bluuebunny/crossref_metadata_2025 huggingface dataset:
IS PERCUTANEOUS MEDIAL COLLATERAL LIGAMENT (MCL) RELAXATION DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION A SAFE OPTION FOR GAINING ACCESS TO THE MEDIAL KNEE COMPARTMENT IN CHILDREN?
Authors: Schlechter John A. , Harrah Tanner , Gornick Bryn , Sherman Benjamin
Published: July 2021

Introduction:

With participation in youth sports anterior cruciate ligament (ACL) injuries are a common occurrence. Nearly 70% of ACL tears in children and adolescents have an associated meniscus tear. Percutaneous medial collateral ligament (MCL) relaxation has been described as utilitarian in accessing the medial meniscus for diagnostic assessment and treatment in the adult population to increase medial compartment working space in arthroscopic surgery. The technique has not been evaluated in the pediatric population. The purpose of this study was to compare the outcomes of children and adolescents that underwent anterior cruciate ligament reconstruction (ACLR) with and without percutaneous relaxation of the medial collateral ligament (MCL) for meniscal tear management.

Methods:

A retrospective review was performed of patients aged 8 to 19 years old that had undergone knee arthroscopy for an (ACLR) with meniscus pathology. Those that underwent MCL relaxation were grouped together and compared to a matched cohort that did not have MCL relaxation performed. Preoperative, operative and postoperative data was analyzed. The primary measurement was obtained using a validated patient reported outcome score (Pedi-IKDC), secondary outcome measures were defined as superficial or deep infection, saphenous nerve dysesthesias, ACL graft failure and return to the operating room. Statistical analysis of the two cohorts was performed.

Results:

Fifty-four patients were included in the study (27 in each group) with average age 15 years (range 10-19). Average follow-up for the MCL relaxation group was 22.4 months versus 58 months for the non-MCL relaxation group. The average Pedi-IKDC score was 93.3 for the MCL relaxation group and 91.4 for the non-MCL relaxation group (p=0.34). There was no difference in patient demographics, return to the operating room (p=0.49), saphenous nerve dysesthesia (p=0.49), superficial or deep infection (p=0.32).

Conclusion:

ACL reconstruction in children and adolescents with MCL relaxation for the management of medial meniscal tears appears to be a safe option. Equivocal patient reported outcome scores as compared to the control group were found with no increase in post-operative complications. In children with ACL tears, appropriate diagnosis and management of medial meniscal pathology is important to maintain secondary restraint to anterior tibial translation and prevent premature graft failure. Pediatric knees can have tight medial compartments, making access difficult, potentially leading to poor visualization and iatrogenic chondral damage. Percutaneous medial collateral ligament (MCL) relaxation has been described in the adult population to increase medial compartment working space without long term sequela. We report similar findings in an all pediatric cohort.
DELAY TO ACL RECONSTRUCTION IN PEDIATRIC AND ADOLESCENT PATIENTS IS ASSOCIATED WITH A LINEAR INCREASE IN THE RISK OF MEDIAL MENISCAL TEARS
Authors: Kolin David A. , Dawkins Brody , Park Joshua , Fabricant Peter D. , Gilmore Allison , Seeley Mark , Mistovich R. Justin
Published: July 2021

Background:

Anterior cruciate ligament (ACL) tears are frequently associated with meniscal tears. Previous studies have shown that secondary meniscal tears—occurring after the initial ACL injury—are associated with greater delays from injury to ACL reconstruction (ACLR), but frequently use dichotomous categories of acute versus delayed ACLR.

Purpose:

As meniscal damage is likely accrued constantly over time, we investigated the variability of concurrent meniscal injuries as a function of time from injury to ACLR in a pediatric and adolescent population.

Methods:

We performed a retrospective review of all patients ≤18 years who underwent an ACLR between 2014 and 2018 at one of two tertiary academic hospitals. Outliers were excluded if time from injury to ACLR was greater than 78 weeks. Records were reviewed to assess patients’ dates of injury and surgery. The prevalence of concurrent medial and/or lateral meniscal injury was evaluated at the time of surgery for each patient. Adjusted relative risks (ARRs) of meniscal injury were calculated using Poisson regression models adjusted for age, sex, and body-mass index. Logistic regression was used to model the predicted probability of medial meniscal tears.

Results:

546 patients met inclusion criteria. The mean age of participants was 15.3 years (S.D., 1.6), and 277 (50.7%) patients were male. Overall, 344 (63.0%) patients had a meniscal tear. 169 (49.1%) tears occurred at the medial meniscus, and 257 (74.7%) occurred at the lateral meniscus (Table 1). Compared to females, males had a greater risk of lateral meniscal injury (ARR, 1.46; 95% CI, 1.20-1.77) but not medial meniscal injury (ARR, 1.01; 95% CI, 0.77-1.31) (Figure 1). When considering all meniscal tears, time from injury to ACLR was not associated with increased risk of a tear (ARR, 1.01; 95% CI, 1.00-1.01). However, for medial meniscal tears, there was a significant association between time from injury to ACLR, in weeks, and meniscal tears (ARR, 1.02; 95% CI, 1.01-1.03, P = 0.003). A ten-week delay was associated with a 20% increased risk of medial meniscal injury (Figure 2).

Conclusion:

In pediatric and adolescent ACLR patients, the risk of any meniscal injury was not associated with delay from injury to surgery. However, the risk of medial meniscal injury increased by 2% each week from injury to surgery. [Table: see text][Figure: see text][Figure: see text]
AEROBIC EXERCISE VOLUME, NOT PRESCRIPTION, INFLUENCES POST-CONCUSSION SYMPTOMS: A RANDOMIZED CLINICAL TRIAL
Authors: Howell David R. , Hunt Danielle , Aaron Stacey E. , Meehan William P. , Tan Can Ozan
Published: July 2021

Background:

Current recommendations for sport-related concussion uniformly emphasize the importance of physical activity. However, specifics of this recommendation remain vague and do not account for an exercise dosage or compliance.

Purposes:

First, we examined if an 8-week individualized sub-symptom threshold aerobic exercise prescription, initiated within the first two weeks of concussion, alleviates symptom severity or affects the amount of exercise performed during the study. Second, we examined whether prescription adherence, rather than randomized group assignment, reflects the actual impact of aerobic exercise in post-concussion recovery.

Methods:

For this single-site prospective randomized clinical trial, participants completed an aerobic exercise test within 14 days of injury, and were randomized to an individualized aerobic exercise program or standard-of-care, and returned for assessments 1 month and 2 months after the initial visit (Table 1). The aerobic exercise group was instructed to exercise 5 days/week, 20 minutes/day, at a target heart rate based on an exercise test at the initial visit. Participants reported their symptom exercise volume each week over the 8-week study period, and reported symptoms at each study visit (initial, 1 month, 2 month).

Results:

Initial symptom severity was not different between randomized groups (Figure 1A), and no significant differences in symptom severity were found at the 4-week (Figure 1B) or 8-week (Figure 1C) assessment. In addition, there was no significant differences between groups for average weekly exercise volume during the first four weeks (Figure 2A) or second four weeks (Figure 2B) of the study. During the first four weeks of the study, 65% (n=11/17) of the exercise intervention participants were compliant with their exercise recommendation (≥100 min/week), compared to 45% (n=9/20) of the standard-of-care group (p=0.33). During the second four weeks of the study, 71% (n=12/17) of the exercise prescription group exercised ≥100 min/week, compared to 55% (n=11/20) of the standard-of-care group (p=0.50). When grouped by exercise volume, the group who exercised ≥100 minutes/week during the first month of the study reported significantly lower symptom severity scores than those who exercised <100 minutes/week (Figure 3B), despite similar initial symptom severity scores (Figure 3A).

Conclusion:

Participant randomization within 14 days of concussion did not lead to a significant reduction in symptoms, or greater exercise volume. Given that greater exercise volume was associated with lower symptoms after one month of the study, researchers and clinicians should pay particular attention to adherence to aerobic exercise programs for the treatment of concussion.

[Table: see text][Figure: see text][Figure: see text][Figure: see text]
PITCHING IN YOUTH SOFTBALL: HOW MUCH ARE PITCHERS THROWING?
Authors: Trotter Cameron A. , Greiner Justin J. , McGuine Tim , Baer Geoffrey S.
Published: July 2021

Background:

Softball is a popular sport among youth female athletes. While multiple youth baseball studies have evaluated the relationship of injury to pitch counts, there is a paucity of literature for youth softball. In contrast to the numerous youth baseball leagues adhering to pitching guidelines, pitch counts are frequently not enforced in youth softball which results in pitchers with exceedingly high volumes.

Purpose:

The purpose of this study was to perform a quantitative analysis of pitching volume in youth softball players. We hypothesized that the majority of pitches would be thrown by a small proportion of pitchers on each team.

Methods:

Seventy youth softball teams including 538 pitchers competing in age brackets eight and under (8U) to fourteen and under (14U) between Spring 2017 and Fall 2019. Game dates and pitch counts were collected for each player using an electronic application. Games played on two or more consecutive days were defined as a tournament. The three highest-volume pitchers from each team defined by total season pitches were analyzed for comparison to the average pitcher.

Results:

538 pitchers on 70 teams were included. The average pitcher threw 813 pitches per year and appeared in 20.0% of games and the average high-volume pitcher threw 2500 pitches per year and appeared in 54.5% of games. The highest-volume pitcher from each team threw 40% of all recorded pitches, the second highest 27.2%, and the third highest 15.2%, totaling 82.4% of all team pitches. Single day pitch counts of >100 and >200 occurred in 17.7%, and 1.1% of same day games with the average pitcher and in 31.2%, and 2.4% of same day games with the average highest-volume pitcher. Tournament pitch counts of >100 and >200 occurred in 51.0% and 13.8% of tournaments with the average pitcher and in 81.4% and 30.8% of tournaments with the average highest-volume pitcher. The average and highest-volume pitcher threw pitches in two or more games on the same day in 37.5% and 48.6% of possible games while pitching two or more consecutive days in 64.0% and 79.6% of possible games, respectively.

Conclusion:

Softball pitchers throw high volumes of pitches while also pitching multiple days consecutively. A disparity among pitchers on softball teams exists as 82.4% of team pitches are thrown by three pitchers. These high-volume pitchers may be engaging in unsustainable pitching practices that could predispose to injury.

Tables:

[Table: see text]
GROWTH OF THE PEDIATRIC KNEE MENISCUS: A CADAVERIC STUDY
Authors: Vuong Brian , Segovia Nicole , Randhawa Sahej , Trivedi Sunny , Tran Emily , Ganley Theodore , Ellis Henry , Wilson Philip , Fabricant Peter , Shea Kevin
Published: July 2021

Background:

The menisci of the knee play a critical role in maintaining structural integrity, as well as in load bearing and shock absorption. In adolescent patients, meniscal tear is a very common sports injury, and is frequently associated with concomitant traumatic injuries including tibial eminence fracture or ACL tear. The incidence of pediatric meniscal tears is increasing, and anatomic studies to guide repair, saucerization and transplantation do not exist.

Hypothesis/Purpose:

This study’s purpose was to evaluate meniscus dimensions in the developing meniscus and provide anatomic parameters for repair, saucerization, resection, transplantation.

Methods:

From images of 29 dissected cadaveric knee specimens between 1 month and 132 months of age obtained on a copy stand (14 left knee, 15 right knee), we made direct length measurements from the inner to outer meniscus rim at 45 degree intervals (12, 1:30/10:30, 3:00/9:00, 4:30/7:30 o’clock, 6 o’clock) using Autodesk Fusion 360 software (Figure 1.1). We also measured width between the outer medial and lateral meniscus rims, as well as CT measurements of coronal and sagittal width of the tibial plateau using OsiriX DICOM software. Generalized linear models were used to evaluate the associations of meniscal length measurements with age, tibial width, and meniscal width measurements. All statistical analyses were completed with a two-sided level of significance of 0.05.

Results:

All radial length measurements were predicted to increase significantly with age (p < 0.01), as coronal tibial width increases (p < 0.05), and as lateral-medial meniscal width increases (p < 0.001) (Figure 1.2). Other than the lateral 3 o’clock measurement (p = 0.119), all radial measurements were predicted to increase significantly as sagittal tibial width increases (p < 0.05). The posterior zones of the medial meniscus (6:00, 4:30/7:30) were found to increase in radial length at a faster rate than the anterior zones. The anterior zones of the medial meniscus (12:00, 1:30/10:30) had the slowest rate of growth.

Discussion/Conclusion:

Meniscus radial length is related to age, tibial plateau width, and lateral-medial meniscus width. Radial dimensions from normal lateral menisci may allow the surgeon to obtain ideal size of resection, saucerization of discoid menisci. The growth of medial meniscus posterior zones is greater than the anterior zones. This may be attributed to increased posterior region load bearing which increases with ambulation in the developing child. Improved anatomic understanding may help surgeons plan for discoid resection/saucerization/repair, and also support appropriate selection of meniscus allograft for transplantation. [Figure: see text][Figure: see text]
Opioid Overprescription in Adolescents and Young Adults Undergoing Hip Arthroscopy
Authors: Hassan Mahad M. , Rahman Omar F. , Hussain Zaamin B. , Burgess Stephane L. , Yen Yi-Meng , Kocher Mininder S.
Published: July 2021

Background:

Previous studies have examined factors related to the increased use of opioids after hip arthroscopy in adults. However, few have focused on the adolescent population.

Purpose:

The purpose of this study was to compare the opioids prescribed to opioids consumed after hip arthroscopic procedures in adolescent and young adult patients, and to determine patient or surgical factors associated with increased postoperative opioid use.

Methods:

Adolescent and young adult patients who underwent hip arthroscopy and associated arthroscopic interventions between January 2017 and January 2020 were included. Patients with a diagnosed pain syndrome or history of chronic pain, as determined by the patient taking opioid medications prior to surgery, were excluded. Daily postoperative opioid intake was recorded via pain-control logbooks. The outcome of the study was defined as the average total number of opioid tablets consumed postoperatively.

Results:

Fifty-eight patients returned completed logbooks, 72% of whom were female patients. The average age was 21.30 years (range, 14.9 – 34.2). Most patients (73%) were prescribed 30 oxycodone tablets. The median amount of tablets consumed was 7 (range, 0-41) over a median duration of 7 days (range, 1-22). The median ratio of tablets consumed to prescribed was 20% and the 95th percentile of opioids consumed was 28 tablets. Bivariate analysis showed that patient age at surgery was positively correlated to the total amount of tablets consumed (r=0.28, p=0.04) and to the ratio of tablets consumed to prescribed (r=0.30, p=0.03). Duration of surgery was negatively correlated to the number of days tablets were consumed (r=-0.31, p=0.03). Multivariate analysis showed that patients who were prescribed more than 30 tablets took on average 7.8 more tablets overall compared to those prescribed 30 or fewer tablets (p=0.003), and that for each additional year of age, the ratio of tablets consumed to prescribed increased by 1% (p=0.02).

Conclusion:

After undergoing hip arthroscopy and associated arthroscopic procedures, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed. This finding mirrors trends in the pediatric knee arthroscopy literature and provides an opportunity to reassess current opioid prescribing behaviors in the adolescent and young adult populations. [Table: see text][Table: see text][Table: see text][Table: see text][Table: see text]
ANXIETY, FEAR, AND MOVEMENT FOLLOWING SPORTS-RELATED CONCUSSION: HOW DOES KINESIOPHOBIA CORRELATE TO SYMPTOMS AND REACTION TIME?
Authors: Reinking Sarah , Seehusen Corrine N. , Walker Gregory A. , Wilson Julie C. , Howell David R.
Published: July 2021

Background:

Fear of pain with movement, also known as kinesiophobia, has been widely studied in various musculoskeletal injuries, yet little is known about its relationship to concussion. Given that concussion can negatively affect neuromuscular control and anxiety, re-integration into sports following a concussion may be associated with kinesiophobia.

Hypothesis/Purpose:

Our primary purpose was to examine kinesiophobia, among youth athletes with concussion compared to uninjured controls. Secondarily, we sought to examine correlations between kinesiophobia with concussion symptom severity and reaction time. We hypothesized adolescents with concussion would demonstrate greater kinesiophobia compared to controls. Additionally, we hypothesized that greater kinesiophobia would be correlated with higher symptom severity and slower reaction times.

Methods:

We conducted a repeated measures study of 48 youth athletes. Participants were evaluated at two time points. The concussion group was assessed within 14 days of injury and once cleared for return to play (RTP) by physician. The control group was tested initially and again approximately 28 days later. Participants completed Tampa Scale of Kinesiophobia (TSK), Post-Concussion Symptom Inventory (PCSI), and clinical reaction time (CRT) assessments. We compared mean group differences and assessed the correlation of TSK with PCSI and CRT, at each assessment.

Results:

We included 26 participants with a concussion and 16 controls (Table 1). The concussion group reported significantly greater TSK scores at the initial assessment (38.0±5.6 vs. 29.3±6.9; p<0.001; Figure 1) and a significantly greater proportion of “high” TSK scores (>36) compared to controls (69% vs. 19%; p = 0.004; Table 1). At the follow-up assessment, there were no significant between group differences in TSK scores (32.8±7.0 vs. 30.4±7.5; p=0.35; Figure 1), or the proportion of “high” TSK scores (38% vs. 25%; p=0.51; Figure 1). TSK scores were significantly and moderately correlated with PCSI for the concussion group at both assessments (r=0.53; p=0.006 at visit 1, r=0.47; p=0.01 at visit 2; Figure 2), but not for controls (Figure 2). Furthermore, TSK scores were significantly and moderately correlated with CRT for the concussion group (r=0.50; p=0.01; Figure 2), but not controls (r= -0.26; p=0.37; Figure 2) at the follow-up assessment.

Conclusion:

Adolescents recovering from concussion commonly reported high kinesiophobia at initial concussion assessment, while many no longer reported high kinesiophobia when given RTP clearance. Furthermore, kinesiophobia was significantly correlated with self-reported concussion symptoms and clinical reaction time scores. The correlation between kinesiophobia and reaction time suggests a perception-behavior relationship with post-concussion movement deficits may exist.

Tables/Figures:

[Table: see text][Figure: see text][Figure: see text]
IS NEAR POINT OF CONVERGENCE ASSOCIATED WITH SYMPTOM PROFILES OR RECOVERY IN ADOLESCENTS AFTER CONCUSSION?
Authors: Walker Gregory A. , Wilson Julie C. , Seehusen Corrine N. , Provance Aaron J. , Howell David R.
Published: July 2021

Background:

Visual impairments, including oculomotor impairments, are common following concussion. Accurate, efficient, and objective measurement of post-concussion visual impairments may help guide treatment pathways. Less is known about how specific concussion symptoms are associated with visual impairments.

Hypothesis/Purpose:

Our purpose was to compare the clinical and injury characteristics of concussion patients who demonstrated receded near point of convergence (NPC) (defined as measurement >6 cm using accommodation rule from bridge of nose) to those with normal NPC (≤6 cm). We hypothesize that patients demonstrating receded NPC would show greater symptom burden and have longer recovery when compared to those with normal NPC.

Methods:

Concussion patients who were seen within 14 days of injury were included. We performed univariable demographic, injury, and clinical characteristic comparisons between those with and without receded NPC break point using independent samples t-tests and Chi-square analyses. We compared NPC break point between those who did not recover within 28 days of injury (PPCS; persistent post-concussion symptoms) and those who did (no PPCS). A multivariable linear regression model was constructed to identify which factors were associated with NPC break point distance.

Results:

We evaluated 123 patients using a multimodal concussion evaluation within 14 days of injury. Those with receded NPC (n=77) were significantly younger than those with normal NPC (n=46; Table 1). The receded NPC group had a significantly greater proportion of patients reporting headaches at initial assessment, as well as significantly greater overall, cognitive and somatic symptom severity (Table 2). The group who went onto experience PPCS had a significantly greater NPC at initial evaluation than those without PPCS (p=0.02; Figure 1). The receded NPC group committed more modified Balance Error Scoring System (mBESS) errors than the normal NPC group, but there were no significant differences for tandem gait test performance (Table 3). In our multivariable model, we observed that among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC (Table 4).

Conclusion:

Those with receded NPC at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without receded NPC. Additionally, we were able to elucidate that those who went on to develop PPCS had greater NPC than those recovered within 28 days. Visual disorders may be an important driver of symptom profiles following concussion in adolescents. The impact of visual disturbance treatment following concussion in adolescents on symptom resolution should be further evaluated.

Tables/Figure:

[Table: see text][Table: see text][Figure: see text][Table: see text][Table: see text]
PARENTS AND ATHLETES PERCEIVE PAIN AND PEER RELATIONSHIPS DIFFERENTLY: EARLY RESULTS OF A PROMIS DYAD STUDY
Authors: Franklin Corinna C , Moran Kevin ,   PRiSM Female Athlete Research Interest Group,   Shriners Sports Medicine Consortium
Published: July 2021

Introduction:

Parents/caregivers are a crucial part of young athletes’ support systems, as their beliefs can have a profound effect on the athletes’ treatment and recovery. However, it is unknown to what degree sports medicine patients and their parents/caregivers are in agreement about their function. We recently instituted the use of a Patient Reported Outcome Measurement Information System (PROMIS) for all patients in our hospital system. In this study, we propose to use PROMIS scores to evaluate whether parents/caregivers have the same perception of their child’s function as the child them self. This is a report of our early findings from one site.

Methods:

IRB approval was obtained for this study. Patients already take PROMIS evaluations as part of their clinical care. After obtaining informed consent, one parent (ideally the primary caregiver) per patient at one visit took the parent-proxy version of PROMIS, in which the parent is asked to answer identical questions on the child’s behalf, without consulting either the patient or their physician. PROMIS domains included mobility, upper extremity, pain, and peer relationships. All parent-child dyads were through sports medicine clinic with an injury or diagnosis related to sports medicine. Patients and parents were compared using independent samples t-tests.

Results:

Twenty-four ( n=24) patient-parent dyads were included in this analysis. Fourteen patients ( n=14) were female and n=10 male. Sixteen patient/parent ( n=16) dyads had similar genders and n=8 were opposite genders. There were significant differences between the patient and their parent for both the pain and peer relationship domains ( p=0.02 for both). Parents rated the patients’ pain as more severe ( M=48.1, SD = 9.3) than the patient rated their own pain ( M=42.2, SD=7.3). Parents also rated the patients’ peer relationships as worse/more affected ( M=53.0, SD=9.4) than did the patients themselves ( M=58.9, SD=7.2). No significant differences were found for the mobility and upper extremity domains, p>0.05. There was no significant difference in concordance between same or opposite gender dyads, p>0.05.

Conclusion:

Early results of this study suggest that parents rate athletes with sports injuries as having more pain and worse/more affected peer relationships than do the athletes themselves. Further study is required to elucidate the impact of this difference on athletes’ performance and recovery.
POST-CONCUSSION PHYSICAL THERAPY REFERALS
Authors: Burkhart Scott , Price August , Caze Todd J. , Knell Gregory , Ellis Christine , Abt John
Published: July 2021

Background:

Treating a concussion is complex, requiring a multi-disciplinary patient-centered approach for optimal outcomes. Physical therapy (PT) is a treatment utilized to facilitate concussion recovery, however little is known about those patients referred to PT.

Purpose/Hypothesis:

The purpose of this study was to report the demographics and other outcome measures of patients referred to PT from an attached specialty concussion clinic.

Methods:

Retrospective data were extracted from medical records for patients who were referred for physical therapy (PT) from its specialty concussion clinic. Patients included in this study were aged 8-18, diagnosed with a concussion, and referred to PT. Demographic data (age, gender, ethnicity, race) were patient reported. Other patient outcome measures (total injury recovery in days, total number of PT visits, total days between the first and last PT visit, positive VOMS score (symptom increase of 2 from baseline on any symptom and/or convergence on any trial >6cm). Statistical analyses included summary statistics and were reported appropriately as proportions, medians (interquartile range [IQR]), and means (± standard deviation [SD]).

Results:

Of the 88 patients referred to PT, the mean (± SD) age was 14.31 (± 2.58), 27.3% were children (8-12 years), 72.7% were adolescents (13-18 years), 65.9% were female, 87.5% were white race, 6.8% were black race, and 12.5% were Hispanic in ethnicity. A total of 84.1% patients had a positive VOMS, 9.1% had a negative VOMS, and 6.8% had an invalid VOMS. On average, patients were seen for 4 (± 2.60) total visits, spanning across an average of 18 (± 14.83) days between initial and last PT visits, with the median recovery between date of injury and medical clearance being 48 days (SD=175).

Conclusions:

This is the first study to provide preliminary demographics of post-concussive PT patients referred from its specialty concussion clinic. These results will be useful in establishing future protocols for future studies to examine the effect of early PT intervention on pediatric concussion recovery.
CLASSIFYING ISCHIAL TUBEROSITY AVULSION FRACTURES BY OSSIFICATION STAGE AND TENDON ATTACHMENT
Authors: Mitchell Brendon C. , Bomar JD , Wenger Dennis , Pennock Andrew T.
Published: July 2021

Background:

Currently, there is no classification system for ischial tuberosity avulsion fractures.

Hypothesis/Purpose:

To provide a new classification system for ischial tuberosity fractures based on the ossification pattern of the apophysis.

Methods:

We performed a retrospective records review of patients diagnosed with ischial tuberosity avulsion fractures at our institution from 2008 to 2018. Skeletal maturity (Modified Oxford score [MOS], Risser score), fracture type, size, and displacement were recorded based on initial injury radiographs. We reviewed a large series of pelvic CT and MRI scans from patients aged 10-19 years old to assess the ossification pattern and tendinous attachments of the ischial tuberosity. Pelvic CT review demonstrated a reproducible 5-stage pattern of ossification spanning the age of 13-19 years for males and 12-17 years for females (Figure 1). Review of available CTs and MRIs indicated that the semimembranosus attaches at the most lateral ossification center, followed by the conjoint tendon and adductor magnus as one moves medially (Figures 1). We created a classification system based on location of the ischial tuberosity avulsion fracture: Type 1 (lateral – semimembranosus and conjoint tendons) or Type 2 (complete – semimembranosus, conjoint, and adductor magnus tendons). An A or B descriptor was then added to distinguish minimally displaced (<1 cm) and displaced (≥1 cm) fractures, respectively (Figure 2).

Results:

We identified 45 ischial tuberosity fractures. Mean age was 14.4 years (range, 10.3–18). Males accounted for 82% of the cohort. Type 1 fractures accounted for 47% of cases and 53% were classified as Type 2. Type 1 fractures were associated with younger age chronological age (p=0.001), lower MOS (p=0.002), lower Risser score (p=0.002), less displacement (p=0.001), and smaller size (p<0.001), when compared with Type 2 fractures (Table 1). Of the 45 patients, 18 had >6 month follow-up with 56% going on to non-union. Non-union was associated with greater displacement (p=0.016) and size (p=0.027). When comparing union rates by fracture location, 33% of Type 1 fractures progressed to non-union, while 78% percent of Type 2 suffered a non-union; however, this difference did not reach statistical significance (p=0.153) (Table 2).

Conclusion:

In younger patients (ages 13-15 years), the lateral ossification centers of the ischial tuberosity, at which the hamstrings attach, are at risk for isolated avulsion injury. However, in older patients (16-18 years), coalescence of the hamstring and adductor magnus ossification centers predispose patients to a combined avulsion injury consisting of a larger fragment and with greater displacement.

[Figure: see text][Figure: see text][Table: see text][Table: see text]
Operative Treatment of Severe Cervical Spine Injuries Sustained in Youth Sports: Experience from a Pediatric Level 1 Trauma Center over a 16-Year Period
Authors: Verhofste Bram P , Hedequist Daniel J , Birch Craig M , Rademacher Emily S , Glotzbecker Michael P , Proctor Mark R , Yen Yi-Meng
Published: July 2021

Background:

Sports-related cervical spine injuries (CSI) are devastating traumas with the potential for permanent disability. There is a paucity of literature on operative CSI sustained in youth athletes.

Hypothesis/Purpose:

The aims of this study aims were to review injury characteristics, surgical treatment, and outcomes of severe pediatric CSI encountered in youth sports.

Methods:

We reviewed children less than 18 years old with operative sports-related CSI at a pediatric Level 1 pediatric trauma center between 2004−2019. All cases underwent modern cervical spine instrumentation and fusion. SCI were stratified according to the American Spinal Injury Association Impairment Scale (ASIA). Clinical, radiographic, and surgical characteristics were compared between groups of patients with and without spinal cord injury (SCI).

Results:

Three thousand two hundred and thirty-one children (mean, 11.3y±4.6y) were evaluated for CSI at our institution during the 16-year period. The majority of traumas resulted from sports/recreational activities and were seen in 1365 cases (42.3%). Of these, 171/1365 patients (12.5%) were admitted and 29/1365 patients (2.1%) required surgical intervention (mean age, 14.5y±2.88y; range, 6.4y–17.8y). Sports included: eight football (28%), seven wrestling (24%), five gymnastics (17%), four diving (14%), two trampoline (7%), one hockey (3%), one snowboarding (3%), and one biking injury (3%). Mechanisms were 19 hyperflexion (65%), eight axial loading (28%), and two hyperextension injuries (7%). The majority of operative CSI were fractures (79%) and/or subaxial defects (72%). Seven patients (30%) sustained SCI and three patients (10%) spinal cord contusion or myelomalacia without neurologic deficits. The risk of SCI increased with age (15.8y vs. 14.4y; p=0.03) and axial loading mechanism (71% vs. 14%; p=0.003). Postoperatively, two SCI patients (29%) improved 1 ASIA Grade and one (14%) improved 2 ASIA Grades. Increased complications developed in SCI than patients without SCI (mean, 2.0 vs 0.1 complications; p=0.02). Clinical and radiographic fusion occurred in 24/26 patients (92%) with adequate follow-up (median, 32 months). Ten patients returned to their previous activity and nine to sports with a lower level of activity.

Conclusion:

The overall incidence of sports-related operative CSI is low. Age- and gender discrepancies exist, with male adolescent athletes most commonly requiring surgery. Hyperflexion injuries had a good prognosis; however, older males with axial loading CSI sustained in contact sports were at greatest risk of SCI, complications, and permanent disability.

[Figure: see text][Table: see text][Table: see text]
Epidemiologic Study of the Discoid Meniscus: Investigating Demographic-Based Predictors in Large-Scale Claims Database
Authors: Randhawa Sahej S , Tran Emily P , Segovia Nicole A , Ganley Theodore J , Tompkins Marc , Ellis Henry , Shea Kevin G
Published: July 2021

Background:

Discoid meniscus epidemiology remains poorly defined for race and sex, in part, due to limitations of retrospective studies and small case series. A better understanding of epidemiology may improve clinical care and diagnostic precision.

Purpose:

Our purpose is to better define the epidemiology of discoid meniscus by analyzing a large, national database for incidence rates by sex and race.

Methods:

Analysis was conducted on the national-scale Clinformatics Data Mart Database by Optum. Proportions of the database’s racial categories (Asian, Black, Hispanic, White, and Unknown) in the total population of diagnosed discoid meniscus cases (n = 1,006) were calculated and compared via chi-squared tests to the total database population (n = 65,759,970). This analysis was repeated for the population of patients who received knee arthroscopies (81,205). Incidence rates were calculated from these populations as well. Finally, a multivariable logistic regression analysis based on the population of arthroscopy-receiving patients was performed to control for age, reported gender, and income.

Results:

Proportions of Asian, Black, Hispanic, and White racial categories in the discoid meniscus group were 5.7%, 7.3%, 20.6%, 66.4%, respectively; the proportions of each racial category in the total population were 5.2%, 10.3%, 13.5%, 71.0%, respectively. Incidence rates (per 10,000) for these groups in the arthroscopy population were 72.9, 25.6, 49.2, 25.6, respectively. Our logistic regression model indicated that race was not a statistically significant predictor for our dataset after income adjusting. Adjusting for other covariates, the odds of a discoid meniscus diagnosis decreased by 6% for each increase in age (p < 0.001) and were 41% lower for males compared to females (p < 0.001). Conclusion: Prior studies have suggested that race (Asian and Hispanic, is a predictor of higher incidence of discoid meniscus – this study did not show a difference in incidence based upon race. Patient sex and age was identified as significant predictors for discoid meniscus, and increasing age showed a decreasing incidence of this condition. This study’s analysis of a large, national claims database allows for a comprehensive epidemiological study on this topic, offering proportions and incidence rates by race appropriate for application to the US population. Its conclusions promote patient sex and age as significant predictors and question the beliefs on race-associated incidence often based on comparing results from the corpus of single-site cohort studies.

Tables/Figures:

[Table: see text]
Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison to Transtibial and Anteromedial Portal Techniques
Authors: Jarvis D.Landry , Vance Danica D. , Riboh Jonathan C.
Published: July 2021

Background:

Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The principles of creating vertical and central femoral tunnels are well accepted to minimize physeal area of injury and are typically accomplished with a transtibial (TT) technique. This, however, may come at the expense of a non-anatomic tunnel. The hybrid transtibial (HTT) technique offers the potential of combining an anatomic femoral position with tunnel geometry similar to the TT technique but has never been assessed in a clinical cohort.

Hypothesis/Purpose:

We hypothesized that tunnels created by a HTT technique would be similar in orientation and physeal location to TT tunnels, but significantly more vertical and central than tunnels created with an anteromedial portal (AM).

Methods:

We retrospectively screened all ACL reconstructions performed in children aged 10 to 16 years, at our institution between 2013 to 2019, with the requirements of having a transphyseal reconstruction and an available post-operative radiographs. Radiographs were then assessed for the coronal femoral tunnel angle (FTA), as well as the location of the tunnel-physis penetration on the AP (LTAP) and lateral (LTL) views. Physeal lesion surface area was calculated. Data were compared between the three groups using ANOVA.

Results:

Forty-seven patients met eligibility criteria with 9 TT, 18 AM, and 20 HTT patients. Mean patient age was 14.3 +/- 1.2 years. The FTA was significantly more vertical in the TT (60.7o +/-7.2) and HTT (54.4o +/- 5.7) groups as compared to the AM group (48.8o +/- 5.9); p = 0.0037 and p = 0.02 respectively. There was no significant difference between the TT and HTT groups ( p = 0.066). The LTAP was not significantly different between groups (p = 0.097). The LTL demonstrated that the HTT tunnels penetrated the physis at a more central location in the sagittal plane (28.9% +/- 4.8%) than the AM tunnels (20.0% +/- 5.1%, p = 0.00002), but was statistically indistinguishable from the TT (24.4%+/- 4.0%, p= 0.066) tunnels.

Conclusion:

The hybrid transtibial technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to the TT technique, significantly less than the AM technique. The HTT also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane. With the known ability of the HTT technique to recreate an anatomic femoral footprint, this may represent the “best of both worlds” for transphyseal ACL reconstruction.

Tables/Figures:

[Figure: see text][Figure: see text][Figure: see text][Figure: see text]
CLINICAL OUTCOMES OF OPERATIVE MANAGEMENT OF CAPITELLAR OSTEOCHONDRITIS DISSECANS IN ADOLESCENT ATHLETES
Authors: Michelin Richard M. , Gornick Bryn R. , Schlechter John A.
Published: July 2021

Background:

Capitellar osteochondritis dissecans (OCD) is commonly encountered in youth athletes. There are limited reports on long term outcomes using validated outcome scores following surgical treatment of elbow OCD in adolescents.

Purpose:

To examine the outcomes of operative treatment of elbow OCD in adolescent athletes and investigate return to sport rate as well as athletic and daily function.

Methods:

17 adolescent athletes (average age 14.2 ± 1.5 years) and 18 elbows with OCD treated arthroscopically were retrospectively reviewed. The average duration of symptoms prior to surgery was 15.4 ± 12.5 months and average follow up was 4.4 ± 3.7 years. Data points examined included pre-operative lesion grade/size, range of motion (ROM), and bone age; intra-operative lesion grade/size; and post-operative ROM, Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score.

Results:

All patients were treated with initial diagnostic arthroscopy. 14/17 patients were definitively treated with arthroscopic debridement and marrow stimulation/microfracture. 3/17 patients required open treatment with two patients amendable to osteochondral fixation and one patient to open marrow stimulation/microfracture. 14/17 athletes returned to their sport post-operatively with 12/17 returning to the same level or higher, and 2/17 returning to a lower level of recreational play. 3/17 athletes did not return to sports but advised that this was by choice not due to their elbow OCD. Overall, there were significant improvements in elbow ROM post-operatively as well as excellent QuickDASH (average 1.9 ± 4.4) and KJOC scores (average 93 ± 8.0) seen amongst all athletes. There was no correlation between pre-operative lesion grade/size, bone age, or open versus arthroscopic treatment with outcome.

Conclusion:

Operative treatment of elbow OCD in adolescent athletes not only leads to high return to sports rates but also high levels of athletic and daily functional activity long term.
CHANGES IN DUAL-TASK GAIT VELOCITY COST FOLLOWING CONCUSSION
Authors: Ernest Kristin M. , Davis Tyler , Dugan Eric L
Published: July 2021

Background:

Changes in gait velocity have been identified in the literature between concussed and non-concussed individuals. Concussed patients demonstrate slower gait speed; the gait velocity cost has not been evaluated as extensively.

Hypothesis:

Hypothesis 1: Dual-task gait velocity cost will decrease at time of clearance compared to initial testing. Hypothesis 2: Subjects with a SRC will demonstrate greater decreases in gait velocity costs than those with non-SRC. Hypothesis 3: Symptom severity will be positively correlated to dual-task gait costs within the first 5 days after concussion.

Methods:

Patients evaluated for concussion in primary care sports medicine clinic within five days of injury were recruited between October 2017 and May 2019. The mechanism of injury was documented and used to classify sport-related (SRC) versus non sport-related (non-SRC) concussion. A standard concussion evaluation was performed at each visit to assess history, symptoms, neurocognitive, neuromuscular and vestibular dysfunction. Dual-task walking trials were incorporated with a cognitive task such as reciting the months of the year in reverse order or spelling words backwards. During the walking trials, gait velocity was measured using an Xsens MVN BIOMCH system (Xsens Technologies BV, Enschede, The Netherlands). A two-way mixed ANOVA with one within-subjects factor (time) and one between-groups factor (mechanism of injury) was used to determine if dual-task gait velocity costs differed over time and between those with a SRC versus those with a non-SRC. A Pearson’s product-moment correlation was used to assess the relationship between symptom severity scores and dual-task gait costs at initial visit.

Results:

There was no statistically significant interaction between the mechanism of injury and time on gait velocity cost, F(1, 79) = .033, p = .86. The main effect of time showed a statistically significant difference in mean gait velocity cost from initial to clearance, F(1, 79) = 6.19, p = 0.015, generalized η2 = .0.013. There was no main effect of mechanism of injury in mean gait velocity costs, F(1, 79) = 0.800, p = 0.374, generalized η2 = 0.008. There was a statistically significant, small positive correlation between symptom severity and dual-task gait velocity costs, r = .30, p < .007, with symptom severity explaining 9 % of the variation in dual-task gait velocity costs.

Conclusion:

The gait velocity cost demonstrates a statistically significant change from the time of injury to clearance in concussion patients. A small but significant relationship also exists between symptom severity and gait velocity cost.
EFFECT OF SKELETAL MATURITY ON INCIDENCE OF ASSOCIATED MENISCAL AND CHONDRAL INJURIES IN ANTERIOR CRUCIATE LIGAMENT INJURED KNEES
Authors: Heldt Brett , Attia Elsayed , Guo Raymond , Kushare Indranil , Shybut Theodore
Published: July 2021

Background:

Acute anterior cruciate ligament(ACL) rupture is associated with a significant incidence of concomitant meniscal and chondral injuries. However, to our knowledge, the incidence of these concomitant injuries in skeletally immature(SI) versus skeletally mature(SM) patients has not been directly compared. SI patients are a unique subset of ACL patients because surgical considerations are different, and subsequent re-tear rates are high. However, it is unclear if the rates and types of meniscal and chondral injuries differ.

Purpose:

The purpose of this study is to compare associated meniscal and chondral injury patterns between SI and SM patients under age 21, treated with ACL reconstruction for an acute ACL tear. We hypothesized that no significant differences would be seen.

Methods:

We performed a single-center retrospective review of primary ACL reconstructions performed from January 2012 to April 2020. Patients were stratified by skeletal maturity status based on a review of records and imaging. Demographic data was recorded, including age, sex, and BMI. Associated intra-articular meniscal injury, including laterality, location, configuration, and treatment were determined. Articular cartilage injury location, grade, and treatments were determined. Revision rates, non-ACL reoperation rates, and time to surgery were also compared between the two groups.

Results:

785 SM and 208 SI patients met inclusion criteria. Mean BMI and mean age were significantly different between groups. Meniscal tear rates were significantly greater in SM versus SI patients in medial meniscus tears(P<.001), medial posterior horn tears(P=.001), medial longitudinal tears configuration(P=.007), lateral Radial configuration(P=.002), and lateral complex tears(P=.011). Medial repairs(P<.001) and lateral partial meniscectomies(P=.004) were more likely in the SM group. There was a significantly greater number of chondral injuries in the SM versus SI groups in the Lateral(p=.007) and medial compartments(P<.001). SM patients had a significantly increased number of outerbridge grade 1 and 2 in the Lateral(P<.001) and Medial Compartments(P=.013). ACL revisions(P=.019) and Non-ACL reoperations(P=.002) were significantly greater in the SI patients compared to SM. No other significant differences were noted.

Conclusion:

SM ACL injured patients have a significantly higher rate of medial meniscus tears and medial longitudinal configurations treated with repair, and a significantly higher rate of radial and/or complex lateral meniscus tears treated with partial meniscectomy compared to the SI group. We also found a significantly higher rate of both medial and lateral compartment chondral injuries, mainly grades 1 and 2, in SM compared to SI patients. Conversely, SI ACL reconstruction patients had higher revision and subsequent non-ACL surgery rates.