bluuebunny/crossref_metadata_2025 huggingface dataset:
PEDIATRIC SPORTS INJURY EPIDEMIOLOGY DURING COVID-19 PANDEMIC
Authors: Johnson Mitchell A. , Pascual-Leone Nicolas , Shah Apurva S. , Bram Joshua T. , Ganley Theodore J.
Published: July 2021

Background:

The COVID-19 pandemic has prompted a multitude of public health response measures including social distancing, school cancellations, and cessation of organized sports. A change in the epidemiology of injuries commonly caused by sporting activities is expected.

Hypothesis/Purpose:

Examine the effect of public health measures on the incidence and characteristics of common pediatric sports injuries.

Methods:

This is a retrospective cohort study comparing sporting injuries presenting to a level I pediatric trauma hospital during the COVID-19 pandemic to sporting injuries during a pre-pandemic period at the same institution. Nine specific injury types were evaluated including ACL injury, meniscus injury, patellar dislocation, osteochondritis dissecans (OCD), shoulder dislocation, ankle sprain, clavicle fracture, medial epicondyle fracture, and tibial spine fracture. Patients were included if they presented for initial care between 3/15/20 and 4/15/20 for the “pandemic” group and the same time window in 2018 and 2019 for the “pre-pandemic” group.

Results:

487 patients were included in our study with an average of 222.5 patients in 2018 and 2019 compared to 42 patients in 2020. The average patient age decreased during the pandemic compared to the pre-pandemic period (9.4 ± 6.0 vs 12.4 ± 4.2, p=0.007). Additionally, a decrease in the proportion of injuries attributed to sports (26.2% vs 47.6%, p=0.005) and those occurring at school/daycare (4.8% vs 10.3%, p<0.001) were observed. During the pandemic there was an increase in the proportion of injuries occurring at the patients home (50.0% vs 16.9%, p<0.001)(Table 1). The distribution was significantly different across the nine injury types included with a decrease in the proportion of ankle sprains (31.0% vs 59.8%, p<0.001) and an increase in the proportion of clavicle fractures (50.0% vs 16.2%, p<0.001)(Figure 1). For ankle sprains, there was no significant difference in the proportion of anterior talofibular ligament injuries to high ankle sprains (p=0.898). There was no delay in presentation in the “pandemic” group compared to the “pre-pandemic” group (6.6 ± 9.6 vs 5.4 ±9.9, p=0.424).

Conclusion:

At our institution, we observed an over fivefold reduction in presentation for common pediatric musculoskeletal injuries typically associated with sports. The dramatic drop off in injuries occurring across both sports and non-sports injury mechanisms raises concern for presentation of untreated injuries in the future. Additionally, the increased proportion of injuries occurring in the home setting creates an opportunity for emphasis to be placed on basic safety precautions, especially for young children.

Tables/Figures:

[Table: see text][Figure: see text]
PEDIATRIC ORTHOPAEDIC TRAUMA AND ASSOCIATED INJURIES AT AN INNER-CITY LEVEL 1 TRAUMA CENTER
Authors: Levidy Michael , Rai Rahul , Chu Alice , Kaushal Neil , Edobor-Osula O. Folorunsho
Published: July 2021

Background/Purpose:

Pediatric orthopaedic trauma in inner city communities often present with unique and modifiable risk factors. The purpose of this study was to characterize and evaluate the pattern and nature of orthopaedic and associated injuries in pediatric patients involved in motor vehicle accidents (MVA), falls, sports related injuries and pedestrian struck either on foot or on bicycle at an inner-city level 1 trauma center.

Methods:

260 pediatric patients who presented to the emergency department after a fall, a sports related injury, MVA, pedestrian struck on foot (PSoF), or pedestrians struck on bicycle (PSoB) with orthopaedic injuries at our institution between 2013 and 2020 were retrospectively reviewed.

Results:

The mean age of our cohort was 9.1 years (SD ±4.60). 36.5% (95/260) were girls, 63.5% (165/260) were boys. There were a total of 260 patients with a total of 331 fractures. 96.3% (319/331) of the fractures were appendicular while 3.6% (12/331) were axial. 43.8% (114/260) of patients had lower extremity fractures and 49.2% (128/260) had upper extremity fractures. Of all mechanisms, MVAs were most commonly associated with axial fractures (p<0.01). Falls were associated most commonly with upper extremity fractures (p<0.01), lower patient age (p<0.01) and negatively correlated with lower extremity fractures (p<0.01). Sports related injuries were most commonly correlated with tibia fractures (p<0.01). Sports etiologies were subdivided into Basketball (29%), Football (27%), Soccer (11%), and other physical activities like Rollerblading (11%) and Skateboarding (9%). PSoF was associated with tibia fractures (p<0.05) and open fractures (p<0.01). PSoB was the most likely mechanism to lead to lower extremity fractures (p=0.01) and head trauma (p<0.01). 75% (6/8) of PSoB were not wearing a helmet at the time of injury.

Conclusion:

Not surprisingly, falls represent the most common mechanism of pediatric orthopaedic injury. Other mechanism of injuries included MVAs, pedestrian struck on foot or bicycle were associated with more significant trauma including vertebral fractures, open fractures, head trauma and compartment syndrome. Preventative measures including education on car seat and seat belt use, helmet use and bicycle safety in children may reduce the incidence of these serious injuries.

[Figure: see text]
OSTEOCHONDRAL ALLOGRAFTING IN THE SKELETALLY IMMATURE KNEE: HIGH RATES OF INCORPORATION AND EXCELLENT EARLY OUTCOMES
Authors: Tisano Breann , Ellis Henry B. , Wyatt Charles W. , Wilson Philip L.
Published: July 2021

Background:

While an excellent option for osteochondral defects in the adult knee, outcomes following fresh osteochondral allograft (OCA) the skeletally immature are limited. Purpose: To compare radiographic and patient reported outcomes (PROs) in mature and skeletally immature adolescents following OCA of the knee.

Methods:

An IRB-approved review of fresh size-matched OCA treatment of knee lesions in patients aged < 19 years within a pediatric sports medicine practice from 1/2006-3/2019 was completed. Following exclusion of patients with less than 12 months follow-up, demographics, lesion characteristics, reoperations, and PROs were evaluated. A novel grading scale (k= 0.832) was utilized to evaluate radiographic OCA incorporation: A=complete, B= >50%, or C= <50% healed.

Results:

Forty-four patients [15.5 years (9.6-19.8) treated with OCA of the distal femur or patella (LFC= 18, MFC=17, Trochlea=6, Patella=3), 24 with open and 20 with closed physes, with 2.2 year follow up (range 1-5.3 years) were evaluated. Overall average graft size was 4.76cm2 and did not differ significantly between groups. Thirty-nine patients underwent at least one prior procedure to the ipsilateral knee, most frequently for attempted osteochondral lesion healing (77%), followed by realignment (22.7%), and meniscal pathology (15.9%). Graft failure occurred in only one skeletally immature patient with a trochlear lesion. Those with open physes were more likely to demonstrate complete graft incorporation (66.6%, p=0.001). 21(88%) patients with open physes and 17(85%) patients with closed physes had radiographic healing grades of A or B one year post-operatively. There was no difference in healing grade based on graft size, depth, or location within the knee. There was no difference in pre-operative PROs or activity scores. At final follow-up, open physes OCA patients demonstrated better KOOS scores (KOOS daily living 97.0 vs 89.5, p=0.02; KOOS pain 95.7 vs 84.6, p= 0.04; KOOS quality of life 157.2 vs 59.6, p= 0.005). Final activity scores did not vary by skeletal maturity (Pedi-IKDC 75.8 vs 77.99; Pedi-FABS 17.2 vs 13.5,) or radiographic healing grade. Daily living and pain scores were better in those with more radiographic healing (KOOS daily living 98.6 vs 86,2, p= 0.02; KOOS pain 96.7 vs 82.3, p= 0.048).

Conclusion:

Fresh osteochondral allograft treatment in the young knee may be expected to yield good early results. Despite relatively large graft size, when indicated for patients with open physes, equivalent or improved healing and patient reported outcomes may be expected.
ORTHOPEDIC INJURIES IN ADOLESCENT GYMNASTS: A SYSTEMATIC REVIEW
Authors: Kim Katie , Saper Michael
Published: July 2021

Background:

Gymnastics exposes the body to many different types of stressors ranging from repetitive motion, high impact loading, extreme weight bearing, and hyperextension. These stressors predispose the spine and upper and lower extremities to injury. In fact, among female sports, gymnastics has the highest rate of injury each year.

Purpose:

The purpose of this study was to systematically review the literature on location and types of orthopedic injuries in adolescent (≤20 years) gymnasts.

Methods:

The Pubmed, Medline, EMBASE, EBSCO (CINAHL) and Web of Science databases were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify all studies reporting orthopedic injuries in adolescent and young adult gymnasts. All aspects of injuries were extracted and analyzed including location, type and rates of orthopedic injuries.

Results:

Screening yielded 22 eligible studies with a total of 427,225 patients. Twenty of 22 studies reported upper extremity injuries of which four specifically focused on wrist injuries. Eight studies reported lower extremity injuries. Nine studies reported back/spinal injuries. Seven studies investigated each body location of injury; one study reported the upper extremity as the most common location for injury and six studies reported the lower extremity as the most common location for injury. Of those seven studies, five (23%) reported sprains and strains as the most common injury. One study reported fractures as the most common injury.

Conclusion:

There is considerable variation in reported injury location. Some studies focused specifically on the spine/back or wrist. The type of gymnastics each patient participated in was also different, contributing to which area of the body was more heavily stressed, or lacking. Current literature lacks data to fully provide evidence regarding which body region is more frequently injured and the type of injury sustained.
SURGICAL TREATMENT OF PATELLAR INSTABILITY IN ADOLESCENT DANCERS
Authors: Nunally KD , Micheli LJ , Zheng E , Hussain Z , Wilson B , Kocher M , Yen YM , Kramer DE , Heyworth BE
Published: July 2021

Background:

Adolescent dancers may be a high-risk population for patellofemoral instability (PFI), but the condition remains under-investigated, to date, in this sub-group of athletes.

Purpose:

The purpose of this study was to (1) investigate the descriptive epidemiology of PFI in adolescent dancers, (2) analyze the efficacy of various patellar stabilization procedures within this population, and (3) compare PFI in dancers to a larger control group of matched, non-dancer athletes.

Methods:

A retrospective review of athletes, ages 10 to 19, who presented to a single tertiary care center with PFI between 2008 and 2017 was performed. Based on each patient’s primary sport, the cohort was divided into a dancer and a non-dancer control group. Demographics, clinical and radiologic features, surgical stabilization technique, and postoperative course and clinical outcomes were collected. Independent categorical groups were tested using chi squared and Fisher exact tests.

Results:

258 adolescent athletes were included, 41 of whom were dancers, all females. This group was therefore matched with a control group of similarly aged, all-female athletes with PFI (Table 1). 54 athletes had bilateral PFI, yielding 285 knees for analysis. There was no difference between dancer and non-dancer athletes’ age, BMI, laterality, mechanism of injury, nor number of preoperative instability events. However, dancers had lower Dejour Classifications (p=0.044), smaller patella inclination angles (20.9±8.14 versus 25.0±9.84; p=0.004), and smaller Caton-Deschamps Indices (1.18±0.161 versus 1.25±0.189; p=0.041). Among dancers, there was no association between surgical stabilization technique and rates of recurrent instability (p=0.418) nor re-stabilization procedures (p=1.0) (Table 2). However, dancers who underwent tibial tubercle osteotomy (TTO) had higher rates of subsequent, non-stabilization procedures (66.7%), all for implant removal, compared to those undergoing isolated medial retinacular repairs (MRP) (3.8%) (p<0.001). There was no difference between the dancer and non-dancer athletes’ rates of recurrent instability (p=0.297), re-stabilization procedures (p=0.061), nor subsequent non-stabilization procedures (p=0.242).

Conclusions:

Female dancers with PFI have similar demographic and clinical features as other female athletes with PFI, but have lower rates or less severe trochlear dysplasia, lateral tilt and patella alta. Therefore, the ligamentous laxity inherent in dancers may be a more powerful risk factor for PFI than other non-modifiable risk factors. Notably, the TTO was a powerful stabilization procedure for this sub-population with low rates of recurrent instability episodes and no revision stabilization procedures performed. Rates of implant removal surgery following TTO may be substantial, though this may be technique or surgeon dependent.

Tables/Figures:

[Table: see text][Table: see text]
SPORT	TYPE AND BASELINE NEUROCOGNITIVE SCORES AMONG HEALTHY HIGH SCHOOL ATHLETES
Authors: Oldham Jessie R. , Howell David R. , Lanois Corey J. , Berkner Paul D. , Mannix Rebekah C. , Meehan William P.
Published: July 2021

Background:

Athletes who participate in collision sports may experience more repetitive head impacts than other sport types. These repetitive head impacts have been theorized as a potential catalyst for cognitive problems later in life. It is unknown, however, if sport type influences neurocognitive performance.

Hypothesis/Purpose:

Our purpose was to investigate the association between sport type and baseline neurocognitive scores in a high school athletic population. We hypothesized that athletes participating in collision sports would demonstrate worse scores on baseline neurocognitive tests compared to those in contact or non-contact sports.

Methods:

We conducted a cross-sectional, observational study using baseline computerized neurocognitive scores of 186,117 high school student-athletes (age: 15.47±2.28 years, height: 168.53±10.77 cm, weight: 63.02±14.83 kg, 45% female) in the state of Massachusetts. The dependent variables were five composite scores (verbal memory, visual memory, visual motor, reaction time, and impulse control) and total symptom score. The independent variables included sport type (collision, contact, non-contact), age, sex, and concussion history. We used univariable one-way ANOVAS to compare composite scores between sport type. We conducted a series of multivariable regression models, controlling for age, sex, and number of previous concussions, to examine the independent association between sport type and composite scores.

Results:

There was a minimal but statistically significant association between sport type and composite scores, with collision sport athletes performing slightly worse than other athletes on most composite scores. Collision sport athletes had a slightly lower symptom burden. (Tables 1 and 2)

Conclusion:

While statistically significant, the differences in neurocognitive function and symptom burden between sport type are of questionable clinical significance. In fact, all of them fall within the reliable change index values of each respective score. As participants were in high school at the time of the study, we cannot determine the potential for associations later in life.

Tables/Figures:

[Table: see text][Table: see text]
UNEVEN PLAYING FIELD: INSURANCE STATUS ADVERSELY AFFECTS CHILDREN WITH TIBIAL SPINE FRACTURES
Authors: Patel Neeraj M. , Leska Tomasina M. , Ganley Theodore J. , Aoyama Julien T. , Cruz Aristides I. , Ellis Henry B. , Fabricant Peter D. , Green Daniel W. , Jagodzinski Jason , Johnson Benjamin , Kushare Indranil , Lee Rushyuan J. , McKay Scott D. , Rhodes Jason T. , Sachleben Brant C. , Sargent M. Catherine , Schmale Gregory A. , Yen Yi-Meng , Mistovich R. Justin
Published: July 2021

Background:

Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Hypothesis/Purpose: The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents.

Methods:

We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.

Results:

Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001).

Conclusion:

Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.
TIBIAL PHYSEAL RESPECTING TUNNEL DRILLING TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN SKELETALLY IMMATURE ATHLETES
Authors: Pearce Stephanie S. , Gagliardi Alexia G. , Howell David R. , Albright Jay C.
Published: July 2021

Background:

ACL reconstruction is common in young patients.

Hypothesis/Purpose:

To report outcomes of a novel tibial drilling technique using an inside-out socket drilling method, with a drill pin and epiphyseal socket drilling in skeletally immature patients. Minimizing disruption to the tibial physis, attempting to prevent growth disturbance with an anatomic ACL that eliminates the graft bend angle at the tibial tunnel.

Methods:

We used a standard all-epiphyseal drilling technique for femoral preparation. The tibial drill guide, set at 55° for our tibial physeal respecting approach, is positioned in the posterior third of the ACL footprint in-line with the posterior aspect of the lateral meniscus anterior root. The FlipCutter (Arthrex Inc., Naples, FL) is drilled from the external proximal tibia. Thus, only a 3.5mm diameter tunnel crosses the proximal tibial physis. With the FlipCutter deployed, the cutting radius is checked to confirm proper position without risk of damage to the meniscal root, PCL, or articular cartilage. With fluoroscopic guidance, the tibial socket is drilled from the intra-articular surface towards the physis, stopping proximal to the physis. This results in a 15 to 20 mm all-epiphyseal socket length. We collected demographics, re-tear rate, physeal arrest (partial/complete), and patient reported outcomes in order to understand potential problems and mid-term outcomes of this procedure.

Results:

Eight male patients were included in the study (average age=10.6±1.5 years). All patients had radiographs >6months post-surgery, and no patient had a clinically significant leg length discrepancy (>2cm) or deformity. The two patients followed >24months post-operatively were cleared to return to sports by one year. No patients demonstrated a positive Lachman or pivot shift test at >6months follow-up. No Patients had a ROM deficit at >6months follow-up. Five patients completed Pedi-IKDC and Lysholm assessments (time from surgery=16.2months+10.6months; range 7–28.8months). Average IKDC and Lysholm scores were 88+10 and 95+9, respectively. There were no graft ruptures in the cohort (average follow-up: 13.8months±8.9 months; range 6.8–30.6months).

Conclusion:

Our preliminary data from this novel tibial physeal respecting technique suggest it may be appropriate for skeletally immature patients with sufficiently large enough femoral epiphyses to hold a 10mm graft tunnel without disturbance to the physis. This technique seems successful in terms of graft survival, patient reported outcomes, and no growth disturbance within 2 years of surgery, although we recognize our small sample size as a limitation. Further studies will better evaluate long-term outcomes of this pediatric ACLR technique.
NERVE BLOCKS FOR PEDIATRIC ACL RECONSTRUCTION: COMPARING FUNCTION, PATIENT-REPORTED OUTCOMES, AND EFFICIENCY
Authors: Leska Tomasina M. , Bram Joshua T. , Pascual-Leone Nicolas , Williams Brendan A. , Ganley Theodore J.
Published: July 2021

Background:

Previous studies have compared the use of continuous nerve catheter versus single-shot nerve block approaches to regional anesthesia in ACL Reconstruction (ACLR), but they have primarily focused on adult populations. A paucity of data exists comparing these regional anesthesia techniques in children.

Hypothesis/Purpose:

To compare postoperative pain, strength, and functional outcomes between pediatric ACLR patients undergoing femoral nerve catheter (FNC) placement with single-shot sciatic block and those receiving femoral and sciatic single-shot nerve blocks (SSNB).

Methods:

Pediatric patients (≤18 years) undergoing primary ACLR between 1/2018-8/2019 at an urban tertiary care children’s hospital were identified. Patients were grouped based on regional anesthetic technique (FNC vs. SSNB). Emergency department (ED) visits, clinic visits, and calls for uncontrolled pain and narcotic refills were compared between these two groups. Outcomes including PROMIS scores, strength testing, and active range of motion (AROM) were also compared. Multiple imputation analysis was used to reduce bias as a result of missed follow-up.

Results:

78 patients met inclusion criteria (FNC-36 patients, SSNB-42 patients). There were no differences in age, sex, BMI, or surgical technique between cohorts (Table I). Block preparation time (p<0.001) and surgical duration (p<0.001) were significantly longer for the FNC group. Ropivacaine dose (mg) of the sciatic nerve block was significantly higher in the SSNB group (35.0 ± 7.5 vs. 30.1 ± 4.1, p=0.001). All SSNB cases were performed at a satellite surgical center compared to 1 (2.8%) FNC case (p<0.001). There were no differences in uncontrolled pain or required narcotic refills between groups, and at 1 week follow-up, the proportion of patients with continued opioid consumption was not different (Table II). At 1 week, SSNB patients reported higher PROMIS physical function - mobility scores (25.5 ± 5.6 vs. 22.1 ± 4.9, p=0.009) with no difference in PROMIS pain interference scores. PROMIS scores were not different between cohorts at 6 weeks, 3 months or 6 months. AROM in extension and flexion also showed no difference between groups. SSNB was associated with a higher hamstrings to quadriceps ratio (quadriceps deficit) at 3 months (77.4 ± 23.8 vs. 66.2 ± 18.0, p=0.028), but there were no differences in isokinetic strength at 6 months.

Conclusion:

SSNB was associated with shorter operative times and better PROMIS physical function – mobility scores at 1 week compared to FNC. No other differences were observed in post-operative pain management, and cohorts were without differences in AROM and isokinetic strength by 6 months.

Tables/Figures:

[Table: see text][Table: see text]
KNEE RADIOGRAPHS DEMONSTRATE SMALL BUT STATISTICALLY SIGNIFICANT INCREASE IN POSTERIOR TIBIAL SLOPE IN PATIENTS WITH OSGOOD-SCHLATTER DISEASE
Authors: Green Daniel W. , Aitchison Alexandra H. , Sidharthan Sreetha , Schlichte Lindsay M. , Fabricant Peter D. , Doyle Shevaun M. , Mintz Douglas N.
Published: July 2021

Background:

Previous research has demonstrated an association between Osgood-Schlatter disease (OSD) and increased posterior tibial slope (PTS) in a small subset of patients with MRI and clinical exam consistent with OSD.

Hypothesis/Purpose:

To determine if children diagnosed clinically with OSD have an increased PTS on routine radiographs compared to controls.

Methods:

Patients 10-18 years old with the clinical diagnosis of OSD and a true lateral knee X-ray between 2016 and 2019 were eligible for the OSD group. Subjects were excluded if they had other significant knee pathology (Figure 1). The same number of controls were selected from patients in the same age and date range with history of anterior knee pain and a true lateral knee X-ray but no evidence of OSD or other significant pathology on clinical exam or X-ray. Demographic data and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores were collected for each subject. PTS measurements were performed on true lateral X-Rays by three blinded investigators. Independent samples t-test and chi-squared test were used to compare variable means and frequency between OSD and control knees. Logistic regression analysis was used to investigate the effects of OSD, age, sex, height, weight, and HSS Pedi-FABS score on PTS (≥12º versus <12º).

Results:

258 total knees (129 with OSD and 129 controls) were included. Mean age was 12.9 ± 1.8 years and 53% knees were male. There were no differences in age, sex, BMI, or laterality of knees between groups (Table 1). Mean PTS was significantly higher in the OSD group (11.6º ± 2.9º) compared to the control group (9.3º ± 2.7º, p<0.0001). In the OSD group, 46% of knees had a PTS ≥12º and in the control group, 19% knees had a PTS >12º (p<0.001). Logistic regression analysis showed that patients with OSD had 3.63 greater odds (95% CI 1.78-7.40) of having PTS ≥12º compared to patients without OSD, when controlling for age, sex, height, weight, and HSS Pedi-FABS score (Table 2).

Conclusion:

This study further supports an association between OSD and a mild increase in PTS. Patients with OSD had 3.6 greater odds of having PTS≥12º. The clinical implications of this finding have not yet been elucidated. We speculate that in patients with OSD, stresses (or force) exerted from the quadriceps muscle group through the patellar tendon loads the anterior portion of the tibia tubercle disproportionately to the posterior segment and causes asymmetric growth and an increased PTS.

Tables/ Figures

[Table: see text][Table: see text][Figure: see text]
CORRELATIONS BETWEEN FUNCTIONAL TESTING AND THE PEDI-CHAMP© AGILITY TEST IN YOUTH ATHLETES
Authors: Tulchin-Francis Kirsten , Ulman Sophia
Published: July 2021

Background:

The Pediatric Comprehensive High-Level Activity Mobility Predictor (Pedi-CHAMP©) is a 4-part agility test which assesses balance, lateral agility, directional changes, and acceleration/deceleration. Designed to assess children with orthopedic conditions or sports medicine injuries, it is unclear if the agility assessed with the Pedi-CHAMP© correlates to other clinical performance measures in uninjured healthy youth athletes.

Hypothesis/Purpose:

To determine if the Pedi-CHAMP component (Single-Limb-Stance [SLS], modified Edgren Side Step [mESS], L-Test, Illinois Agility Test [IAT]) and composite scores are correlated to the Lower Quarter Y-Balance Test (LQ-YBT) and sprint speed.

Methods:

Uninjured youth athletes were recruited to undergo a battery of tests as part of the Specialized Athlete Functional Evaluation (SAFE) Program. Completion times for each component of Pedi-CHAMP© were converted to points using age-sex matched scoring algorithms. Each participant completed the LQ-YBT and a single repetition of 10m and 20m sprints. Spearman correlations assessed relationships between the Pedi-CHAMP© component and composite scores and the LQ-YBT components, LQ-YBT composite score, and sprint times.

Results:

Forty-two, right-leg dominant youth athletes (30F, age:13.9±2.6yrs; BMI:20.±3.1) completed functional testing. 62% of participants specialized in a single sport and 83% participated in high-impact sports. There were no significant correlations between the SLS component score and functional tests (Table 1). While the posteromedial and posterolateral components of the LQ-YBT showed significant, fair correlations to the mESS (PM:r=0.338, PL:r=0.379), L-Test (PL only:r=0.374), IAT (PM:r=0.307, PL:r=0.407) and Pedi-CHAMP© composite scores (PM:r=0.370, PL:r=0.361), the anterior component and LQ-YBT composite scores were not significantly correlated to the Pedi-CHAMP©. There were strong correlations between the 10m and 20m sprints and the mESS (10m:r=-0.660, 20m:r=-0.693), L-Test (10m:r=-0.663, 20m:r=-0.736), IAT (10m:r=-0.704, 20m:r=-0.693) and Pedi-CHAMP© composite score (10m:r=-0.617, 20m:r=-0.678, all p<0.001).

Conclusion:

Performance on the mESS, L-Test, and IAT components of the Pedi-CHAMP© correlated to sprint times and posterior components of the LQ-YBT. The SLS component of the Pedi-CHAMP© may not be challenging enough for the older youth athlete, as this simple 30sec single limb balance test was designed for children with injuries or underlying orthopedic conditions. Replacing the SLS with one or more LQ-YBT components may be more appropriate for uninjured youth, particularly elite athletes. It is not surprising that forward sprint speeds were highly correlated with the agility portions of the Pedi-CHAMP© in this cohort of relatively high-level youth athletes. Future work should focus on evaluating the ability of the Pedi-CHAMP© to detect differences based on sport.

Tables/Figures:

[Table: see text]
MANAGEMENT OF FIRST-TIME PATELLAR DISLOCATION: A SURVEY OF PRISM MEMBERS
Authors: Parikh Shital N , Veerkamp Matthew ,   *PF RIG, Ellington Matthew , Finlayson Craig J , Molony Joseph , Friel Nicole , Green Daniel W , Mikutis Jeffery L , Milbrandt Todd A , Pace James L , Pendleton Albert M , Redler Lauren H , Rhodes Jason , Safier Shannon D , Schlechter John A , Stein Beth E Shubin , Vandenberg Curtis , Vaughn Jeffrey M , Wall Eric J , Warnick Drew E , Yaniv Moshe , Parikh Shital N
Published: July 2021

Background:

There are no current guidelines for optimal management of first-time patellar dislocation in children and adolescents.

Purpose:

To develop consensus-based guidelines for management of first-time dislocation in adolescents.

Methods:

A 29-question, case-based, multiple-choice survey was developed after 2-rounds of iterations by 20 members of the Patellofemoral RIG. The survey contained two case scenarios of first-time patellar dislocation in adolescents - one with and one without an osteochondral fracture. The survey was administered to primary sports medicine and orthopedic surgeons of the PRISM Society in April 2020 and the responses were analyzed. Consensus-based guidelines were generated when at least 66% of the respondents agreed

Results:

81/276 (29%) members responded to the survey and 6 consensus-based guidelines were generated from those responses. [Table: see text] There was no consensus between conservative (60%) and operative (40%) treatment of contralateral patellar dislocation. Free-text analysis revealed several variables that influence the decision-making process.

Conclusion:

There are changes in trends related to management of first-time dislocation in adolescents. MRI, though not recommended for all patients with first-time dislocation, was obtained by 51% of respondents. The survey provides details of conservative treatment, including the role and duration of bracing and physical therapy. For first-time dislocation with an osteochondral fracture, concomitant patellar stabilization is preferred over isolated fixation. Simultaneous guided-growth for genu valgum correction is recommended. There were several variables that influenced the decision-making process and there were several areas of discordance. Further research studies on these parameters could potentially improve outcomes.
ISOLATED MPFL RECONSTRUCTION VS. TIBIAL TUBERCLE OSTEOTOMY AND MEDIAL RETINACULAR PLICATION FOR RECURRENT PATELLAR INSTABILITY: A MATCHED, COHORT ANALYSIS OF CLINICAL OUTCOMES COMPARING TWO TECHNIQUES
Authors: Heyworth Benton E. , Zheng Evan T. , Hussain Zaamin B. , Wilson Benjamin R. , Nunally Kianna D. , Kocher Mininder S. , Yen Yi-Meng , Kramer Dennis E. , Micheli Lyle J.
Published: July 2021

Background:

Historically, the most commonly utilized technique to address recurrent patellofemoral instability (PFI) was a combined proximal and distal realignment, specifically the tibial tubercle osteotomy (TTO) with a proximal medial retinacular plication/reefing/tightening/repair (MRP). Rising interest in the medial patellofemoral ligament reconstruction (MPFLR) over the last decade, now frequently performed as a more powerful isolated proximal realignment procedure, has prompted debate over the optimal technique to treat this common condition.

Hypothesis/Purpose:

The study hypothesis was that no difference would be detected in recurrent PFI rates or revision surgery rates between patients who underwent TTO-MRP vs. MPFLR.

Methods:

With cohorts derived from a large, single-center PFI database of 523 patients who underwent a variety of stabilization procedures, 114 eligible MPFLR patients were matched to 109 TTO patients based on age, gender, BMI, and TT-TG distance. Propensity score matching was conducted using logistic regression models to produce 1:1 matching, and a caliper of 0.2 standard deviations of the estimated propensity score was used to for the nearest neighbor matching algorithm. Final matching procedure resulted in 84 MPFLR patients and 84 TTO patients. These were compared on demographics and post-operative clinical results.

Results:

Demographic and radiologic comparisons of the cohorts are shown in Table 1, with the only difference between groups being an expected higher rate of patients with open physes in the MPFLR cohort. Table 2 shows the TTO-MRP group had longer follow up times, but comparable rates of return to sports. The MPFLR group had a higher rate of recurrent instability, but not to a significant degree, and a significantly higher incidence of revision patellar stabilization surgery (p<0.001). The TTO group had a higher rate of additional knee surgery, the majority of which were implant removal for TTO screws.

Conclusion:

The TTO-MRP shows equivalent or superior results to the MPFLR for treatment of PFI. However, implant removal may be common with TTO, though this may be somewhat technique-dependent. In the current landscape of increasing interest and utilization of MPFLR as an all-encompassing PFI surgery, the influence of distal bony realignment to minimize recurrence should not be underappreciated.

Tables/Figures:

[Table: see text][Table: see text]
SURGICAL OUTCOMES OF ACCESSORY NAVICULAR IN ADOLESCENT ATHLETES
Authors: Yang A , Hennrikus WL. , Bone Penn State Hershey Pediatric ,   Institute Joint, Hershey PA
Published: July 2021

Introduction:

An accessory navicular (AN) is a plantar medial enlargement of the navicular bone of the foot. Patients with AN present with a foot bump. Only some patients are symptomatic with pain. The purpose of this study is to report the surgical outcomes in a consecutive series of adolescent athletes with symptomatic AN.

Methods:

The study was approved by the College of Medicine IRB. 16 patients were evaluated. Patient gender, age, complaints, family history, sports played, conservative treatments attempted, duration of symptoms, surgical technique, complications, outcomes, average follow up, time to return to normal activity, # that returned to sports, and the time to return to sports were recorded. Radiographs were used to identify the type of AN (Coughlin system), skeletal maturity, and presence of pes planus. Pes planus was determined by standing lateral foot radiograph talo-first metatarsal angle.

Results:

16 patients and 17 feet were studied. 15 were female (94%). The average age at surgery was 13 years (range 10 to 18 years). 0 patients had a family history of AN. The presenting complaint was foot pain and a bump. Sports including 2 basketball, 2 cheer, 4 gymnastics, 3 soccer, 1 volleyball, 1 dance, 1 softball, 2 multiple sports. The average duration of symptoms was 22 months (range 1 to 36 months). Conservative care methods attempted included: shoe inserts, activity modification, anti-inflammatory medications, icing, crutches, and changes in footwear. Pre-op radiographs demonstrated 9 Coughlin Type 1, 3 Type 2, and 5 Type 3 AN’s. Pre-op radiographs demonstrated 8 feet (47%) had flat foot. 9 feet (53%) had fused the calcaneal growth plate. All patients had a simple excision of the AN and 13 feet (76%) had an additional reefing of the posterior tibial tendon. The average time to return to normal activities was 13 weeks (range 8 to 16 weeks). 15/16 patients (94%) were able to return to their pre surgery sports. The average follow-up time was 8.5 months. At final follow up, 13 feet (76%) reported no pain, 3 (18%) with minimal pain, and 1 (6%) with no change in pain. No complications were reported.

Discussion and Conclusion:

Symptomatic AN is more common in females. Surgical success was unrelated to a closed growth plate. Surgery eliminated pain in 76% of patients and allowed 94% of patients to return to sport. Residual pain in 4 patients was correlated with a pre-op flat foot (4/8 patients: 50%).
EFFECTIVENESS OF PRE-SEASON PHYSICAL PERFORMANCE TESTS IN IDENTIFYING IN-SEASON LOWER EXTREMITY INJURIES IN ADOLESCENT GYMNASTS
Authors: Farzanegan Danielle A , Francione Emily , Melfi Nicole
Published: July 2021

Background:

Artistic competitive gymnastics results in a wide, unique spectrum of injuries. Due to the high number of injuries and the current lack of research related to pre-competitive testing in adolescent gymnasts, it is crucial to find a method to predict the likelihood of an athlete sustaining an in-season injury.

Purpose:

The purpose of this study was to 1) describe the frequency and type of pre-season and in-season injuries, 2) determine if there were differences in physical performance tests between those who had a lower extremity (LE) injury in-season and those who did not, and 3) determine if there were differences in age, level, sex, BMI, sport modifications, previous injury, and current injury between those who had a LE injury and those who didn’t.

Methods:

Thirty-seven adolescent gymnasts (average age: 12.81 years) were included with levels ranging from 5 (novice) to 10 (elite). Participants (15 males and 22 females) were surveyed for previous and current injury. The athletes completed a performance battery before the competition season including: Lower Quarter Y-Balance Test (LQYBT), Closed Kinetic Chain dorsiflexion (CKCDF), single hop (SH), triple hop (TH), and the Functional Movement Screen (FMS). Follow-up data was collected at the end of the competitive season for comparison. The data was analyzed using descriptive methods and comparative analyses including chi-square and independent t-tests with an alpha level set at .05.

Results:

Sixty-five percent reported an injury in the last year and seventy-eight percent reported pre-season injuries at testing day. The most common location for pre-season injury was the ankle/foot (24% and 31% respectively). There were no differences between injured and non-injured athletes when comparing asymmetries in CKCDF, LQYBT posteromedial or posterolateral reach, hop testing, or FMS. The LQYBT-anterior scores were significantly different at p=.049 between the injured versus uninjured groups, with 91% of the in-season injury group having a difference <4cm. Similarly, the LQYBT-composite score using a cut-off of 95% was significant at p=.043 with those >95% category being more likely to get injured. There were no significant differences in demographic information comparing injury occurrence.

Conclusion:

The tested physical performance battery may be useful in tracking gymnasts over time, but may not be beneficial in forecasting injuries in a sport with high percentages of acute injuries. The collected injury volume may not be reflective of a standard season as COVID-19 decreased the number of competitions. Additional research to identify athletes at risk for injury requires further investigation.
CHARACTERISTICS OF FOREARM RE-FRACTURE IN YOUTH ATHLETES
Authors: Kapadia Ami , Wyatt Charles W. , Montgomery Gerad K. , Wilson Philip L. , Ellis Henry B.
Published: July 2021

Background:

The forearm is the most common site of fracture, and perhaps re-fracture, in the pediatric population. Although both bone forearm (BBFA) fractures represent approximately 30% of pediatric upper extremity fractures, little is known about BBFA re-fractures, particularly among youth athletes.

Purpose:

To evaluate characteristics of BBFA re-fracture and recurrent fractures.

Methods:

An IRB-approved retrospective chart review based on CPT and ICD-9/10 codes of forearm fractures (ages 10-18 years) treated by a single academic pediatric orthopedic group from June 2009 to May 2020 was conducted. All BBFA, radial, or ulnar fractures with ipsilateral same-site, or non-identical ipsilateral or contralateral forearm fracture were included. Demographics, injury characteristics, length of immobilization, timing of return to activity, and radiographic data (angulation, distance between radius fracture and ulna fracture [in mm], position of fracture within bone, and radiographic healing). An analysis was performed to evaluate associations of ipsilateral same-site re-fracture versus ipsilateral or contra-lateral non-identical site fractures.

Results:

Twenty-nine of 686 BBFA and distal radius fractures were identified to have recurrent fracture (4.23%), with an average age of 11.5 years and male-to-female ratio of 6.25:1. 67% of ipsilateral same-site re-fractures occurred within one year. The most common mechanisms of primary fracture were contact sports (40%) and tumbling (30%), and re-fracture occurred 182 days after original fracture. 52% percent of recurrent fractures were ipsilateral same-site re-fractures, while 48% occurred in a non-identical site, either ipsilaterally or contralaterally. The most common mechanisms of recurrent fracture were contact sports (38%), falls (38%), and tumbling (14%). Ipsilateral same-site re-fractures compared to other recurrent fractures, were significantly associated with a mid-shaft location (p=0.0029), increased radius to ulna fracture distance (21.14 mm versus 11.3 mm, p=0.0277) [Figure 1], and earlier occurrence following index fracture (re-fracture= 397.33 days versus non-identical recurrent fracture= 884.07 days, p=0.0056). Degree of angulation was not significantly associated with re-fracture.

Conclusion:

Recurrent fracture may occur at different times and locations following primary injury treatment. Ipsilateral same-site re-fractures tend to occur within the first year of treatment following mid-shaft fractures incurred during contact sports and tumbling, with widely spaced radial and ulnar fracture sites. Further research may be warranted to evaluate biologic, bone health, or personality traits that may lead to recurrent and re-fractures in pediatric forearm fractures.

[Figure: see text]
DESCRIPTIVE EPIDEMIOLOGY STUDY OF THE JUSTIFYING PATELLAR INSTABILITY TREATMENT BY EARLY RESULTS (JUPITER) COHORT
Authors: Bishop Meghan E , Brady Jacqueline M , Gruber Simone , Veerkamp Matthew , Nguyen Joseph T , Green Daniel W , Wall Eric J , Parikh Shital , Shubin Stein Beth E ,   the JUPITER Group
Published: July 2021

Background:

Patellar instability is a common injury in young patients and can lead to significant morbidity and arthritis. Its management is controversial. JUPITER (Justifying Patellar Instability Treatment by Early Results) is a hypothesis-driven, multi-center, multi-armed, prospective cohort study developed to describe clinical characteristics and predictors of clinical outcomes in the young patellar instability population.

Purpose:

To describe the formation of JUPITER and provide a descriptive, epidemiologic analysis of patient demographics and clinical features of the patients in this prospective cohort.

Methods:

After training and institutional review board approval, surgeons began enrolling patients between 10-30 years of age who sustained a patellar dislocation. Patient demographics, dislocation history, physical exam characteristics, and PROMs were collected.

Results:

By January 1, 2019, 28 surgeons from 12 sites had prospectively enrolled 661 patients (677 knees) with patellar instability. 62% were female and mean age was 15.8 years. 447 knees (66%) were in the operative group and 230 (34%) in the non-operative group. 55% of knees reported that they had more than 1 dislocation (operative group 73%; non-operative group 27%, p<0.001). Operative treatment was indicated in 39% of first-time dislocators and 85% of recurrent dislocators (p<0.001). Recurrent and operative group patients had more positive physical exam findings than first-time and non-operative group patients on the affected knee (p<0.05 for J-sign, apprehension, crepitus) and the contralateral knee (p<0.05 J-sign, apprehension). The recurrent group was nearly twice as likely to be ligamentously lax (Beighton score 5 or greater) compared to first-time patients (p<0.001). Baseline PROMs varied with the recurrent group having lower Pedi-FABS (p=0.001) and KOOS-QoL (0.008) scores and higher Kujala (0.009), KOOS ADL (0.008), KOOS Sports (<0.001), and Pedi-IKDC (0.014) scores than the first-time dislocator group.

Conclusions:

The JUPITER Group has been able to accumulate the largest prospectively collected patellar instability database to date. Over half of patients in this group reported they sustained more than one dislocation. Operative management was indicated in 39% of first-time dislocators, 50% of which had sustained an osteochondral fracture, and 85% of recurrent dislocators. Recurrent dislocators were more likely to have positive physical exam findings on both the affected and contralateral knee.