bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Management of Patellofemoral Instability in Adolescents with High Grade Trochlear Dysplasia
Authors: Wilson Benjamin R. , Nunally Kianna D. , Cook Danielle L. , Hussain Zaamin B. , Zheng Evan T. , Yen Yi-Meng , Kramer Dennis E. , Micheli Lyle J. , Kocher Mininder S. , Heyworth Benton E.
Published: May 2022

Background:

High-grade trochlear dysplasia (HGTD) has previously been identified as a risk factor for failure of surgical management of patellofemoral instability (PFI). However, limited data exists on the influence of the type of surgical procedure performed on postoperative outcomes in these patients.

Hypothesis/Purpose:

The purpose of this study was to identify the rates of failure of primary PFI surgery in patients with HGTD compared to those without HGTD and to assess the effect of the type of surgery on recurrent instability and return to OR.

Methods:

A retrospective review was performed on patients aged ≤19 years who underwent primary surgery for PFI at a single tertiary care center between 2008 and 2017. Patients underwent procedures including medial retinacular plication/reefing/advancement (MRP), graft-based medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy with or without MRP (TTO), or combined MPFLR + TTO. Exclusion criteria were BMI >30kg/m2, surgery for fixation of chondral fractures >1cm, and diagnosis of a syndromic disorder. Trochlear dysplasia was evaluated based on pre-operative MRI according to the Dejour classification system. Those with Dejour grade B or higher were designated as having HGTD. Comparisons were made between HGTD patients and non-HGTD patients, with logistic regression utilized to determine if surgery type was associated with recurrent PFI and revision PFI surgery.

Results:

303 patients (mean age 15.1 years, 71% female) underwent primary surgical stabilization for PFI with median follow up time of 3.0 years. Approximately half (149/303, 49%) of the cohort had HGTD. Demographics were comparable between HGTD and non-HGTD patients (Table 1). HGTD and non-HGTD cohorts showed similar rates of post-operative instability, revision PFI surgery, and non-PFI secondary surgery. HGTD patients (Table 2) who underwent MPFLR had a 63% decrease in the odds of post-operative PFI compared to those who underwent MRP (OR=0.37; p=0.03). HGTD patients who underwent TTO had an 80% decrease in the odds of post-operative PFI compared to patients undergoing MRP (OR=0.20; p=0.002).

Conclusion:

Adolescents with PFI and HGTD have similar results after surgical stabilization to those patients without HGTD. Within the HGTD cohort, however, the type of surgery performed significantly influenced outcome. Patients with HGTD that underwent MRP had significantly more recurrent PFI and revision PFI surgery than patients that underwent other procedures, suggesting a limited role for this procedure in this sub-population of PFI patients. [Table: see text][Table: see text]
The Effects of Blood Flow Restriction Training on Strength and Function During Early Rehabilitation After Anterior Cruciate Ligament Reconstruction in Adolescents
Authors: Giampetruzzi Nicholas , Fredericks Arthur , Roman Dylan , Prue Jennifer , Lolic Adel , Pace Lee , Crepeau Allison , Weaver Adam
Published: May 2022

Background:

Blood flow restriction training (BFRT) has gained popularity due to reported benefits in reducing muscle atrophy and mitigating strength deficits following anterior cruciate ligament reconstruction (ACLR). While there are a number studies that have reported on the use of BFRT in the adult population, there is limited information about the use of BFRT in the adolescent population and its effect on muscle strength and function.

Hypothesis/purpose:

The purpose of this study was to determine the effect of adding BFRT to traditional rehabilitation in the adolescent population after ACLR. This study’s primary aim was to investigate the impact BFRT has on isometric strength testing and patient reported function at 3 months post-operatively.

Methods:

A prospective intervention group was compared to an age matched retrospective control group as part of an ongoing clinical trial. This included patients between 12 and 18 years of age, who underwent primary ACLR at Connecticut Children’s from January 2020 to present. In addition to a standardized rehabilitation protocol these patients utilized a personalized tourniquet system for BFRT with limb occlusion pressure of 80%. A standardized BFRT protocol was followed over initial 12 weeks, completing 3 BFRT exercises per session. Load progression was based on the patient’s perceived level of exertion. A three month strength assessment was completed by patients in both groups. The test included isometric knee extension and flexion strength at 60° of knee flexion. Peak torque was normalized to body weight and used to calculate limb symmetry index (LSI). IKDC scores were recorded. Two-sample t tests were used to determine differences between the BFRT and control groups.

Results:

The BFRT group consisted of 11 patients (6 females; 14.9 ± 1.8 years old). The control group consisted of 47 patients (24 females; 15.2 ± 0.6 years old). Age, height, and weight were not significantly different between groups (Table 1). Significant differences were seen between the BFRT and control groups for peak knee extensor torque when normalized to body weight in both the surgical (1.8 ± 0.4 vs 1.4 ± 0.6 Nm/kg, p=0.02) and nonsurgical limbs (2.7 ± 0.6 vs 2.1 ± 0.5 Nm/kg, p=0.03) (Table 2). No significant differences were seen between groups for knee extensor or flexor LSI or IKDC scores (Table 2).

Conclusions:

In adolescents, BFRT may impact bilateral knee extensor force production during early post-operative ACLR rehabilitation. Continued investigation is needed to further evaluate the impact of BFRT in this population. [Table: see text][Table: see text]
Rotator Cuff Injury in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Treatment Center
Authors: Harwood Kathleen , Oganezova Karina , Orellana Kevin J. , Ashe Katherine , Williams Brendan A. , Horneff J. Gabe
Published: May 2022

Background:

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of traumatic and overuse injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce leading to management derived largely from adult-based evidence. Greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to guide clinical decision-making.

Purpose:

To identify pediatric patients with MRI-confirmed RCI treated at a single center in order to summarize injury characteristics, treatment and outcomes.

Methods:

A retrospective review of pediatric patients (<18yo) diagnosed with and treated for a RCI between 1/1/2011 and 1/31/2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was also used to compare operatively and nonoperatively treated cohorts.

Results:

Fifty-two pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Table 1.1 details injury characteristics, treatment modalities, and patient outcomes overall and each treatment cohort. Mean age was 14.9yo (10-17) and 67% of patients were male. Injuries were most commonly related to participation in the throwing sports (baseball, football, and softball). Operative management was employed in 23% of patients while 77% were managed nonoperatively. Treatment cohorts differed based on tear type with all complete tears being managed operatively (p<0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. One operative patient experienced a retear. Return to play was longer for operatively managed patients (7.1 vs. 4.5 months, p<0.01).

Conclusion:

The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated sports and typically involve the supraspinatus tendon. RCIs are not restricted to skeletally mature patients and are frequently associated with other shoulder pathology. RCIs were associated with good outcomes and low rates of reinjury in patients managed both non-operative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients. The optimal treatment strategy for each tear type remains uncertain, but outcomes appear favorable for patients overall. [Table: see text]
Variability Exists in Pain Management Practices for Pediatric ACL Reconstruction
Authors: Wagner K. John , Beck Jennifer J. , Carsen Sasha , Crepeau Allison E. , Cruz Aristides I. , Ellis Henry B. , Mayer Stephanie W. , Niu Emily , Pennock Andrew T. , Stinson Zachary S. , VandenBerg Curtis , Ellington Matthew D.
Published: May 2022

Background:

Effective pain management for anterior cruciate ligament (ACL) reconstruction may improve both patient satisfaction and function. However, there is limited data supporting clear guidelines regarding pain management for ACL reconstruction in the pediatric population.

Hypothesis/Purpose:

The purpose of this study is to survey current pain management practices for ACL reconstruction among pediatric orthopaedic surgeons.

Methods:

A cross-sectional survey study was conducted in which orthopaedic surgeons were asked about their pain management practices for pediatric ACL reconstruction. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America (POSNA). Inclusion criteria were performs ACL repair or reconstruction on patients under age eighteen and willing to participate in the survey. Responses were anonymous and consisted of demographics, training, current practice, and pain management strategies. Survey data were assessed using descriptive statistics, Pearson’s chi-squared test and Fisher’s exact test for categorical variables, and two-sample t-test for continuous variables.

Results:

There were 77 responses, of which 64 fit the inclusion criteria. The average age of respondents was 48.9 years, 84.4% were male, and 31.3% practiced in the southern region of the US (Table 1). 39.1% of respondents utilized preemptive analgesia, 90.6% utilized perioperative blocks, 82.8% routinely advocated for scheduled non-narcotic medications post-operatively, and 93.8% recommended cryotherapy post-operatively (Table 2). Respondents that reported not using a peri-operative block and not advocating for scheduled non-narcotic pain management post-operatively were older on average than those that did (57.6 vs. 47.7 years, p=0.04; 56.7 vs. 47.0 years, p<0.01; respectively). Acetaminophen was the most commonly used pre-operative medication (31.3%), the most common perioperative block was an adductor canal block (73.4%), and the most typically prescribed post-operative analgesic medication was ibuprofen (60.9%). Most respondents reported prescribing 10-20 opioid pills (46.9%), 20.3% prescribed >20 opioid pills, and 10.9% did not prescribe opioid pain medication at all. In total, 89.1% of respondents reported prescribing opioid pain medication post-operatively, however, only 59.4% reported counseling patients on appropriate disposal of extra pills. Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.

Conclusion:

Significant variability exists in pain management practices in pediatric ACL reconstruction. There is a need for more evidence-based practice guidelines regarding pain management. [Table: see text][Table: see text]
The Effect of A Home Exercise Program on Visio-Vestibular Function in Concussed Pediatric Patients
Authors: Roby Patricia R. , Storey Eileen P. , Master Christina L. , Arbogast Kristy B.
Published: May 2022

Background:

A home exercise program (HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. It is unclear if pediatric patients prescribed a HEP demonstrate improved visio-vestibular function.

Purpose:

To explore if a HEP affects visio-vestibular function in concussed pediatric patients.

Methods:

This observational study included 1,041 patients (614 female(59.0%); age=14.0±2.5 years) reporting to a specialty care concussion center for an initial visit within 28 days of injury and a first follow-up visit within 60 days of injury. All patients completed a Visio-Vestibular Examination (VVE) at both time points, which consisted of 9 maneuvers: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Patients were given a HEP at initial visit which consisted of exercises, including saccades, gaze stability, convergence, and balance, and instructed to complete these exercises 1-2 times daily. At follow-up, patients were asked to report their progress with the HEP, which was categorized as 1) has not done the HEP, 2) is currently doing the HEP, or 3) has completed the HEP. Primary outcomes included HEP status at first follow-up, VVE subtests (normal/abnormal), and total VVE (abnormal=2+ abnormal subtests). Separate chi-square tests with Bonferroni corrections were used to determine if the proportion of abnormal VVE outcomes was associated with HEP status (α=0.017 a priori).

Results:

At initial visit, 812 (77.6%) patients presented with abnormal total VVE. The proportion of abnormal subtests at initial visit ranged from 16.0% (right monocular accommodation) to 77.4% (horizontal gaze stability). At first follow-up, the proportion of abnormal total VVE did not differ among patients reporting not doing the HEP (101(62.0%)), patients currently doing the HEP (516(69.0%)), and patients who had completed the HEP (51(69.0%)). However among VVE subtests, a lower proportion of patients who completed the HEP presented with abnormal smooth pursuit (7.5%), horizontal (3.8%) and vertical (3.8%) saccades, and complex tandem gait (0%) relative to patients who were currently doing the HEP (P≤0.003) and to patients not doing the HEP (P≤0.01).

Conclusions:

Our findings indicate that patients who completed the HEP presented with better aspects of visio-vestibular function (smooth pursuit, saccades, and complex tandem gait) relative to those who did not start or were currently doing the HEP. This suggests that a HEP may be effective in reducing visio-vestibular dysfunction following concussion. Additional research investigating cost-effective concussion management tools is needed to improve patient outcomes.
Spre-Pubertal Runners Demonstrate Different Temporal-Spatial Parameters Than Mid- and Post-Pubertal Runners
Authors: Garcia Micah C. , Jordan Emily A. , Vollmar Brittany , Bazett-Jones David M.
Published: May 2022

Background:

Temporal-spatial parameters (TSPs; e.g., cadence, step length) have been associated with running-related injuries in adult long-distance runners. However, it is unknown if TSPs are different among adolescent runners of different physical maturation stages. During sprinting, pre-pubertal runners demonstrated lower cadence and shorter step length than mid- and post-pubertal runners, but TSPs have not been investigated for adolescents of different physical maturation stages when running at submaximal speeds.

Hypothesis/Purpose:

The purpose of this study was to compare TSPs among adolescent long-distance runners of different physical maturation stages. It was expected that pre-pubertal runners would demonstrate a lower cadence and shorter step length than mid- and post-pubertal runners but there would be no differences in TSPs between mid- and post-pubertal runners.

Methods:

The study was a cross-sectional design with 93 adolescent long-distance runners (F=48, M=45). Participants were categorized into pre- (n=15, age=10.3±1.6 y), mid- (n=35, age=13.0±1.1 y), and post-pubertal (n=43, age=16.4±1.2 y) physical maturation groups. Participants underwent a three-dimensional running analysis at a comfortable self-selected speed. TSPs (cadence [steps/min], step length [m]) were compared among physical maturation groups using one-way ANCOVA (covariate=running speed) with Sidak pairwise comparisons when a main effect was found (P<.05).

Results:

The average running speeds for pre-, mid-, and post-pubertal runners were 3.36±0.51 m/s, 3.49±0.71 m/s, and 3.79±0.69 m/s, respectively. ANCOVA analysis showed significant differences in cadence (P<.001) and stride length (P<.001) among physical maturation groups when controlling for running speed (Table 1.1). Pre-pubertal runners had a greater cadence (178±13 steps/min) than mid- (169±12 steps/min, P=.01) and post-pubertal runners (168±11 steps/min, P<.001). Pre-pubertal runners also had a shorter step length (1.13±0.20 m) than mid- (1.24±0.20 m, P=.01) and post-pubertal runners (1.36±0.21 m, P<.001). There were no significant differences between mid- and post-pubertal runners (P>.22).

Conclusion:

When controlling for running speed, pre-pubertal runners demonstrated a greater cadence and shorter step length than both mid- and post-pubertal runners. Lower cadence and longer stride lengths have been associated with running-related injuries in adults. If TSPs have the same association with injury in adolescents as adults, then our study suggest mid- and post-pubertal runners may be at a higher risk of sustaining a running-related injury than pre-pubertal runners due to their lower cadence and longer step lengths. However, prospective research is necessary to better understand the importance of TSPs and running-related injuries in adolescent long-distance runners. [Table: see text]
Does Shortening Change in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures?
Authors: Perkins Crystal A , Nepple Jeffrey J ,   FACTS Study Group, Heyworth Benton E
Published: May 2022

Background:

Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment in clavicle fractures. However, the degree to which shortening may actually change in the weeks following injury has not been well studied.

Purpose:

The purpose of this study was to evaluate the potential change in shortening of adolescent clavicle fractures in the first 2 weeks following injury.

Methods:

This was an IRB-approved multi-center study of prospectively collected data which was acquired as a part of a larger cohort study evaluating functional outcomes of adolescent clavicle fractures. A consecutive series of patients ages 10 – 18 years of age with completely displaced diaphyseal clavicle fractures with a baseline AP clavicle radiograph (0-6 days from date of injury) and a follow-up AP clavicle radiograph (7 – 21 days from date of injury) were included. Measurements of end-to-end clavicle shortening were performed with validated techniques.

Results:

142 patients met inclusion criteria. Baseline radiographs were obtained at a mean of 1 day +/- 1.7 days following injury. Mean baseline shortening was 22.3mm +/- 0.6mm. 69% of patients had >/= 20mm of shortening. Follow-up radiographs were obtained at a mean of 13.8 days +/- 3.8 days post-injury and demonstrated a mean change in shortening of 5.4mm, compared to baseline films. 41% of patients had >5mm of change in shortening and 15% of patients had >10mm change in shortening. Using a threshold shortening of 20mm, 26% of patients had a change from baseline to follow-up from either above to below 20mm or below to above 20mm. This includes 28% of patients with 20-25mm of shortening at baseline that were less than 20mm at follow-up.

Conclusion:

Significant changes in fracture shortening occur in many adolescents with completely displaced clavicle fracture in the first 3 weeks. More than a quarter of patients demonstrated a drop from above to below 20mm, a commonly used threshold for surgical decision making. While there is minimal evidence to suggest that shortening influences outcomes following this fracture in adolescent sub-populations, the findings of this study support repeat radiographic assessment 2-3 weeks post-injury prior to making definitive treatment decisions.
Quantifying the Relationship Between the Medial Patellofemoral Complex and Patellar Borders: A Pediatric Cadaveric Study
Authors: Baskar Danika , Stavinoha Tyler , Rohde Matthew , Tompkins Marc , Ganley Theodore J. , Ellis Henry B. , Wilson Philip L. , Green Daniel W. , Segovia Nicole , Shea Kevin G.
Published: May 2022

Background:

The medial patellofemoral complex (MPFC) is comprised of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The anatomy of the pediatric MPFL has been well-described, however, the MPFC in skeletally immature patients and its relationship to the quadriceps tendon and superior patellar border has yet to be described.

Purpose:

To evaluate the relationship between the MPFC attachment and quadriceps tendon and patella in skeletally immature patients.

Methods:

16 pediatric knees were dissected to analyze the MPFC insertion on the quadriceps tendon. Dissection was performed using a lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate the MPFC fibers from its undersurface. The patellar articular length (PL), patellar width, and quadriceps tendon attachment (QTA) of the MPFC above the superior pole of the patella were measured using the ImageJ program. Additionally, the ratio of quadriceps tendon attachment to patellar length was calculated as a percent (QTA/PL%). Two sample t-tests were used to identify significant differences.

Results:

The average age of the specimens included in this study was 9.6 years. Specimens were divided into two cohorts: a younger cohort (4-8 years), and an older cohort (9-12 years). The QTA above the patella averaged 10.6 mm in the younger cohort and 13.4 mm in the older cohort with no significant difference between the two groups (Figure 1). There was no significant difference in average QTA/PL% which was found to be 47.8% and 48% for the younger and older cohorts respectively (Figure 1). PL was significantly longer in the older cohort (Figure 1). As shown in Figure 2, the insertion of the proximal MPFC into the quadriceps tendon can be variable across specimens.

Conclusion:

This study clarifies the anatomy of the pediatric MPFC in exceptionally rare pediatric specimens. The MQTFL relationship to the quadriceps tendon is important to guide surgical reconstructions of the medial stabilizers of the patellofemoral joint. Primary and recurrent patella instability remains a significant problem in those under 20 years. A better understanding of the MPFC (both the MQTFL and MPFL components) will support anatomic reconstructions to stabilize the joint. [Figure: see text][Figure: see text]
Quantifying Knee Strength Deficits and Muscular Contribution to Torque Generation in ACL-Injured Adolescents Using A Simple Musculoskeletal Model
Authors: Flaxman Teresa E. , Romanchuk Nicholas , Shourijeh Mohammad S. , Carsen Sasha , Bel Michael Del , Benoit Daniel L.
Published: May 2022

Background:

Surface electromyography (sEMG) is commonly used to elucidate the effect of anterior cruciate ligament (ACL) injury on neuromuscular function. To facilitate comparisons, sEMG is normalized to a known value, such as peak activation during a maximum voluntary isometric contraction (MVIC). However, voluntary muscle inhibition after an injury compromises one’s ability to achieve a true MVIC value. Musculoskeletal modeling can be used to quantify this strength deficit by comparing a theoretical MVIC torque to the actual MVIC torque.

Purpose:

This study sought to evaluate voluntary knee extensor and flexor strength deficits and individual muscle contribution to peak torque generation in ACL injured (ACLi) and uninjured (CON) adolescent populations using a simplified subject-specific modeling framework.

Methods:

Thirty-nine ACLi (25 females) and 39 CON (25 females) adolescents (12-17years) completed knee extension and flexion MVICs on an isokinetic dynamometer. Peak experimental torque (TE) was identified. A subject-specific modeling framework used normalized sEMG of the quadriceps, hamstrings, and gastrocnemius muscles to determine theoretically ideal torque (TI) for each exercise, assuming agonist muscles were fully activated. Strength deficit ratios (TE/TI) and individual muscle contribution to TE were computed. Group mean differences were compared using independent t-tests.

Results:

ACLi demonstrated significantly lower extension (2.53±0.94 vs 3.07±0.57Nm/kg, p<0.001) and flexion (1.14±0.50 vs 1.37±0.31Nm/kg, p<0.001) peak TE compared to CON (FIG 1.A). Significant between group differences in sEMG of antagonist muscles were observed. Both groups demonstrated similar TI values (FIG 1.B-upper). Significantly lower trends in strength ratios (TE/TI) were maintained between groups (FIG 1.B-lower). However, percent between group differences were minimized from 17.8% to 6.3% for knee extension, and 16.7% to 10.0% for knee flexion, when TE is expressed relative to TI. Significantly lower medical gastrocnemius contribution to flexion TE was also observed in the ACLi (24.7±0.08%) compared to CON (30.9±10.1%, p=0.037).

Conclusion:

Significant between group differences in peak extensor or flexor torques were observed. Our model confirmed a strength deficit in ACLi compared to CON, however, between group differences were less prominent when described relative to TI. This may be attributed to between group differences in antagonist contributions (i.e. co-contraction) during MVIC exercise. Simplified modeling frameworks that can incorporate muscle activations as well as torque generation may be more appropriate for evaluating functional outcomes of ACLi populations in a clinical setting. [Figure: see text]
The Association Between Physical Competence and Psychological Response Among Young Athletes Following ACL Reconstruction
Authors: Zwolski Christin M. , Paterno Mark V. , Thomas Staci , Hand Brittany , Goodway Jackie , Quatman-Yates Catherine , Schmitt Laura C.
Published: May 2022

Background:

The traditional index of return to sport (RTS) readiness following anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical for successful RTS among young athletes.

Hypothesis/Purpose:

The purpose of this study was to test the hypothesis that young athletes with higher actual and perceived physical competence will demonstrate a more positive psychological response at time of RTS after ACLR.

Methods:

Thirty-eight athletes (median age=16.9 years [IQR: 16.1, 18.8]) following primary ACLR completed testing within 8 weeks of medical clearance to RTS. All participants completed isokinetic knee extension strength (180°/s) and single-limb crossover hop for distance, in addition to the Knee injury and Osteoarthritis Outcome Score (KOOS), Self-Perception Profile Athletic Competence, and ACL Return to Sport after Injury (ACL-RSI) questionnaires. Criteria for the achievement of actual (APC) and perceived physical competence (PPC) were operationally defined based on established age- and activity-relevant cutoff scores (Table 1). Psychological response was assessed with ACL-RSI overall score, in addition to each ACL-RSI subscale score (Emotions, Confidence, Risk Appraisal). Multiple linear regression analyses were used to determine differences in ACL-RSI scores based on achievement of APC and PPC, while adjusting for age and sex.

Results:

Of the 38 participants, 9 (23.7%) were able to meet all criteria for High APC, while 29 (76.3%) participants were categorized as Low APC. Twenty-one (55.3%) of the 38 participants were categorized as Very Good PPC, and 17 (44.7%) were categorized as Somewhat Good PPC. The regression model for overall ACL-RSI score was significant ( F (4,33) = 5.224, p=0.002, adj. R2 = 0.313), with age explaining 26.4% of the total variance (p=0.001). In evaluating the ACL-RSI subscales, the regression model for the ACL-RSI Emotions score was significant ( F(4,33) = 7.760, p<0.001, adj. R2 = 0.422), with age, sex, and PPC explaining 33.9% (p<0.001), 7.0% (p=0.04), and 7.7% (p=0.03) of the total variance, respectively. Lastly, the regression model for ACL-RSI Risk Appraisal score ( F(4,33) = 3.416, p=0.019, adj. R2 = 0.207) was significant, with age and PPC explaining 10.5% (p=0.034) and 12.9% (p=0.02) of the total variance, respectively (Table 2).

Conclusion:

In partial accordance with our hypothesis, higher PPC, but not APC, was significantly associated with a more positive psychological response among young athletes after ACLR. Interventions to improve self-perceptions of competence may optimize psychological readiness to RTS. [Table: see text][Table: see text]
Older Age and Surgical Delay May Affect Medial Meniscus Repairability During Anterior Cruciate Ligament Reconstruction in Adolescents and Young Adults
Authors: Saper Michael , Mand Simran , Sorey Woody , Kweon Chris , Gee Albert , Schmale Gregory A. , Bompadre Viviana , Hagen Mia S.
Published: May 2022

Background:

In the setting of meniscus pathology, earlier treatment of meniscus tears may increase the likelihood of repair in young patients. Moreover, delayed anterior cruciate ligament reconstruction (ACLR) has been associated with an increased risk of meniscus injury. There is, however, limited data on the relationship between surgical delay and meniscus repairability in the setting of an ACLR in young patients.

Purpose:

The purpose of this study was to examine meniscus tear patterns and the likelihood of repair at the time of ACLR in young athletes, and specifically, to determine whether age and time from injury to surgery are correlated with tear patterns or meniscus repairability.

Methods:

Records were retrospectively reviewed on patients aged 13-25 years who underwent primary ACLR from January 2017 through December 2017. Patients with multi-ligament knee injuries were excluded. Demographic data were collected including age, sex, BMI, race/ethnicity, insurance status, primary sport, mechanism of injury, and time from injury to surgery. Operative reports were reviewed to document meniscus tear type/pattern and all concomitant pathology/procedures. Univariate and logistic regression analyses were used to determine factors associated with meniscus repair.

Results:

89 eligible patients underwent ACLR during the study period. 59 (51% females) with mean age 19.3 ± 3.4 years had concomitant meniscus pathology and were included for analysis. The mean time to surgery was 5.2 ± 7.4 months. Combined medial and lateral meniscus tears accounted for 37% of tears, followed by lateral (32%) and medial (31%) tears. For tear type, medial and lateral tears were most commonly vertical (57.5%) and complex (34%), respectively. Surgical repair was performed in 67.5% of medial tears but only 34% of lateral tears. Univariate analyses demonstrated a statistically significant correlation between medial meniscus repair and time to surgery ( p=0.01) and age ( p=0.01), with repair less likely with a surgical delay >3 months and age >18 years. However, time to surgery was not significant after adjusting for age. There was a statistically significant difference in age between those with a surgical delay > 3 months (20.6 ± 3.4 vs.18.3 ± 3.0; p=0.01). Age and time to surgery did not affect the location or type of meniscus tear. There was no correlation between other demographic or surgical variables and time to surgery.

Conclusion:

In the setting of concomitant ACL and medial meniscus injury, age >18 years and surgical delay >3 months may decrease the likelihood of medial meniscus repair in young athletes.
Understanding the Progression of Function and Psychological Readiness of Pre-Adolescent Athletes Following Anterior Cruciate Ligament Reconstruction
Authors: Greenberg Elliot M. , Dyke Julie , Link Meredith , Todd Lawrence J. , Ganley Theodore
Published: May 2022

Background:

Patient reported outcome measures (PROM) allow for a comprehensive assessment of physical and emotional factors not accounted for by functional performance testing after anterior cruciate ligament reconstruction (ACLR). The ACL-RSI gauges an athlete’s psychological readiness to return to sport and recent evidence suggest this measure may help identify individuals at risk of secondary injury. Our current knowledge of how physical function and psychological preparedness change during recovery after ACLR in youth athletes it limited. Understanding the change and interplay between these factors will help optimize rehabilitation and improve patient care.

Purpose:

The purpose of this study was to evaluate changes in psychological readiness (ACL-RSI), knee related function (Pedi-IKDC) and generalized activity (Pedi-FABS) throughout the course of rehabilitation in a group of pre-adolescents after ACLR.

Methods:

A prospective observational cohort study of pre-adolescent athletes who underwent ACLR within a single institution. All subjects had surgery between 12/2017-12/2020 and followed institutional specific protocol emphasizing clinical rehabilitation for a duration of 7-9 months. Subjects completed a series of PROM (ACL-RSI, Pedi-IKDC and Pedi-FABS) quarterly for the initial 12 months following ACLR. Friedman’s test for repeated measures and Wilcoxon Matched Pairs Signed Ranks Test with a Bonferonni correction (p <= 0.017) was used to determine if differences existed amongst each measure over time.

Results:

A total of 28 subjects were included in this analysis (21 male; mean age 12.43 ± 1.40 yrs). Pedi-FABS and Pedi-IKDC both demonstrated significant changes from 3 months (Pedi-FABS 2.63 ± 3.95, Pedi-IKDC 70.84 ± 11.36) to 6 months (Pedi-FABS 9.9 ± 8.55, Pedi-IKDC 87.05 ± 8.03) and from 6 to 9 months (Pedi-FABS 16.57 ± 6.88, Pedi-IKDC 94.40 ± 5.24) (p <= 0.017)(Figure 1 & 2). ACL-RSI approached significance for 3 months (57.81 ± 24.73) to 6 months (70.36 ± 19.77) (p = 0.019) and was definitively significant for changes between 6 to 9 months (85.83 ± 11.02) (p = 0.003) (Figure 3). No significant change was observed between 9-12 months post-operatively for any of these measures.

Conclusion:

In preadolescent athletes, steady improvements in generalized activity and knee function occur during the first 9 months following ACLR. Psychological readiness to return to sport trended upwards, but didn’t reach statistical significance until later in recovery. Beyond 9 months, physical function and psychological preparedness remain largely unchanged. These data support a prolonged recovery period is required to maximize self-reported function and psychological readiness after ACLR in preadolescent athletes. [Figure: see text][Figure: see text][Figure: see text]
A Modified Lemaire Lateral Extra-Articular Tenodesis in High Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Two-Year Clinical Outcomes
Authors: Cordasco Frank A. , Perea Sofia Hidalgo , Brusalis Christopher , Green Daniel W.
Published: May 2022

Background:

The incidence of anterior cruciate ligament reconstruction (ACLR) in patients aged 19 years or younger is increasing significantly and many patients possess risk factors that predispose to ACL re-tear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL re-tear.

Purpose:

To evaluate the safety and efficacy of performing a lateral extra-articular tenodesis (LET) with a modified Lemaire technique (MLT) in conjunction with anterior cruciate ligament reconstruction (ACLR) in children and adolescents at increased risk for failed ACLR.

Methods:

A consecutive series of patients who underwent ACLR and LET with a minimum of 2-year follow-up data was analyzed retrospectively. ACLR techniques included all-epiphyseal (AE) and complete transphyseal (CT) and were indicated based on skeletal age. Skeletally immature patients underwent a QUAD ACLR. Patients with closed or closing growth plates underwent a BTB ALCR. Outcome measures included participants’ return to sports, concomitant or subsequent surgical procedures and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores.

Results:

Sixty-seven consecutive patients (mean age 15.16 ±1.74 years, range 11-19 years, 64% female) were analyzed (Table 1). Sixty-five patients (97%) participated in organized sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. The median grade at the time of surgery was 9th grade. Eleven patients (16%) were revision ACLR procedures. Eight (12%) patients underwent AE and 59 (88%) underwent CT ACLR. Forty-six (69%) cases employed a QUAD autograft, while 21 (31%) utilized a BTB autograft. All patients underwent a LET with a MLT and 2 patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum. At two-year follow-up, median SANE score was 97, median Pedi-IKDC score was 91, and median HSS-Pedi Fabs score was 25. RTS rate was 93%. Fifteen patients had subsequent surgical procedures, including 3 hardware removal procedures for hemiepiphysiodesis, 4 contralateral ACLR, 5 meniscus surgeries, 1 lysis of adhesions, 1 hammertoe correction and 1 revision ACLR for BTB graft re-rupture. Two patients were lost to follow-up and excluded from the study.

Conclusion:

The findings suggest that concomitant LET and ACLR in adolescent patients with risk factors for failed ACLR is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at two years follow-up. [Table: see text]
Pluralistic Ignorance in Concussion Reporting Among Student- Athletes
Authors: Berkner Paul D. , Driscoll Haley T. , Marchetti Gregory F. , Penna Joseph W. , Ali Humza , Jewell Danielle E. , Herrmann Lily
Published: May 2022

Background:

The underreporting of concussions is a persistent problem among student athletes and has the potential to lead to negative health outcomes. The reasons for underreporting are multifactorial and included cultural norms and peer pressures of which one component is pluralistic ignorance.

Purpose:

To evaluate the impact of pluralistic ignorance on the decisions of concussion reporting amongst Division III athletes. We propose that gender, age, and type of sport will impact the responses that individuals make within a survey that they took in a group setting.

Methods:

A Qualtrics® survey was created which contained an array of questions including; concussion knowledge, impulsivity, intention of self and teammate to report concussions and cultural reporting norms. The survey was administered in a group team setting and contained video vignettes depicting concussions and other injuries. The survey was administered to 295 NCAA Division III athletes representing 13 different sports: men’s baseball, basketball, ice hockey, football, and women’s field hockey, volleyball, soccer, softball, squash, and men’s and women’s Nordic skiing, lacrosse, rugby, ultimate frisbee.

Results:

295 student athletes participated, 150 were women, 142 were men, 3 gender identified as other, and their ages ranged from 18 to 26. Individuals were excluded from the analysis if the individual responded inconsistently to both validator questions. Contact sport participants had higher scores on the knowledge questions and had increased agreement for teammate intention to report than their non-contact and collision counterparts (Kruskal-Wallis H = 9.61, P = .008) and had overall lower measures of impulsivity (H = 7.88, P = .019). Collision sport participants were less likely (59%) to endorse a teammate culture that was supportive of concussion reporting (C2 = 13.56, P = .036) however female athletes (72%) and non-contact participants (79%) were more likely to endorse a culture supportive of self-reporting. Overall, regardless of gender, intention to play (self and teammate) despite concussion symptoms was endorsed by 66% of athletes and was more common among collision (75%) and contact participants (70%, C2 = 12.14, P = .016).

Conclusion:

Despite the fact that the majority of college athletes don’t endorse pluralistic ignorance within their teams (i.e. a cultural of not reporting) two-thirds of the college athletes still indicate they would not report their concussion symptoms.
K-12 Athletic Trainers’ Current Concussion Baseline Practice Patterns
Authors: Williams Richelle M. , Hattrup Nicholas , Pardini Jamie E. , Shapiro Marla
Published: May 2022

Background:

Concussion baseline assessments are often administered during the pre-season of sports. Current recommendations suggest that baseline assessments may be useful in aiding and interpreting post-injury evaluations but are not necessary. However, it has become common practice for athletic trainers (ATs) to administer and implement baseline assessments in athletes.

Hypothesis/Purpose:

The purpose was to determine K-12 ATs’ current concussion baseline assessment practice patterns.

Methods:

A Qualtrics survey was designed and implemented to 443 ATs (193 males, 244 females, 5 prefer not to answer, n=1 missing). Most respondents had earned a master’s degree (n=288, 65.0%), and were employed full-time (n=381,86.4%). Respondents were solicited over email to complete the survey which consisted of multipart, multiple-choice, and open-ended questions. Responses are reported as frequencies and percentages. Chi-square analysis was run to determine group (years of experience) and baseline practice patterns, p<0.05.

Results:

Seventy-five percent of respondents (n=330) reported administering baseline concussion assessments, with 37 (8.4%) reporting they do not administer baseline assessments but plan to in the future. The top five most reported assessment tools used were ImPACT (n=245, 55.3%), SCAT 5 (n=59, 13.3%), CNS Vital signs (n=25, 5.6%), BESS (n=25, 5.6%), and VOMS (n=22, 5.0%). The majority of respondents reported standard of care (n=226, 51%), provide better care (n=202, 45.6%%), school/organization policy (n=197,44.5%), to help diagnose concussion (n=139, 31.4%), concussion education (n=117, 26.4%), and liability (n=101, 22.8%), as the top reasons for using concussion baseline assessments. No differences were found between ATs with less than 10 years of experience, 11-20 years of experience, or 21+ years of experience in having formal training on administration of baseline assessments ( p=.164), or having received formal training on interpretation of baseline assessments ( p=.104). However, differences were noted by years of experience for reviewing baseline assessments for validity 2= 8.68, p=.013, and for those who restrict testing when individuals are sleep deprived 2=10.06 p=0.039. The majority reported receiving formal training to administer (n=209, 66.8%) and to interpret (n=178, 56.9%) neurocognitive baseline assessment. The majority of respondents report feeling extremely comfortable (n=214, 69%) and extremely competent (n=205, 65.9) in administering neurocognitive assessments, and moderately comfortable (n=117, 38.2%) and moderately competent (n=137, 45.1%) in test interpretation.

Conclusion:

The majority of ATs reported administering baseline concussion assessments and felt comfortable and competent in the administration and interpretation of assessments in adolescent athletes. Most ATs reported standard of care and providing better care as reasons for implementing assessments.
Pupillary Light Reflex Metrics Differ in Adolescents with Acute Concussion VS. Persistent Post-Concussion Symptoms
Authors: Master Christina L. , Podolak Olivia E. , Ciuffreda Kenneth J. , Joshi Nabin R. , McDonald Catherine C. , Margulies Susan S. , Grady Matthew F. , Arbogast Kristy B.
Published: May 2022

Background:

A potential objective measure that may assist in identifying vision disorders after concussion is the pupillary light reflex (PLR), which is under autonomic control and contributes to normal convergence and accommodative function which is altered after concussion. This study sought to compare pupillometry measures in adolescents with concussion initially presenting for care in the early acute time frame (≤ 2 weeks post-concussion) to those presenting in the later acute time frame (4 ± 1 weeks).

Hypothesis:

To determine whether PLR metrics are similar or different between athletes with concussion presenting earlier (≤ 2 weeks post-concussion) for care vs. those presenting later for care (4 ± 1 weeks).

Methods:

Athletes, ages 12-18 years, with a diagnosis of sport-related concussion (n = 110) were recruited. 89 concussed subjects had their PLR assessment performed at an early acute time point ≤ 2 weeks after concussion, while 21 concussed subjects had their first assessment at a later acute time point (4 week±1 week). Pupillary dynamics were measured in response to a brief, step-input, white light stimulus (154 ms duration; 180 micro watts power) via a Neuroptics PLR-3000 hand-held, infrared, automated, monocular pupillometer (Neuroptics, Irvine, CA). The means of the PLR metrics were compared between groups with one-way Student’s t test. Bonferroni correction was applied.

Results:

The baseline pupil diameter (mean ± SD) was significantly larger (p<0.05) for the subjects seen later 4 ± 1 week (5.09 mm ± 0.63) as compared to the cohort of subjects who presented earlier within 2 weeks after injury (4.72 ± 0.79mm). Average constriction velocity ACV for the later-presenting cohort (3.35±0.45 mm/s) was significantly faster compared to the early-presenting cohort (3.04±0.59 mm/s). Similarly, maximum constriction velocity for the groups were significantly different (early 4.82±0.90 versus late 5.31±0.70 mm/s), even after Bonferroni correction (p<0.05), with alpha of 0.025. All the other pupillometric parameters were not different from each other.

Conclusion:

When comparing adolescents with concussion presenting early in the acute phase ≤ 2 weeks after concussion to those presenting later in the acute timeframe to care 4±1 weeks, those presenting later demonstrate enhancement of certain PLR metrics, namely larger baseline pupil diameter and faster average constriction velocity (ACV) and maximum constriction velocity (MCV). Differences in these PLR metrics in those presenting later in the acute timeframe may represent findings in those who are more likely to have persisting post-concussion symptoms, potentially shedding light on pathophysiological underpinnings of lingering symptoms.