthew D.
Published: March 2019

Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios—five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.
Research on water and fertilizer irrigation system of tea plantation
Authors: Jia Xuetao , Huang Ying , Wang Yanhua , Sun Daozong
Published: March 2019

In this article, water and fertilizer irrigation system of tea plantation was developed to ensure stable yield, quality of tea, and appropriate irrigation and fertilization. Wireless sensor network node and gateway node are designed and deployed in the tea plantation for collecting soil moisture in real time. Each of the sensor nodes was composed of a STM32F103ZET6 microprocessor and a CC2420 transceiver module. Microcontroller S3C2410X is the kernel of hardware platform in the gateway nodes. All data were transmitted by wireless sensor network. The images of the tea leaves are collected by the high-speed camera loaded onto the unmanned aerial vehicle for analysis of the tea deficiency. The monitoring system is mainly used to display the humidity information about each node, the switch status of the water pump, the battery valve, and so on. It is convenient for user to manage the tea plantation. System configuration and parameter modification can be configured through the monitoring system. The dynamic time warping algorithm is used to judge the abnormal situation of the system. Diamond deployment is used in the network, and the networking experiments were conducted comparing with random deployment. Result showed that both time delay and congestion of network increased as the network scale varied from 5, 10, and 15 to 20 nodes. The topology stabilization time gets prolonged simultaneously. Packet loss rate decreased while data transmission interval varied from 10, 20, and 30 to 40 s. Packet loss rate values in diamond deployment are lower than those in random deployment. In order to improve the accuracy of tea deficiency detection, data fusion technology was adopted. A block-based histogram is employed and similarity distance is adopted to confirm the diagnosis of absence of one or more nutrients of tea. The image information and the spectral information are acquired. The principal component factor is extracted and input into the back propagation neural network to judge the quality of the tea. The number of principal component factors of image information and spectral information is set to six and three; the overall recognition rate reached 97.8%. Therefore, the level of the system abnormality can be determined by the dynamic time warping distance. Test results indicate that it is possible to accurately determine whether tea is deficient and accurately determine whether the system data acquisition is abnormal.
Pre-procedural simulation for precision stent-assisted coiling of cerebral aneurysm
Authors: Kaneko Naoki , Minhas Arjun , Tateshima Satoshi , Colby Geoffrey P , Szeder Viktor , Hinman Jason D , Nour May , Jahan Reza , Duckwiler Gary
Published: March 2019

Artificial vascular models are emerging as a newly-inexpensive and accurate way to simulate a procedure before the treatment. Through utilization of precision three-dimensionally printed, silicone-reconstructed, patient-specific models of aneurysms, we can compare the performance of devices including stents, and accurately predict the behavior of the microcatheter and stent-assisted coiling in the aneurysm to not only reduce procedural time, but also make the procedure safer. Here we report two challenging cases of wide-necked aneurysms, which could be safely treated with stent-assisted coiling as simulated in the patient-specific aneurysm models.
Adapted particle swarm optimization algorithm–based layout design optimization of passenger car cockpit for enhancing ergonomic reliability
Authors: Liu Xin , Liu Zheng , Yu Suihuai , Gong Tiancheng
Published: March 2019

The mechanical reliability problem of passenger car cockpit facilities layout is increasingly complex and has potential and uncertain risks for human safety while the number of private cars is increasing. A new system of layout design optimization is proposed to solve this problem. First, the optimization sequences of facilities are determined using a hybrid method of multiple-attribute decision-making and entropy. Second, the degree of feeling crowded in the cockpit layout can be adjusted based on customers’ preference. Third, an adapted particle swarm optimization algorithm is proposed to solve the problem of three-dimensional layout optimization in car cockpit human–machine interface according to the ergonomic principles, and the adapted algorithm called smoothing iteration particle swarm optimization is contrasted with those of other common algorithms to demonstrate its advantages. Finally, the optimized layout is analyzed by virtual simulations and compared with the original layout to show the feasibility and effectiveness of the proposed design system. Analysis results indicate that the optimized layout by the new particle swarm optimization can make the operation easier and safer than the original one to enhance ergonomic reliability.
Post-natalizumab disease reactivation in multiple sclerosis: systematic review and meta-analysis
Authors: Prosperini Luca , Kinkel Revere P. , Miravalle Augusto A. , Iaffaldano Pietro , Fantaccini Simone
Published: March 2019

Background:

Natalizumab (NTZ) is sometimes discontinued in patients with multiple sclerosis, mainly due to concerns about the risk of progressive multifocal leukoencephalopathy. However, NTZ interruption may result in recrudescence of disease activity.

Objective:

The objective of this study was to summarize the available evidence about NTZ discontinuation and to identify which patients will experience post-NTZ disease reactivation through meta-analysis of existing literature data.

Methods:

PubMed was searched for articles reporting the effects of NTZ withdrawal in adult patients (⩾18 years) with relapsing–remitting multiple sclerosis (RRMS). Definition of disease activity following NTZ discontinuation, proportion of patients who experienced post-NTZ disease reactivation, and timing to NTZ discontinuation to disease reactivation were systematically reviewed. A generic inverse variance with random effect was used to calculate the weighted effect of patients’ clinical characteristics on the risk of post-NTZ disease reactivation, defined as the occurrence of at least one relapse.

Results:

The original search identified 205 publications. Thirty-five articles were included in the systematic review. We found a high level of heterogeneity across studies in terms of sample size (10 to 1866 patients), baseline patient characteristics, follow up (1–24 months), outcome measures (clinical and/or radiological), and definition of post-NTZ disease reactivation or rebound. Clinical relapses were observed in 9–80% of patients and peaked at 4–7 months, whereas radiological disease activity was observed in 7–87% of patients starting at 6 weeks following NTZ discontinuation. The meta-analysis of six articles, yielding a total of 1183 patients, revealed that younger age, higher number of relapses and gadolinium-enhanced lesions before treatment start, and fewer NTZ infusions were associated with increased risk for post-NTZ disease reactivation ( p ⩽ 0.05).

Conclusions:

Results from the present review and meta-analysis can help to profile patients who are at greater risk of post-NTZ disease reactivation. However, potential reporting bias and variability in selected studies should be taken into account when interpreting our data.
Signal intensity increases in dentate nucleus/globus pallidus/pulvinar on unenhanced T1WI MR images after multiple examinations with gadodiamide
Authors: Koiso Takao , Yamamoto Masaaki , Watanabe Shinya , Barfod Bierta E
Published: March 2019

Background and purpose

Elevated signal intensity (SI) in the dentate nucleus (DN), globus pallidus (GP) and pulvinar (PUL) was reportedly observed on unenhanced T1-weighted (T1WI) magnetic resonance (MR) images in patients receiving multiple enhanced MR examinations. We aimed to clarify whether this phenomenon influences the long-term neurological status of patients.

Materials and methods

We studied 196 radiosurgically treated patients undergoing ≥10 MR examinations using a single dose of gadodiamide and the same 1.5 Tesla MR unit. SI ratios were calculated by referencing the brainstem (BS) for the DN and the thalamus (TH) for the GP and PUL. We compared the SI ratios at the first, fifth, and 10th, and at the most recent examinations. The neurological symptoms of all 196 patients were assessed at each MR examination by one of the authors (MY).

Results

The DN/BS and GP/TH SI ratios were significantly increased at the fifth examination ( p < .0001, p = 0.0094) and, thereafter, gradually increased. Although the PUL/TH SI ratio was not significantly increased at the fifth examination ( p = 0.2515), a significant increase was noted at the 10th examination ( p < .0001). There were no significant predictive factors for DN/BS SI increases. Younger age, no brain metastasis, and normal estimated glomerular filtration rate were related to GP/TH SI ratio increases ( p = 0.0308, p = 0.0001, p = 0.0306). Higher age and total bilirubin level were related to an increased PUL/TH SI ratio ( p = 0.0276, p = 0.0097). No patients experienced gadodiamide-related health problems.

Conclusions

Although the SI ratios rose as numbers of gadodiamide administrations increased, no adverse health effects have developed to date.
Charles Ives’s Decoration Day: A Conductor’s Guide
Authors: Coffill Brian
Published: March 2019

Charles Ives’ Decoration Day, a dreamy haze of almost-forgotten memories and half-remembered tunes, depicts recollections American Civil War through the eyes of a Connecticut youth at the end of the nineteenth century. The work, originally published as the second movement of Ives’ New England Holidays Symphony for orchestra, is a musical representation of the composer’s childhood memories of that eponymous holiday.

This paper links Ives’ own descriptions of the composition, his childhood, and his memories of the somber annual memorial to the musical gestures in the score, synthesizing extant scholarship with practical analysis and performance experience. Through better understanding Charles’ connections to the Civil War, specifically by way of his father, the bandmaster George Ives, Decoration Day comes to life as a stirring epitaph for a boy’s long-lost hero.
Traumatic Memory of One’s Son Gone Missing in War: Content Analysis Using Krippendorff’s Alpha
Authors: Kozina Slavica , Kowalski Martin , Vlastelica Mirela , Mastelić Tonći , Borovac Josip A.
Published: March 2019

Our aim was to determine (a) how parents deal with experiences like having a son missing in war, and (b) what expectations they have in terms of outcomes. This qualitative study included 29 parents of 21 sons gone missing in war. We used content analysis singling out narrative patterns and coded these. We assessed intercoder reliability using Krippendorff’s alpha coefficient. Items passing the Krippendorff’s alpha threshold of ≥.50 were verified using Cronbach’s alpha. Three of five coders showed acceptable intercoder agreement on 23 of the 173 identified topics (13.3%; Krippendorff’s alpha: .50-.82). Cronbach’s alpha coefficient confirmed intercoder reliability of .7903. Fathers’ narratives differ from mothers’. Statistics are a valuable tool for identifying specific motifs in grieving narratives of parents who have lost their child. Content analysis can provide insights without interfering with authentic personal experience sparing interviewees from reliving the traumatizing experience.
Secondary Rhinoplasty: Aesthetic and Functional Concerns
Authors: Loghmani Shahriar , Loghmani Alireza , Maraki Fatemeh
Published: March 2019

Background:

Aesthetic and functional concerns, especially after multiple revision rhinoplasties, continue to provide a challenge even for the experienced surgeon.

Objective:

This study aimed to report the results in terms of “secondary rhinoplasty,” performed by the senior author after previous rhinoplasty.

Methods:

This descriptive prospective study was carried on 150 patients with surgical indication of secondary rhinoplasty and they were asked to fill out the questionnaire divided into 3 parts: overall epidemiological questions, questions of patients’ aesthetic and functional complaints, and objective evaluation by the surgeon. The nasal problems in the upper and middle regions were divided into high or low, broad or narrow, crooked, irregularity of nasal bridge, or other alterations. The patients included in the study had surgical programming of secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previous rhinoplasty with the same or different surgeon.

Results:

There were 136 females and 14 males with the mean age of 31.52 (6.36) years. The most common complaints were related to the nose tip with 123 cases included deviated tip and pinched (bilateral) with 25.3%, 30.7%, and 25.3%, middle nose with 78 cases included mid vault deviation, inverted V, and polly beak with 31.3%, 18%, and 9.3%, and upper nasal region with 69 cases included dorsum irregularity and wide dorsum with the rates of 22.7% and 16.7%, respectively; respiratory problem was reported in 13 cases.

Conclusion:

Unilateral or bilateral twisting at the nasal tip had the highest percentages, and the lowest incidence was in relation to the complaints of the upper nasal part.
SEX-BASED DIFFERENCES IN THE OUTCOMES OF ACL RECONSTRUCTION WITH QUADRICEPS TENDON – PATELLAR AUTOGRAFT IN ADOLESCENT PATIENTS
Authors: Gagliardi Alexia G. , Carry Patrick , Parikh Harin B. , Traver Jessica L. , Albright Jay
Published: March 2019

Background:

Female athletes suffer anterior cruciate ligament (ACL) injuries at a 2- to 10-fold greater rate than male athletes participating in the same sports. Previous research demonstrates worse patient reported outcomes and increased postoperative laxity in females with an HA autograft or BTB autograft compared to their male counterparts. Quadriceps tendon-patellar autograft has been established as a reliable graft choice for adolescent ACL reconstruction. The purpose of this study is to investigate sex-based differences in graft survival, patient reported outcomes, and joint laxity after ACL reconstruction with QPA among adolescent patients.

Methods:

All patients who underwent ACL reconstruction with QPA between November 2013 and November 2015 who were a minimum of 1-year post-operative were identified. Demographic data, surgical information, and graft failure was collected retrospectively. Subjects were then contacted by phone to administer International Knee Documentation Committee (IKDC) and Lysholm questionnaires. KT1000 arthrometer measurements were available for a subset of patients who attended a clinic follow-up appointment greater than 1 year postoperative.

Results:

The final cohort included 18 females and 20 males ages 10 to 18 years old. After adjusting for age and medial meniscus procedures, the hazard of graft failure among male athletes was 2.11 times [95% CI: 0.17 to 26.10, p = 0.5577] the hazard of failure among female athletes. No significant sex-based differences were found in time to return to sport, contralateral ACL injuries, or patient reported outcomes. KT 1000 joint laxity measurements were similar in male [median: 1 mm, IQR: 1 to 2 mm] and in female athletes [median: 1 mm, IQR: 1 to 2 mm]. After adjusting for BMI and medial meniscus procedures performed, KT1000 measurements were 8.74% higher [95% CI: 16.4% lower to 41.40% higher, p = 0.51999] in male athletes compared to female athletes.

Conclusion/Significance:

There were no differences between males and females in patient reported outcomes, post-operative laxity, or graft failure among subjects who underwent ACL reconstruction with QPA at a minimum of 1 year postoperative. The quadriceps tendon-patellar autograft is a reliable graft choice for both adolescent males and females. We will be completing further data collection in the next month and aim to consider subjects who are a minimum of 2 years postoperative.
IMPACT OF DISTAL ULNAR RESECTION AND ELBOW JOINT POSITIONS IN RELATION TO LOAD TRANSMISSION ACROSS THE RADIOCAPITELLAR JOINT
Authors: Sadwal Shivani , Shmeling Gregory , Grey Jason , Graf Alexander , Daley Roger , Wang Mei , Mason Bonnie
Published: March 2019

Introduction:

The ulna is often resected to treat injuries resulting from trauma, congenital anomalies, as well as a result of procedures for tumors and arthritis in the wrist. However, there is no literature discussing the impact of ulnar shortening on force transmission. This study looks at how force is transmitted across the radiocapitellar joint (RCJ) after varying lengths of ulnar resection.

Methods:

4 fresh-frozen cadaveric forearms (mean age 44.5 years) each with an intact elbow and distal humerus were secured onto a mounting plate, allowing for range of elbow motion to be tested: 45 degrees and 90 degrees in flexion, as well as supination, pronation, and neutral positioning of the forearm. Tests were done with varying ulnar conditions: normal intact, resected by 2 cm, resection of a quarter of the length, and resection of half of the length. Step loading was applied to a maximum of 150 N and resultant force across the RCJ was measured using a joint pressure sensor. Data from the four ulnar conditions were compared using repeated measure ANOVA with statistical significance set at p=0.05.

Results:

With the radioulnocarpal joint intact, the average force transmitted to the RCJ was 94.3±72.3 N with the elbow in 45-degree flexion and 123.6±69.3 N with 90-degree flexion and neutral pronation/supination. 45-degree supination caused a decrease in radiocapitellar force to 87.2±49.2 N and 81.7±56.2 N respectively, while 45-deree pronation increased the force to 123.2±67.5 N and 131.7±66.8 N respectively. In comparison to the control, an increase of statistical significance was found in supinated 90-degree flexion and supinated 45-degree flexion for both quarter- and half-length ulnar resections. In 45-degree flexion with neutral supination/pronation, the RCJ force was significantly higher than the intact after 2-cm ulna resection (p<0.03).

Conclusion:

This study demonstrates that with an intact ulna, 63% of applied axial force was transmitted to the RCJ when the elbow was flexed at 45, and 85% at 90 degrees. It also showed that the RCJ force transmission decreases with supination and increases with pronation. As the ulna is progressively shortened, increased force is transmitted across the RCJ, especially in elbow flexion and supination. A pronated position was observed to be protective of the RCJ.
DOES A COMBINED INTRA-ARTICULAR AND EXTRA-ARTICULAR ACL RECONSTRUCTION EFFECT EXTERNAL KNEE VALGUS MOMENT ASYMMETRY?
Authors: Zynda Aaron J. , Ellis Henry B. , Tulchin-Francis Kirsten , Anderson Anthony , Mitchell Parker , Wilson Philip L.
Published: March 2019

Introduction:

Peak external knee valgus moment can predict future ACL injury and is, often times, asymmetric following anatomic intra-articular ACL reconstruction. The purpose of this study is to evaluate the external knee valgus moment during a drop landing and a single limb squat 2 years following an iliotibial band (ITB) intra-articular and extra-articular physeal-sparing ACL reconstruction. Methods: Fourteen study subjects (mean age: 14.3 ± 2.6 yrs) who had previously undergone a physeal-sparing ACL reconstruction, as originally described by McIntosh using an ITB autograft, were enrolled in this IRB-approved study. All subjects were seen at a minimum of 24 months after surgery (mean follow-up: 55.0 ± 28.9 mos) and clinical, radiographic, and patient reported outcomes were collected. During functional testing, subjects underwent drop landing (DL) and unilateral squat (US) tasks. Isokinetic muscle strength of the hip and knee was collected using an isokinetic dynamometer at 60°/s. Paired student’s t-tests evaluated differences between affected (AFF) and unaffected (UNAFF) limbs.

Results:

During a drop landing, the AFF limb, compared to the UNAFF limb, did not demonstrate a difference in external knee valgus moment (0.50° vs. 0.51°, p=0.736). However, in the AFF limb, the mean knee peak knee valgus angle was 2.8 degrees less than the UNAFF limb during a drop landing (p=0.039). This difference was not considered within the range of a minimal clinical difference (MCD) of 5.1 degrees. Similar trends were found during a single limb squat with no significant difference seen in peak knee valgus moment between AFF and UNAFF (0.14° vs. 0.07°, p=0.150) with a statistical, yet not minimal clinical difference, in knee valgus angle at 45° squat position (-2.4° vs. 0.7°, p=0.033; MCD = 5.2). Thus, no asymmetry in peak knee valgus moment during a drop landing or a single limb squat following an ITB intra- and extra-articular ACL reconstruction was observed. In this series at 2 years’ post-op, the Pedi-IKDC and HSS Pedi-FABS were 96.54 ± 5 and 22.6 ± 5, respectively. Subjects demonstrated return to pre-operative Tegner Activity scores (8.42 vs. 8.17, p=0.33). Normalized hip abduction strength was significantly stronger in AFF (1.05 Nm/kg) vs. UNAFF (0.93 Nm/kg, p=0.02).

Conclusion:

Overall, there were no clinically significant differences, or asymmetry, in functional knee valgus in subjects following combined intra- and extra-articular iliotibial band ACL reconstruction during a drop landing or single leg squat. Young athletes can be expected to return to pre-operative activity levels and demonstrate appropriate knee valgus control following this physeal-sparing ACL reconstruction.
ARE THERE SIDE-TO-SIDE DIFFERENCES IN KNEE MORPHOLOGY IN PATIENTS WITH BILATERAL PATELLAR INSTABILITY
Authors: Parikh Shital , Rajdev Neil
Published: March 2019

Introduction

It is not known if there are side-to-side differences in knee morphology in patients with bilateral patellar instability (BPI). Such knowledge would help to answer the question whether similar treatment and prognosis could be expected for both knees in patients with BPI. The purpose of our study was to evaluate and compare anatomic / morphologic risk factors between knees in patients with BPI.

Materials and Methods

Of 294 patients who underwent surgical stabilization for patellar instability (2008-2017), 32 patients were identified who underwent staged or simultaneous bilateral surgery. This formed the study cohort. Demographic data, mechanism of initial injury and first knee side to be symptomatic were recorded. Radiographs and MRI of these 64 knees were evaluated for trochlear dysplasia (trochlear depth), patellar height (Caton-Deschamps index, Insall-Salvati ratio), patellar tilt, TT-TG distance, sulcus angle (cartilaginous and bony) and trochlear bump (cartilaginous and bony). The number and percentage of knees with pathologic values for measured risk factors were analyzed. For each risk factor, 15% side-to-side differences were considered significant. Statistical correlation was calculated between the time of presentation (first symptomatic knee) and magnitude of risk factors. All measurements were repeated after a 3-week interval and ICC was calculated to determine intraobserver reliability.

Results

The mean age of 32 patients was 14.6 years. 17/32 patients were females. 29 patients had staged surgery with mean interval of 21 months between surgeries; 3 patients had simultaneous surgery on each knee. Patients with BPI had multiple risk factors. 22/32 patients (69%) had the same Dejour type of trochlear dysplasia. For each measured risk factor, the number and percentage of patients with 15% or more side-to-side differences is shown (Table 1). There were significant side-to-side differences in patellar height ratios, TT-TG distance, and trochlear bump. The timing of presentation did not correlate with increased risk factors, i.e, the knee that presented earlier did not have increased risk factors compared to contralateral knee. ICC showed excellent intraobserver reliability.

Conclusion

There were significant side-to-side differences between knees in patients with BPI. Treatment and prognosis should be based on anatomic risk factors for each knee in patients with BPI. [Table: see text]
VITAMIN D TRENDS IN THE PEDIATRIC ORTHOPAEDIC POPULATION: A SURVEY
Authors: Williams Kevin A. , Horan Michael
Published: March 2019

Background:

Vitamin D deficiency is a global issue, affecting adults and children of all ages, races and genders. Within the last decade, multiple studies have demonstrated the potential health benefits of vitamin D supplementation including improved bone health, reduced fracture risk, protection from autoimmune disease, and decreased cancer risk. Because of the prevalence of vitamin D deficiency in pediatric populations despite recent evidence of increased vitamin D supplementation in the US, our goal is to assess the knowledge of current vitamin D recommendations among Pediatric Society of North America (POSNA) members. It is our purpose to use the data to increase awareness and understanding of vitamin D amongst all pediatric providers.

Methods:

Our survey was distributed to 1316 POSNA members via a series of 2 email requests in which they were invited to participate in the survey on the Survey Monkey website. Their participation was entirely voluntary and they agreed to participate by responding positively on the first page of the survey. The data was depersonalized and analyzed via chi square and Fisher’s exact testing.

Results:

395 responses were recorded. 9 participants opted out of the survey. 69% of participants rated their vitamin D knowledge as fair to good. 68% of participants have been in practice over ten years and represented most US geographic regions fairly equally. Most estimate that over 25% of their practice is vitamin D deficient with about a 50% compliance rate of supplementation. Over 30% of participants feel vitamin D management is mostly the role of the pediatrician, however 64% of participants discuss or check vitamin D levels in their practice for patients with repeat fractures, medical comorbidities, or nonunions most commonly.

Conclusion:

Survey participants demonstrated a wide variety of responses indicating their understanding of vitamin D testing and supplementation. Although providers estimate a high deficiency rate, many do not routinely check vitamin D. When they do check, there is no standard indication for testing or supplementation and many believe this to be the role of the pediatrician or endocrinologist. More studies are needed to provide a standardized protocol for vitamin D testing/supplementation in the pediatric orthopaedic literature.
ANATOMICAL DISSECTION AND CT IMAGING OF THE ANTERIOR CRUCIATE AND MEDIAL COLLATERAL LIGAMENT FOOTPRINT ANATOMY IN SKELETALLY IMMATURE CADAVER KNEES
Authors: Shea Kevin , Cannamela Peter C. , Dingel Aleksei , Fabricant Peter D. , Polousky John D. , Anderson Allen , Ganley Theodore J.
Published: March 2019

Background:

Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in skeletally immature patients are increasingly recognized and surgically treated. However, the relationship between the footprint anatomy and the physes are not clearly defined. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and define the footprint anatomy in relation to the physes in skeletally immature knees.

Methods:

Twenty-nine skeletally immature knees from 16 human cadaver specimens were dissected and divided into two groups: Group A (ages 2-5 years), and Group B (ages 7-11 years). Metallic markers were placed to mark the femoral and tibial attachments of the ACL and MCL. CT scans were obtained for each specimen used to measure the distance from the center of the ligament footprints to the respective distal femoral and proximal tibial physes.

Results:

Median distance from the ACL femoral epiphyseal origin to the distal femoral physis was 0.30 cm (interquartile range, 0.20 cm to 0.50 cm) and 0.70 cm (interquartile range, 0.45 cm to 0.90 cm) for Groups A and B, respectively. The median distance from the ACL epiphyseal tibial insertion to the proximal tibial physis for Groups A and B were 1.50 cm (interquartile range, 1.40 cm to 1.60 cm) and 1.80 cm (interquartile range, 1.60 cm to 1.85 cm), respectively. Median distance from the MCL femoral origin on the epiphysis to the distal femoral physis was 1.20 cm (interquartile range, 1.00 cm to 1.20 cm) and 0.85 cm (interquartile range, 0.63 cm to 1.00 cm) for Groups A and B, respectively. Median distance from the MCL insertion on the tibial metaphysis to the tibial physis was 3.05 cm (interquartile range, 2.63 cm to 3.30 cm) and 4.80 cm (interquartile range, 3.90 cm to 5.10 cm) for Groups A and B, respectively.

Conclusion:

Surgical reconstruction is a common treatment for ACL injury, and occasionally MCL reconstruction or repair is also required. Cadaveric dissection and CT scanning of exceptionally rare pediatric tissue clearly defines the location of the ACL and MCL with respect to the femoral and tibial physes, and may guide surgeons for physeal respecting procedures for both ACL reconstruction, and ACL repair procedures. Clinical Relevance: In addition to ACL reconstruction, recent basic science and clinical research suggest that ACL repair may be more commonly performed in the future. MCL repair and reconstruction is also occasionally required in skeletally immature patients. This information may be useful to help surgeons avoid or minimize physeal injury during ACL/MCL reconstructions and/or repair in skeletally immature patients. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]
BODY IMAGE AND ITS ROLE IN YOUTH SPORTS PARTICIPATION
Authors: Davelaar Cassidy Foley
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]
DEFINING A SAFE ZONE FOR ALL INSIDE LATERAL MENISCUS REPAIRS IN PEDIATRIC PATIENTS: A MAGNETIC RESONANCE IMAGING STUDY
Authors: Beck Jennifer , Shifflett Kendall , Greg Danielle , Ebramzadeh Edward , Bowen Richard E.
Published: March 2019

Purpose

All-inside posterior horn lateral meniscal (PHLM) repair puts the popliteal neurovascular bundle (PVNB) at risk of injury by meniscal repair devices. The purpose of this study was to establish a safe zone of all-inside meniscal fixation in pediatric patients using MRI measurements between the popliteus tendon (PT) and popliteal neurovascular bundle (PNVB). We hypothesize that males and older age groups will have a larger distance between PT and PNVB.

Methods

Axial MRIs of 250 pediatric (5-16 yrs.) patients were retrospectively reviewed. Patients were grouped by age: group I (5-7yrs.): 61; II (8-10yrs.): 59; III (11-13yrs.): 60; IV (14-16yrs.): 70. At the level of the lateral meniscus, two lines starting at the lateral patella tendon border ending at the medial edge of the PT (D1) and the lateral edge of the PNVB (D2) were made on an axial knee MRI. D3 connected D1 to D2 at the meniscocapsular junction of the PHLM. D4 was derived geometrically, parallel and 8 mm anterior to D3 simulating the anterior edge of the PHLM.

Results

Analysis showed significant correlation between age and sex for D3 (p<0.0001). For D3, there were significant differences among all age groups, except between groups III and IV. Average (STD) D3 for age groups was: 14.1mm(3.1), 15.8(2.5), 17.0(3.3), 17.2(3.1). For D4, the average (STD) was: 11.9 mm(2.9); 13.9(2.5); 15.4(3.0); 15.2(2.9). There was significant difference in D3 and D4 in males versus females (17.6 vs 15.7 mm; p <0.001; 14.9 vs 13.2; p <0.001), particularly in III and IV (17.0 vs 13.8 and 16.8 vs 13.9).

Conclusions

This study provides normative data of the distance between popliteal neurovascular bundle and popliteus tendon at the meniscocapsular junction (D3) and anterior edge of the posterior horn lateral meniscus (D4) with the knee in full extension. Combined with previous studies showing the addition of knee flexion increases the distance between the meniscus and the neurovascular bundle, surgeons can use this data to improve safety of posterior horn lateral meniscus repair in pediatric patients.
CONTINUED CLAVICULAR GROWTH DURING ADOLESCENCE AND EARLY ADULTHOOD
Authors: Hughes Jessica , Newton Peter , Bastrom Tracey , Pennock Andrew
Published: March 2019

Background:

As more adults undergo surgical fixation of clavicle fractures, there is a renewed interest in the management of adolescent fractures. While the medial clavicular physis does not fuse until 23-25 years, literature reports limited residual growth of the clavicle during adolescence. The aim of this study is to evaluate the longitudinal clavicular growth on serial thoracic radiographs in adolescents and young adults.

Methods:

A review was performed on two cohorts of patients: 1. Scheuermann’s Kyphosis patients and 2. A prospectively collected adolescent idiopathic scoliosis registry. Patients, 10-25yrs old, were included if they had serial thoracic radiographs over 5 years with at least 3 serial radiographs capturing the entire length of at least one clavicle. Radiographs were excluded for malrotation. Known surgical implant dimensions were utilized to normalize measurements. The measurements were organized into 3 groups: 12-15yrs, 16-19yrs and =20yrs. The overall growth, the growth per year and the growth percentage per year were calculated for each clavicle.

Results:

Fifty-seven patients met the inclusion criteria (22 males and 35 female). For male patients, age 12-15yrs, the clavicular growth was 5.2 mm/yr and 4.2%/yr, age 16-19yrs: 3.0 mm/yr or 2.3%/yr and for ages 20-25yrs: 1.7mm/yr or 1.4%/yr. For female patients, 12-15yrs, there was 4.6mm/yr and 3.9%/yr, 16-19yrs: 2.0mm/yr or 1.6%/yr, and for age 20-25yrs: 0.8mm/yr or 0.6%/yr. We were unable to detect an age of terminal growth for either gender because residual growth was still ongoing in most patients of the oldest group.

Conclusion/Significance:

This study suggests that there is continued growth potential of the clavicle after the age of 18yrs and as such more remodeling potential during adolescence than may have otherwise been appreciated. It is unclear how this data will influence surgical decision making in clavicle fracture treatment.
THE DISCRIMINATE ABILITY OF THE PEDIATRIC ADOLESCENT SHOULDER SURVEY (PASS)
Authors: Bastrom Tracey , Pennock Andrew , Edmonds Eric W.
Published: March 2019

Purpose:

The purpose of this study was to examine whether improvements in the Pediatric and Adolescent Shoulder Survey (PASS) are seen at 3 months following surgical treatment for shoulder instability and whether the PASS can discriminate between patients with differing outcomes based on clinical exam and the single assessment numeric evaluation (SANE). Performance of the PASS was contrasted with an adult validated tool, the quickDASH.

Methods:

Patients who underwent surgical treatment for shoulder instability with completed PASS forms available at pre-operative and 3 months post-operative (range 2.5-4.5mos) were included in this review. The PASS consists of 13 questions that assess (in child friendly language) symptoms, limitations, need for compensatory mechanisms, and emotional distress related to shoulder dysfunction. Responses are on a 0-5 or 0-10 scale with a score calculation based on percentage of total possible points (100% indicates no/minimal impact on quality of life from shoulder dysfunction). Patients were grouped based on range of motion or strength (within 10 degrees to contralateral extremity or no discrepancy in strength score was considered no deficit) and SANE score (=80% vs <80%) at the 3-month visit. Alpha was set at p<0.05 to declare significance.

Results:

50 patients with a mean age of 16 years (range 13.5-18 yrs) were identified in this review with a mean post-operative follow-up of 3.2 ± 0.5 months. Scores on the PASS improved significantly from pre-operative (57 ± 16%) to post-operative (74 ± 16%, p<0.001). The quickDASH similarly showed improvement (27 ± 16 pre vs 18 ± 16 post, p=0.003) although the magnitude of the effect for the PASS was larger (f=0.84 for PASS vs f=0.48 for quickDASH). Ceiling effect (>15% reporting the highest score) was observed at 3 months with the quickDASH (16% with top score), but not with the PASS (4%, p=0.03). While both tools were able to discriminate between patients with SANE score =80% vs <80%, the difference in quickDASH score between patients with/without diminished motion did not reach significance (p=0.07, Table).

Conclusion:

The PASS shows anticipated improvements in shoulder function following surgical intervention for instability without ceiling effects. The PASS is able to discriminate between patients with differing post-operative outcomes at 3 months following surgery. [Table: see text]
TIBIAL TUBERCLE FRACTURES IN CHILDREN AND ADOLESCENTS
Authors: Haber Daniel B. , Tepolt Frances , McClincy Michael , Kalish Leslie , Kocher Mininder S.
Published: March 2019

Background:

Tibial tubercle fractures are uncommon sports related injuries. Only small series are reported in the literature. The purpose of this study is to report patient characteristics, fracture types, treatment methods, and clinical outcomes of children and adolescents treated for tibial tubercle fractures.

Methods:

Patients age 18 and under treated for tibial tubercle fractures at a single institution from 1995 to 2015 were identified and their medical records were retrospectively reviewed. Clinical and radiographic outcomes were reported for patients with minimum follow up of 6 months.

Results:

Two-hundred thirty-six tibial tubercle fractures were identified in 228 patients, 198 (86%) of whom were males. Mean age was 14.3 years (range 7.7-17.6). Mean body mass index (BMI) was 25.0 (range 16.1-38.9). Osgood-Schlatter disease was identified in 72 (31%) cases and was most commonly associated with type I fractures (p<0.001). Two-hundred and three fractures (86%) occurred while participating in athletics, most commonly basketball (87, 43%). Thirty percent of fractures occurred while landing, 26% resulted from a direct blow to the leg, and 22% occurred while jumping. Type III fractures were most common (96, 41%) followed by type I fractures (67, 29%). Initial treatment was surgical for 157 (67%) fractures. Type I fractures were most commonly treated non-operatively (91%) and types II-V fractures were most commonly treated surgically (89%, p<0.001). Operative fractures were associated with higher BMI z-scores (mean 1.16, p=0.05) than those treated non-operatively. Compartment syndrome was identified in 4 (2%) patients, 3 of which were had type IV fractures. Eighty-eight percent of patients returned to sports. Among those treated operatively, 55% had hardware removed and 7% developed post-operative infection. At last follow up, 45% of surgical patients reported pain on palpation at the tibial tubercle and 26% reported pain with squatting.

Conclusions:

Tibial tubercle fractures are sports related injuries and occur most commonly in adolescent males. They are associated with Osgood-Schlatter disease, a higher than average BMI, and a small but relevant risk of compartment syndrome, particularly in type IV fractures. Whether treated surgically or non-surgically, most patients return to sports despite a high incidence of post-treatment pain at the tibial tubercle.