bluuebunny/crossref_metadata_2025 huggingface dataset:
DEVELOPMENT AND EXTERNAL VALIDATION OF A NOVEL CLINICAL SCORE TO QUANTIFY THE PRESENCE OF INSTABILITY CHARACTERISTICS IN PATIENTS WITH BORDERLINE ACETABULAR DYSPLASIA
Authors: Schwabe Maria , Graesser Elizabeth , Rhea Lee , Pascual-Garrido Cecilia ,   ANCHOR Group, Clohisy John C , Nepple Jeffrey J
Published: April 2020

Background

Treatment of borderline acetabular dysplasia (BD) is controversial with some patients having primarily instability-based symptoms while others have impingement-based symptoms. The existing literature lacks direct comparisons of different treatment approaches, and generally fails to report other important diagnostic characteristics beyond the lateral center edge angle (LCEA).

Purpose

The purpose of this study was (1) to identify the most important patient characteristics influencing the diagnosis of instability vs. non-instability, (2) to develop a clinical score (Borderline Hip Instability Score, BHIS) to collectively characterize these factors and (3) to externally validate BHIS in a multicenter cohort BD patients.

Methods

In Part 1, this study utilized a retrospective cohort study of 186 hips undergoing surgical treatment of BD (LCEA 20°-25°) from a single surgeon experienced in arthroscopic and open techniques. Multivariate analysis determined characteristics associated with presence of instability (treated with PAO +/- hip arthroscopy) or absence of instability (treated with isolated hip arthroscopy) based on clinical diagnosis of the single surgeon. During the study period, 39.8% of the cohort underwent PAO. Multivariate analysis with bootstrapping was performed and results were transformed into a BHIS nomogram (higher score representing more instability). In Part 2, BHIS was externally validated in 114 BD patients enrolled in a multicenter prospective cohort study across 10 surgeons (with varied treatment approaches from arthroscopy to open procedures).

Results

In Part 1, the most parsimonious, best fit model included 4 variables associated with the diagnosis of instability: acetabular inclination (AI), anterior center edge angle (ACEA), maximum alpha angle, and internal rotation in 90 degrees of flexion (IRF). Sex and LCEA were not significant predictors. Mean BHIS in the population was 50.0 (instability 57.7 ±7.9; non-instability 44.8±7.3, p<0.001). BHIS demonstrated excellent predictive (discriminatory) ability with c-statistic=0.89. In Part 2, BHIS maintained excellent c-statistic=0.92 in external validation. Mean BHIS in the external cohort was 53.9 (instability 66.5±11.5; non-instability 43.0±10.8, p<0.001).

Discussion

In patients with BD, key factors in diagnosing significant instability treated with PAO were AI, ACEA, maximum alpha angle, and IRF. The BHIS score allowed for differentiation of patients with and without instability in the development and external validation cohort.
SPINAL RANGE OF MOTION AND BACK PAIN IN FEMALE ARTISTIC GYMNASTS DURING BACK WALKOVERS AND BACK HANDSPRINGS
Authors: Sweeney Emily A , Potter Morgan N , Pimentel Richard E , Carollo James J , Howell David R
Published: April 2020

Background:

Back pain is a common complaint among gymnasts. Gymnastics skills require large amounts of spine flexion, extension, rotation and compression. The combination of these movements in a repetitive fashion during gymnastics may contribute to the development of back pain. Gymnasts perform unique skills on various equipment and surfaces, which makes their movements difficult to evaluate using traditional movement analysis approaches.

Hypothesis/Purpose:

Our purpose was to measure gymnasts’ movement patterns in their native environment using wearable sensors. Specifically, we examined spine range of motion (ROM) during back walkovers (BWO) and back handsprings (BHS) on the floor and balance beam. We hypothesized that female youth gymnasts with a recent history of back pain would have larger spine ROM compared to gymnasts without back pain when performing these skills.

Methods:

Female artistic gymnasts ages 8 to 18 years in the Junior Olympic USA Gymnastics program participated in the study. We grouped gymnasts into two groups: those having back pain within the past 12 months and those with no reported back pain in the past 12 months. Gymnasts performed 3 repetitions of BWO and BHS on floor and balance beam while wearing APDM Opal V2 wearable sensors. A BWO requires a controlled bridge kickover while a BHS requires the athlete to jump backwards to her hands (Figure 1). Spine kinematics were then processed via Moveo Explorer. Valid spine sagittal plane maximums, minimums, and ROM of each skill repetition were compared between groups via Kruskal Wallis analysis of variance.

Results:

Seventeen participants (6 with back pain) completed BWOs and BHSs with acceptable sensor data. There were no demographic differences between the two groups for age, height, weight, competition level, or years of experience (p≥0.129, Table 1). During BWO skills, gymnasts with back pain had greater peak extension and greater ROM in the sagittal plane of the spine (p≤0.032, Figure 2). There were no differences between groups in peak extension, peak flexion, or ROM during BHS skills (p≥0.054, Figure 2).

Conclusion:

Gymnasts with a history of back pain had increased spinal motion when performing BWO skills. To perform a BWO, gymnasts must have higher levels of shoulder, spine, and hip flexibility, which may relate to back pain. This study suggests the need for future studies to evaluate if increased spinal motion during gymnastics is a contributing factor to the development of back pain.

[Figure: see text][Table: see text][Figure: see text]
LATERAL MENISCUS WIDTH AT THE POPLITEUS RECESS AND THE RELEVANCE TO SAUCERIZATION OF DISCOID LATERAL MENISCI
Authors: Gamble Jamison G. , Abdalla Abdalla B. , Meadows Molly , Rauer Thomas , Chan Charles M. , Ganley Theodore J. , Shea Kevin G. , Gamble James G.
Published: April 2020

Background:

Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm.1,2

Purpose/Hypothesis:

The primary purpose of this research is to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis is that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM.

Methods:

We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 120 months.) We measured one four-year-old specimen with bilateral complete DLM. We also measured 39 digital images of specimens (ages 1 month to 132 months) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens.

Results:

Figure 2 shows the relationship of meniscus width as a function age. The average width of specimens <3-years-old was 5.5mm. The average width of the ten-year-old specimens was 12mm. The average width of the skeletally mature specimens was 16mm. The four-year-old DLM specimen measured 19 mm.

Conclusions:

We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient.

References:

Kocher MS, Logan CA, Kramer DE. Discoid lateral meniscus in children: diagnosis, management, and outcomes. J Am Acad Orthop Surg 2017;25:736-743. Hayashi LK, Yamaga H, Ida K, Miura T. Arthroscopic meniscectomy for discoid lateral meniscus in children. J Bone Joint Surg. 1988;70-A: 1495-1500. [Figure: see text][Figure: see text]
THE RELATIONSHIP BETWEEN MENTAL HEALTH HISTORY AND SYMPTOMS, SEX, AND RECOVERY TIME IN A CONCUSSED PEDIATRIC POPULATION
Authors: Allred Richard Cameron , Stremlau Sara , Gerkin Richard , Erickson Steven , Pardini Jamie
Published: April 2020

Background:

The Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire (PHQ-9) are mental health screening instruments that assess symptoms of depression and anxiety. Studies of patients with concussion suggest that history of mental illness is associated with prolonged recovery; however, little research has examined the value of these tools in a concussed pediatric population (Iverson et al., 2017).

Hypothesis/Purpose:

The purpose of this study was to explore the relation between anxiety and depression symptoms, mental illness history, sex, and time to recover in a concussed pediatric population. We hypothesized that mental health symptoms and history, and female sex would predict longer recoveries in the pediatric population.

Methods:

IRB-approved retrospective chart review was used for data collection. Demographics, self-reported mental health history, GAD-7, and PHQ-9 scores were acquired for 250 adolescents ages 12-18 (45.2% female) who presented to an outpatient concussion clinic for their initial visit. Days to recover was imputed for all patients who had been discharged by clinic physicians based on international return to play standards.

Results:

Mann-Whitney U tests were used for analysis of this nonnormally distributed data. Males were found to recover more quickly than females (female median = 15 days, IQR 7-27; male median = 12 days, IQR 6-23; p=.013). No significant differences were observed in days to clearance based on reported history of mental health disorder (p=.066). Individuals who scored above cutoff (see Kroenke et al., 2001; Spitzer et al., 2006) on the GAD-7 (below cutoff median = 12.00 days; above cutoff median = 21.00 days) and PHQ-9 (below cutoff median = 23.5 days; above cutoff median = 57.00 days) required longer recovery times (p <.001).

Conclusion:

We found longer recovery times in females versus males, and in those whose scores fell above cutoff for the PHQ-9 and GAD-7 at their initial clinic visit. Although a trend existed, there were no significant differences in recovery time for those who reported a mental health history compared to those who did not. Results suggest that the GAD-7 and PHQ-9 may be useful screening measures in a concussion clinic and may provide additional insight into potential recovery times for pediatric patients.
STUDY OF NORMAL VALUES OF PROPRIOCEPTION BASED ON AGE
Authors: Nault Marie-Lyne , Chémaly Olivier , Grimard Guy , Sarda Mélanie , Trottier Marie-Pier , Tan Xue Wei
Published: April 2020

Background:

Proprioception is an important function which allows the brain to perceive the body’s position. It is a safety mechanism aiding the generation of movements to correct and maintain balance. During a return to sports for adults, it is essential to have a good postural control. However, this requirement is applied subjectively in a pediatric setting. The Biodex Stability System (BSS) is a validated instrument capable of evaluating proprioception by producing stability indexes. Unfortunately, the stability indexes for a healthy pediatric population and the associated characteristics have not yet been determined.

Purpose:

The primary objective was to establish normal pediatric values of proprioception using the BSS. The secondary objectives were to find correlations between various subgroups (sex, physical activity participation and joint laxity, etc) and the stability indexes.

Methods:

An observational cohort study was done. Patients from July 2018 to September 2018 were included from the facture clinic. Inclusion/exclusion criteria were: (1) a consolidated upper limb fracture, (2) no previous history of lower limb injury, (3) no congenital anomalies of the lower limb or neuromuscular disease. Included subjects underwent 3 test trials of 20 seconds each of single-leg shoeless postural control with eyes open and at a stability level of 4. The overall stability index (OSI), anteroposterior stability index (APSI) and mediolateral stability index (MLSI) were noted. The protocol was conducted on both legs. Kolmogorov-Smirnov test will be used for the primary objective and, Pearson correlation for secondary objective.

Results:

Seventy-one participants (29 girls and 42 boys) with a mean age of 12.75±2.2 years old and a mean Beighton laxity score of 2.5±2.5 were recruited. The mean left OSI is 4.4±3.1 and the mean right OSI is 4.5±3.3. When comparing the subgroups, we were able to find correlations between the body mass index (BMI) and the OSI for both legs (left: r= 0.312, p = 0.008; right: r= 0.437, p = 0.001). We did not find any other correlations for any other groups (sex, age and Beighton score).

Conclusion:

A larger sample size will be needed to establish normal values based on sex and skeletal maturity but a mean value for OSI for a normal pediatric population was established. This study illustrates that, in our pediatric population, an increase in BMI is associated with an increase in OSI. Therefore, children with a higher BMI could potentially benefit from a proprioception training program in order to prevent the occurrence of injuries.
CAN NEAR POINT CONVERGENCE IN PEDIATRIC CONCUSSION PATIENTS PREDICT STUDENTS’ SUCCESSFUL RETURN TO LEARNING?
Authors: Koschmeder Katelyn , Mortazavi Mohammed , Rierio Hector , Handmaker Hirsch ,   CACTIS Foundation
Published: April 2020

Purpose:

The purpose of this study was to identify whether abnormal near point convergence (NPC) could be used as a clinical predictor of a 10-18 year old student’s ability to successfully return to learning (RTL).

Methods and Study Design:

This was a retrospective chart review of 122 students who initially visited a sports medicine clinic between 11/22/17 to 02/27/19 due to a concussion. A total of 268 visits were analyzed. RTL is graded in color zones, with red = no school, orange = half time or less, yellow = half time or more, green = full time with accommodations, and blue = full clearance. No patients were reported in the red zone in our cohort due to its severity. Patients with learning disabilities or oculomotor deficits were excluded.

Results:

Of the patients who met the inclusion criteria, we found a statistically significant difference in average NPC between the blue and orange zones (p<0.001) using a pooled proportions test. Average NPC was 7.03cm for blue, 8.84cm for green, 12.67cm for yellow, and 14.40cm for orange representing a positive linear correlation with an R2 of 0.975. Whereas 81% of patients in the blue zone had a normal NPC (<9cm), this was true for only 31% of patients in the orange zone. There was a 43% increase in average NPC from yellow to green zone. Yellow was the most frequent color zone with 56.7% of all visits in this zone.

Conclusions:

NPC appears to have a strong correlation with academic tolerance and can be predictive of RTL zones.

Significance:

Currently, little research has been done on clinical predictors of RTL. This data supports the use of oculomotor testing, such as NPC, which can easily be completed at office visits, as predictive tools that may indicate which patients presenting with concussion need increased academic accommodations.

[Figure: see text]
ARTHROSCOPIC SHOULDER STABILIZATION IN HIGH SCHOOL FOOTBALL PLAYERS: RECURRENT INSTABILITY WITH RETURN TO CONTACT SPORT
Authors: Stambaugh Jessica , Edmonds Eric , Pennock Andrew
Published: April 2020

Background:

The etiology of recurrent shoulder instability after arthroscopic surgery in the high school American football population remains unknown.

Purpose/Hypothesis:

To determine the risk of recurrent instability after shoulder arthroscopy upon return to competitive football. The hypothesis was that the rate of recurrence would be greater in high school players with more years of eligibility remaining (YER), suggesting greater likelihood of return to football after surgery.

Methods:

Consecutive male high school football players with at least one year of eligibility remaining who sustained traumatic in-season shoulder instability episode(s) and underwent arthroscopic labral stabilization by two Orthopaedic Sports surgeons at Rady Children’s Hospital San Diego between 2012 and 2017 were identified. 64 subjects aged 14-17 met inclusion criteria of which 45 were able to be contacted and included in analyses. Average follow up period was 4.06 years. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistics were conducted using chi square analysis to compare recurrence of instability with return to sport.

Results:

Surgery itself was career ending in 50% of cases due to reported fear of recurrent football-related injury. The hypothesis that career longevity in terms of years of eligibility remaining (YER) affects return to game play in this young active population remains unclear although preliminary results suggest positive exponential correlation. Comparative analysis demonstrates a statistically significant difference between rate of recurrence in high school football players that return to contact sports vs transition to non-contact activity after arthroscopic shoulder stabilization. Interestingly, football players who concurrently played baseball during high school demonstrated decreased risk of postoperative instability episodes.

Conclusion:

Risk of recurrent instability after shoulder arthroscopy is increased in high school football players who return to competitive contact sports whereas transition to non-contact and/or recreational activity likely confers protective effect. High school football players who play baseball may derive functional benefit from cross training.

[Figure: see text]
EPIDEMIOLOGY OF PEDIATRIC CARTILAGE RESTORATION PROCEDURES IN THE UNITED STATES: INSURANCE AND GEOGRAPHY PLAY A ROLE
Authors: Hall Tyler B. , Hyman Max J. , Patel Neeraj M.
Published: April 2020

Background:

A number of surgical options are available for sizeable articular cartilage lesions of the knee. These include osteochondral autograft (OAU) or allograft (OAL) transfer, or autologous chondrocyte implantation (ACI). In the pediatric population, there is little data on the patients undergoing these procedures or evidence to support one technique over another, which may lead to variation in preferred practice.

Hypothesis/Purpose:

The purpose of this study is to analyze the epidemiology of children and adolescents undergoing OAU, OAL, and ACI in the United States, with attention to variation along the lines of demographic and geographic factors.

Methods:

The Pediatric Health Information System, a national database consisting of 49 children’s hospitals, was queried for all patients undergoing OAU, OAL, and ACI between 2012 and 2018. Demographic information was collected for each subject. United States Census guidelines were used to categorize hospitals geographically into regions. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.

Results:

A total of 809 subjects with a mean age of 15.4±2.4 years were included in the analysis. Of these, 393 (48.6%) underwent OAL, 339 (41.9%) underwent OAU, and 77 (9.5%) underwent ACI. The most common diagnosis at the time of surgery was osteochondritis dissecans in 360 patients (44.5%) followed by an associated cruciate ligament injury in 126 (15.6%) and patellar instability in 98 (12.1%). After adjusting for confounders in a multivariate model, ACI was more 3.4 times more likely to be performed in patients with private insurance than those that were publicly insured (95% CI 1.5-7.5, p=0.002). Furthermore, a patient in this Northeast was 29.3 times more likely to undergo ACI than in the West (95% CI 4.0-217.4, p=0.001). OAU was performed most frequently in the West and Midwest (52.4% and 51.8% of the time, respectively; p<0.001). Univariate analysis also revealed differences along the lines of race, but these findings did not maintain statistical significance in multivariate analysis.

Conclusion:

In the United States, there is substantial variation in the procedures performed for cartilage restoration in children and adolescents. Though ACI is the least commonly selected operation overall, it is significantly more likely to be performed on patients with private insurance and those in the Northeast. OAU is the most commonly performed procedure in the West and Midwest.
THE RELATIONSHIP BETWEEN PATELLAR MORPHOLOGY AND LATERAL PATELLAR INSTABILITY
Authors: Andelman SM. , Hedgecock J. , Solomito M. , Kostyun R. , Pace JL.
Published: April 2020

Background:

Lateral patellar instability (LPI) is a substantial cause of morbidity in the pediatric population. Previously identified risk factors for LPI include trochlear dysplasia, a lateralized tibial tubercle, genu valgum, femoral anteversion, and external tibial torsion. Less is known regarding the relationship between patellar morphology and LPI.

Purpose:

The goal of this study is to determine whether there exists a relationship between patellar morphology and LPI.

Methods:

Magnetic resonance imaging (MRI) evaluation was performed for patients under 18 years of age with LPI and compared to a control group of MRIs of patients with anterior cruciate ligament (ACL) rupture. Using T2 axial MRI images, the lateral and medial facet angle of both the bone and cartilage of the patella was measured at three locations: the most proximal and distal aspects of the patella where the cartilage of the facets could be identified and the widest point of the patella. The width of the patella at each point was also recorded, resulting in 15 total data points per subject (5 at each of the three locations on the patella). Results were analyzed and compared between the instability group and the control group to determine any relationship between facet angle and LPI.

Results:

196 MRIs were reviewed, 97 in the instability group and 96 in the control group. The LPI group was noted to have a less steep angle at the proximal medial patellar facet of both the bone (LPI 27.2° ± 9.3° ; control 32.7° ± 8.8°, p < 0.001) and cartilage (LPI 26.5° ± 8.8°, control 32.7° ± 8.4°, p < 0.001) as well as a less steep angle of the cartilage at the distal lateral facet (LPI 23.4° ± 7.2°, control 25.6° ± 6.6°, p = 0.033). No other differences were noted for the remaining 12 data points.

Conclusion:

The are very few differences in patellar morphology between patients with and without LPI. Patients were LPI have a less steep angle of the bone of the proximal medial facet, the cartilage of the proximal medial facet, and the cartilage of the distal lateral facet when compared to a control group.

[Figure: see text]
OUTCOMES OF ARTHROSCOPIC LOOSE BODY MANAGEMENT IN PATELLA INSTABILITY: MEDIAL PATELLOFEMORAL LIGAMENT NEGLECT OR REPAIR VERSUS RECONSTRUCTION
Authors: Johnson Kristina P. , Carroll Alyssa N. , Pennock Andrew T.
Published: April 2020

Background:

Patellar instability is common in adolescents during their growth. Management of the actual patellar instability at the time of arthroscopic treatment for concomitant intra-articular loose body has been debated since many surgeons will manage first-time dislocations without surgery.

Hypothesis/Purpose:

To demonstrate that medial patellofemoral joint reconstruction, rather than neglect or repair of the ligament, should be performed at the time of arthroscopic loose body removal for first-time patellar instability events in children.

Methods:

Retrospective study design was performed on all patients who sustained a patellar instability event that resulted in an intra-articular loose body between 2011 and 2017 at our institution. Data was collected using ICD-9/10 and/or CPT codes. Patients included in the analysis were required to have a minimum of 24 month follow-up documented. We then performed chart review and radiographic review (XR and MRI). Variables collected included: demographics, weight, BMI, pain score, SANE score, Kujala score, subsequent recurrent instability, need for second surgery, growth plate status, trochlear dysplasia, TT-TG, Insall-Salvati ratio, and Blackburne-Peel ratio. Data analysis pooled the “neglect” and “repair” groups together and compared it to the “reconstruction” group. Continuous variables were examined for normal distribution and homogeneity and analyzed with ANOVA or Mann Whitney. Chi square was utilized for categorical variables.

Results:

64 patients (34 males, 30 females) with a mean age at surgery of 14 years (range 9 to 18) met criteria. These participants had a reported mean weight (kg) and BMI of 67.6 kg and 23.9, respectively. In our two-cohort analysis, the reconstruction cohort demonstrated significantly less subsequent instability, with the rate of recurrence being 58.7% in the neglect/repair compared to 16.7% in the reconstruction group (p=0.002). In addition, the reconstruction group demonstrated significantly less patients that required second surgery (p=0.024). The only continuous variable that showed any statistically significant difference was the Insall-Salvati ratio (p=0.048) with the reconstruction group being a mean 1.3 versus a mean 1.4 in the neglect/ repair group. There was no difference was found for age, weight, BMI, Blackburn ratio, TDI, TT-TG, Pain, SANE, Kujala score, satisfaction, or length of follow-up.

Conclusion:

Medial patellofemoral ligament reconstruction in the setting of adolescent patellar instability with an intra-articular loose body results in significantly less recurrent instability and reduced need for subsequent surgery compared to those who do not undergo a concomitant ligament reconstruction.
THE CHALLENGES OF TREATING FEMALE SOCCER PLAYERS WITH ACL INJURIES: IS THERE A BEST GRAFT CHOICE?
Authors: Britt Elise , Ouillette Ryan J. , Johnson Kristina P. , Edmonds Eric W. , Chambers Henry G. , Bastrom Tracey P. , Pennock Andrew T.
Published: April 2020

Introduction:

While Anterior Cruciate Ligament (ACL) injuries are common in female soccer players, the optimal graft option is currently unclear.

Purpose:

The purpose of this study was to compare outcomes of female soccer players undergoing an ACL reconstruction with either hamstring tendon autograft versus bone-patellar tendon-bone (BTB) autograft.

Methods:

A retrospective review of all skeletally mature adolescent female soccer players who underwent a primary ACL reconstruction with either hamstring tendon or BTB autograft between 2013 and 2016 was performed. Patients who had a multi-ligamentous reconstruction, a prior ACL injury, or had follow-up less than 2 years were excluded. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm, Single Assessment Numerical Evaluation (SANE), Tegner activity, visual analog pain, and satisfaction scores. Ability to return soccer as well as their pre-injury level of play and any reason that they could not return was documented.

Results:

Ninety-three female soccer players met the inclusion criteria of which 76% (41 BTB and 30 hamstring) were available for a minimum 2 year follow-up or had a documented graft failure prior to this time. The mean age of the cohort was 15.4±1.3 years. The BTB group had a Body Mass Index (BMI) that was significantly lower than the hamstring group (23±3 vs 25±4; p=0.02). There were no other differences in demographic, injury, or surgical variables between groups. Patient reported outcomes demonstrated that most patients did well with a mean Lysholm, SANE, Satisfaction, and pain scores of 92, 88, 8.9, and 1.1 respectively with no differences between groups. The BTB autograft group did achieve a significantly higher Tegner score (6.0 vs 4.3; p=0.004). Although not reaching significance, the BTB group had a greater percentage return to pre-injury level of play (44% vs 30%; p=0.31), or return to any level of soccer play (71% vs 53%; p=0.21 and. Of the patients that returned to soccer, 30% sustained another ACL injury (retear or contralateral tear) with no differences identified based on graft selection.

Conclusion:

Adolescent female soccer players undergoing an ACL reconstruction have relatively high satisfaction and outcome scores independent of autograft choice. Patients and families, however, need to be counseled that less than half of patients will return to their pre-injury level of sport and if an athlete attempts to return there is a high risk of further ACL injury.
CLASSIFICATION OF ACL TEARS IN THE PEDIATRIC AND ADOLESCENT POPULATION
Authors: Kushare I , Beran M , Klingele K , Ettia E , Elabd A , Inneh I , McKay S
Published: April 2020

Background:

There have been previous imaging classification schemes in the literature that described ACL tears in adults and pediatric patients. More recent publications have described the epidemiology, injury mechanisms, and repair versus reconstruction techniques. None have proposed an arthroscopic classification for pediatric patients.

Purpose:

To describe our experience with a novel arthroscopic classification using 4 patterns of ACL tears depending on the type of tear and the tissue quality.

Methods:

An IRB approved prospective with 2 parts to this study: Part 1: Single center prospective case series using descriptive statistics of intraoperative findings. We included children ≤18 years old with an ACL tear who underwent surgery within 8 weeks of injury. Those with associated ligamentous injuries or revision surgery were excluded. We proposed a 4-stage classification as follows: I. Avulsion off femur II. <10% tear from femoral end III. Midsubstance tear IV. Single bundle tear. Part 2: Four fellowship-trained surgeons from two tertiary children’s hospitals classified ACL injury based on intraoperative video of 33 randomly selected surgeries. 2 rounds of classification were performed. Inter and intra-observer reliability studies were calculated using Kappa statistics.

Results:

120 patients (73 males and 47 females) with mean age of 16 (9-20) years and mean BMI 26 (16-51) were included in this study. 59 patients (49%) had left sided injury while 61 (51%) had right sided injury. 29 (24%) patients reported contact injury while 91 (76%) reported non-contact. Isolated ACL injury was recorded in 49 patients only (41%) while concomitant injuries were recorded in 71 patients (59%). The most common associated injury was the lateral meniscus tear (33%), followed by lateral and medial meniscus tear (13.4%). According to our classification, 23 (19.2%) patients were type I, 15 (12.5%) were type II, 65 (54.2%) were type III, and 17 (14.2%) were type IV. The intra-rater reliability was excellent for 2 reviewers, good for 1 and marginal for another. The overall inter rater reliability for all 4 reviewers was marginal for both readings (k=0.35, 95% CI: 0.23-0.44; k=0.26, 95%CI: 0.16-0.35 respectively).

Conclusion:

With renewed interest in ACL repairs and techniques, a classification system for ACL tears can guide a proper surgical plan. Our classification system provides a step to achieve this goal. It showed overall good intra-observer reliability, with marginal inter-observer reliability.
Can EOS imaging substitute traditional AP pelvis radiographs? A Comparative study
Authors: Powell Jenna , Gibly Romie , Faulk Wade , Mayer Stephanie Watson , O’Donnell Courtney Michelle
Published: April 2020

INTRODUCTION:

Young patients followed for hip disorders often require serial imaging and incur significant radiation to the abdomen and pelvis. The EOS imaging system offers a low-radiation alternative. However, consistency with radiographic parameters from conventional radiographs (CR) have not been studied. We evaluated the reliability and validity of EOS imaging in comparison to CR in evaluating acetabular morphology.

METHODS:

48 hips (27 patients, 66.67% female, 14.4 ± 3.6 years old), indicated for open hip preservation procedure between 2015-2017, which had both EOS imaging and AP pelvis CR taken pre-operatively were examined. Both symptomatic and contralateral hips were measured, excluding hips with prior osteotomies. Three orthopaedic surgeons measured Tonnis angle, lateral center edge angle (LCEA), acetabular depth ratio (ADR), and extrusion index (EI) in both imaging modalities. Images were measured twice, two weeks apart. Reliability was assessed using intraclass correlation coefficients (ICC). Bland-Altman analysis was used to evaluate test-retest agreement and inter-modality agreement.

RESULTS:

Test-retest reliability was excellent for all raters on all tests (ICC range 0.8047 to 0.9714). Inter-rater reliability was also excellent for all measures on both modalities (ICC range 0.8593 to 0.9547). ICC values were consistent across EOS and CR. By Bland-Altman analysis, test-retest agreement was high, with no statistically significant mean differences in any test or modality (p > 0.6) except LCEA measured on EOS images (p = 0.02), which was 1.16° lower. Tonnis angle (p < 0.005) and ADR (p < 0.001) were statistically different from EOS to CR. Bias was also not uni-directional across tests: LCEA and ADR were, on average, higher on CR while Tonnis angle and EI were, on average, higher on EOS images. Reliability between the EOS and CR images was excellent for all raters on all tests (ICC range 0.8402 to 0.9458).

DISCUSSION AND CONCLUSION:

LCEA, ADR, EI, and Tonnis angle have consistently high test-retest reliability, test-retest agreement, and inter-observer reliability in both EOS imaging and CR to evaluate acetabular morphology. Inter-modality disagreement was observed between EOS and CR, but the difference was small and likely not clinically significant. When establishing acetabular morphology, these results suggest that EOS may provide an opportunity to minimize radiation exposure for patients followed long-term for hip pathology while maintaining the accuracy of diagnostic measures.

[Table: see text][Table: see text]
RELIABILITY OF A NOVEL KOCHER CLASSIFICATION FOR OSTEOCHONDRITIS DISSECANS
Authors: Mathew Stephen T. , Lins Laura A. , Miller Patricia , Kocher Mininder S.
Published: April 2020

Background:

Current radiographic classification systems for osteochondritis dissecans (OCD) of the knee utilize different characteristics of lesions to rate the stability and severity of disease. Classification systems such as Hefti and Nelson are widely used as the current standards for radiographic imaging and arthroscopic evaluation is the gold standard to assess stability. The purpose of this study was to compare the reliability of this new method with that of older, more established methods, as the first step in establishing its validity and clinical utility.

Methods:

One hundred twenty-four standardized knee MRIs of established patients with knee OCD were pre-selected to capture the spectrum of lesion types both regarding progression and location of the lesion. Each of the MRIs were classified independently by 2 readers into the Kocher, Hefti, and Nelson classification systems and a random sample was re-reviewed by one rater 6 weeks after initial review. The inter-rater and intra-rater agreement was evaluated by estimating Krippendorff’s alpha.

Results:

108 knees were classified by the Kocher, Hefti, and Nelson classification systems, as 16 of the studies had an absence of the appropriate imaging sequences necessary. There were no differences in agreement across classification systems. Krippedorf’s alpha for interrater agreement was 0.51 (CI 0.33-0.66) for the Hefti classification, 0.50 (0.34-0.64) for the Nelson classification, and 0.49 (0.32-0.65) for the Kocher classification. The intrarater agreement was 0.88 (0.75-0.97) for the Hefti classification, 0.94 (0.86-0.99) for the Nelson classification and 0.98 (0.94-1.00) for the Kocher classification system.

Conclusions:

The novel Kocher classification for knee OCD had almost perfect intrarater agreement and moderate interrater agreement, consistent with well-established classification systems. This new classification system would be simpler with only three categories, whereas the Hefti (five) and Nelson (four) sysems had more. This simpler classification system could be widely applicable because the results could more accurately drive clinical treatment decision making for clinicians.
PEDIATRIC ELBOW COLLATERAL AND ANNULAR LIGAMENT ANATOMY: A CT-BASED CADAVERIC STUDY
Authors: Stavinoha Tyler J. , Cannamela Peter C. , Ganley Theodore J. , Shea Kevin G.
Published: April 2020

Background:

The medial and lateral ligamentous complexes of the elbow provide static restraint to the elbow and serve as important components of posteromedial and posterolateral rotatory instability. Many collateral ligament and medial epicondylar injuries require surgical repair in those with open physes. Little is known about the anatomy of the pediatric elbow and the relationship between these ligaments and physes. Purpose: To evaluate the anterior bundle of the medial collateral ligament complex, lateral ulnar collateral ligament, annular ligament, and relationships to the joint surfaces and physes.

Methods:

Two cadaveric elbows from a 3 year-old donor were dissected. Collateral and annular ligaments were isolated and left intact at their osseous attachment. Pins were placed at the origins and insertions and CT scans were used to establish precise anatomic relationships. All dissections and measurements were performed by a single orthopedic surgeon with specialization in pediatric sports medicine.

Results:

The MUCL origin was a mean 4.10 mm distal and anterior to the medial epicondyle, 10.09 mm from the distal humeral articular surface, and 9.01 mm distal to the medial physis. The distal insertion of the MUCL spanned a mean 3.09 mm and was posterior and medial to the sublime tubercle. In the longitudinal axis, the MUCL insertion footprint spanned the tubercle. The origin was a mean 1.20 mm proximal to the sublime tubercle and the distal extent averaged 2.53 mm distal to the tubercle. The center of the MUCL insertional footprint was 0.38 mm distal to the tubercle. The center of the MUCL was 3.87 mm from the olecranon articular surface. The annular ligament had consistent medial and lateral attachments to the ulna. Distance from the annular ligament attachments to the tip of the coronoid averaged 4.6 mm (4.46 & 4.74 lateral and medial for left; 4.80 & 5.27 lateral and medial for right). The LUCL origin was distal and anterior to the lateral epicondyle. It was 3.43 mm from the lateral epicondyle, 7.51 mm from the articular surface and 0.74 mm distal to the physis.

Conclusions:

This study is the first to describe anatomy of the elbow collateral and annular ligaments in pediatric cadaveric specimens, through a reliable, CT-based identification method. Knowledge of the precise ligamentous attachments and relationships to the physis and to the joint surface is important for reconstructive procedures. A better understanding of these relationships may assist with surgical planning that preserves adjacent physeal growth regions.
ALTERED BRAIN FUNCTIONAL CONNECTIVITY FOLLOWING A SEASON OF COMPETITIVE FEMALE HIGH SCHOOL SOCCER AND THE EFFECT OF A JUGULAR VEIN COMPRESSION COLLAR: A NETWORK-BASED STATISTICS ANALYSIS
Authors: Dudley Jonathan A. , Diekfuss Jed A. , Yuan Weihong , Foss Kim D. Barber , DiCesare Christopher A. , Logan Kelsey , Leach James L. , Myer Gregory D.
Published: April 2020

Background:

Cumulative exposure to repetitive sub-concussive head impacts in contact sports may have deleterious effects on brain function, even in the absence of acute symptoms. Moreover, anatomical and biomechanical factors may predispose female athletes to higher risk compared to males. At present, there is no effective injury prevention strategy to protect female athletes from sports-related head impact.

Hypothesis/Purpose:

(1). We aimed to use resting-state fMRI to investigate the effect of a full season of competitive soccer on brain functional network integrity in female high school athletes. (2). We also aimed to evaluate the efficacy of a jugular vein compression neck collar device, designed to mitigate potential injury by reducing the brain slosh effect.

Methods:

A total of 125 high school female soccer athletes were included in this study. These athletes were assigned randomly to a non-collar (n=55, age=16.06±1.06 yrs) or collar group (n=70, 15.81±0.95 yrs) before the season started. High resolution 3D T1-weighted images and resting-state fMRI data were collected prospectively at pre-season and again at post-season. Data processing and analysis were conducted in the MATLAB-based programs Statistical Parametric Mapping (SPM12) and Connectivity Toolbox (Conn). Functional connectivity was computed between each pair of 105 anatomically delineated regions of interest (ROI). Network Based Statistics were applied to detect coherent patterns of altered connectivity from pre- to post-season.

Results:

The non-collar group showed a significant pattern of altered connectivity (p-FWE = 0.047) spanning 60% of ROIs (63/105) and 1.7% of ROI-ROI connections (94/5,460). 65 of the 94 altered connections were weakened from pre-to-post season and tended to occur in the right hemisphere. 29 of the 94 altered connections were strengthened from pre-to-post season and tended to involve regions in the occipital lobe. The collar group did not show any statistically significant change (p-FWE = 0.223).

Conclusion:

The results of this study indicate that exposure to repetitive sub-concussive head impacts during a single season of competitive female soccer induces changes in brain functional connectivity. The observed increases and decreases of functional connectivity strength comprising the pattern of altered connectivity are congruent with a heterogeneous response to insult wherein some connections are reduced in strength due to neuronal damage and other “detour” connections are strengthened to preserve network function. Comparatively, the absence of alterations in the collar group suggest that the jugular vein compression collar may have generated a potentially protective effect to preserve brain functional network integrity during exposure to head impacts.

[Figure: see text]
PROSPECTIVE MEASURES OF INTRA-REGION BRAIN REGULARITY DIFFERENTIATES ACL INJURED AND UNINJURED ATHLETES
Authors: Bonnette Scott , Diekfuss Jed A. , Grooms Dustin R. , Myer Gregory D.
Published: April 2020

Background:

Anterior cruciate ligament (ACL) injuries are debilitating for athletes. While numerous motor and biomechanical deficits contribute to the inciting ACL injury mechanism, the limited knowledge about the underlying neural drivers of these deficits has impeded intervention development to reduce ACL injury rates. A prospective investigation using functional magnetic resonance imaging (fMRI) in female soccer players revealed decreased connectivity between the primary somatosensory cortex and cerebellum for athletes that went on to ACL injury athletes compared to their healthy teammates. Although information about inter-region connectivity patterns is informative, this finding does elucidate the individual, intra-region brain activity that may be further underlie ACL injury mechanisms.

Hypothesis/Purpose:

The purpose of this study was to prospectively investigate the intra-region regularity of the blood oxygen-level dependent (BOLD) signal activity in 25 knee-related regions of interests (ROI) between athletes who sustained an ACL injury and matched controls.

Methods:

Adolescent female soccer athletes were evaluated using fMRI to capture resting-state brain connectivity prior to their competitive season. Two of these athletes (16.0±0yrs, 169.0±2.8cm, 60.1±8.3kg) later experienced an ACL injury and were matched to eight uninjured teammates (15.9±0.8yrs, 164.0±4.9cm, 58.3±7.6kg). Standard fMRI data processing was used to determine resting-state BOLD signal activity in 25 knee-related ROIs. Sample entropy (SampEn) was then used to quantify the regularity of each individual ROI. A lower SampEn value indicates a ROI’s BOLD signal activity was more regular (predictable) and a higher value indicates a signal’s activity was more irregular (unpredictable). T-tests—with a Bonferroni correction for the familywise error rate ( p < .002)—were used to compare SampEn values between both groups for all 25 ROIs.

Results:

ACL injured athletes ( M = 0.35±0.01) exhibited higher SampEn values in the left primary motor cortex than matched, uninjured athletes ( M = 0.29±0.02; t(8)=4.62, p=.0017, d=3.65).

Conclusion:

Athletes who sustained an ACL injury exhibited less regularity in BOLD signal activity of the left primary motor cortex. As the primary motor cortex serves as the final destination in the brain before efferent information is sent to the spinal cord to initiate movement, decreased BOLD signal regularity in this region may alter such cortical-spinal transmission. Considering ACL injuries often occur during unpredictable environments, irregular activity of motor cortex activity may dampen an athlete’s ability to sustain a safe knee position. These findings may help to guide development of brain-driven biofeedback training to promote adaptive neuroplasticity that ‘pushes’ the motor cortex towards more regular activity.

[Figure: see text]
LONG TERM QUALITY OF LIFE HEALTH OUTCOMES IN PATIENTS RECEIVING ULTRASOUND GUIDED INJECTIONS: PRELIMINARY ANALYSIS
Authors: Stracciolini Andrea , Kobelski Greggory , McKee-Proctor Maxwell , Yen Yi-Meng , d’Hemecourt Pierre , Sugimoto Dai
Published: April 2020

BACKGROUND:

Hip pain is a common complaint in athletes of all ages. Hip pathology includes both intra- and peri-articular pain generators. Ultrasound (US) evaluation and guided injections are used in the clinical setting for diagnostic and therapeutic purposes. However, evidence regarding the impact of US-guided injections on quality of life (QoL) health outcomes in patients with hip pain and injury is understudied.

PURPOSE:

To examine the long-term efficacy of US-guided injections on QoL outcomes in patients presenting to a tertiary level academic hip preservation program.

METHODS:

Prospective longitudinal study design was used to evaluate 12-55 years old patients with hip pain/pathology. Patients completed a Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire at the initial evaluation, 1.5-months, 4.5-months, and 12-months. Main outcome measures included change in QoL HOOS scores. Repeated measures analysis of variance (ANOVA) was performed to compare patients who received US-guided injections and patients who did not receive US-guided injections over time. Bonferroni pairwise comparison was performed as a post-hoc analysis.

RESULTS:

A total of 175 patients were included with a mean age of 24.1±9.8 years. There were 104 patients who received US-guided injections while 71 patients did not have US-guided injections. An interaction between US-guided injections over 12-months on QoL scores was identified. QoL increase over time was 6.5 points in patients without US-guided injection compared to 10.0 points in patients who had an US-guided injection ( P=0.040, Figure 1). Main effect of US-guided injections on QoL was not detected ( P=0.276). However, main effect of time on QoL was found ( P=0.003). Bonferroni post-hoc analysis indicated differences between initial evaluation and 1.5 months ( P=0.004, Figure 2), and initial evaluation and 12-months ( P=0.002, Figure 3).

CONCLUSION:

US-guided injections appeared to improve quality of life outcomes over the 12-month study period. US-guided injections may serve to help patients with hip pain presenting to clinic over time and promote and support non-surgical treatment regimes.

[Figure: see text][Figure: see text][Figure: see text]