bluuebunny/crossref_metadata_2025 huggingface dataset:
HOW OFTEN ARE STUDY DESIGN AND LEVEL OF EVIDENCE MISREPORTED IN THE PEDIATRIC ORTHOPAEDIC LITERATURE?
Authors: LeBrun Drake G. , Kocher Mininder S. , Baldwin Keith D. , Patel Neeraj M.
Published: April 2020

Background:

Observational studies are the most commonly employed study designs in the pediatric orthopaedic literature. The differences between observational study designs are important but not widely understood, leading to potential discrepancies between the reported and actual study design. Study design misclassification is associated with a potential for misreporting level of evidence (LOE).

Purpose:

To determine the degree of study design and LOE misclassification in the pediatric orthopaedic literature.

Methods:

The Institute for Scientific Information (ISI) Web of Science was queried to identify all pediatric orthopaedic observational studies published from 2014-2017. Reported study design and LOE were recorded for each study. The actual study design and LOE were determined based on established clinical epidemiological criteria by reviewers with advanced epidemiological training. Studies with a discrepancy between reported and actual study design and LOE were identified. The following covariates were recorded for each study: subspecialty, inclusion of a statistician coauthor, sample size, journal, and journal impact factor. Chi-square analysis was used to identify factors associated with study design and LOE misreporting.

Results:

One thousand articles were screened, yielding 647 observational studies. Three hundred thirty-five publications (52%) did not clearly report a study design in either the abstract or manuscript text. Of those that did, 59/312 (19%) reported the incorrect study design (Figure 1). The largest discrepancy was in the 109 studies that were reported to be case series, among which 30 (27.5%) were actually retrospective cohort studies. Three hundred thirteen publications (48%) did not report a LOE. Of those that did, 95/334 (28%) reported the incorrect LOE (Figure 2). Thirty-three studies (19%) reported a LOE that was higher than the actual LOE and 62 (35%) under-reported the LOE.

Conclusion:

The majority of observational pediatric orthopaedic studies either did not report a study design or reported the wrong study design. Similarly, the majority of studies did not report or misreported their LOE. Greater epidemiological rigor in classifying and evaluating observational studies is required on the part of investigators, reviewers, and journal editors.

[Figure: see text][Figure: see text]
EARLY SPORT SPECIALIZATION IN YOUNG FEMALE FIGURE SKATERS
Authors: Sugimoto D , Lambrinakos-Raymond K , Kobelski GP , Geminiani ET , Stracciolini A , Meehan WP
Published: April 2020

BACKGROUND:

Understanding the association between sport specialization in young athletes and injury continues to be an important goal of sports medicine specialists. However, studies focused on females were scarce. Additionally, studies dedicated to sport specialization in the performing artistic athletes, including figure skaters are deficient at this time.

Purpose:

1) To investigate the prevalence of sport specialization in a cohort of female figure skaters, and 2) to determine if low back injury is more common in specialized female figure skaters compared to female figure skaters who are not classified as specialized.

METHODS:

Cross-sectional survey study design was used. Questionnaire data was collected from three major figure skating clubs in the Greater Boston area. Female figure skaters (age range: 5 to 22 years) were asked the following questions based on established sport specialization criteria: 1) Do you solely perform figure skating?, 2) Did you quit other sports to focus on figure skating?, and 3) Do you participate in figure skating more than 8 months/year? Status of specialization was defined as a “yes” answer to all 3 questions while “no” to any of the 3 questions was labeled as non-specialized. All participants were asked about a history of low back injuries, including muscular spine pain, stress fracture (spondylolysis/spondylolisthesis), disc protrusion/herniated disc, sciatica, and spinal cord injury. Descriptive statistics and chi-square analyses were performed, with p ≤ 0.05 as the critical statistical value.

RESULTS:

A total of 132 female figure skaters (mean age: 14.0±4.0 years) were analyzed. Approximately, 85% (112/132) of female figure skaters solely participated in figure skating and 54% (71/132) quit other sports to focus on figure skating. Almost all of the female figure skaters (99%) (131/132) engaged in figure skating lessons/practices > 8 months/year. About 62% (82/132) of figure skaters were classified as specialized, and 38% (50/132) were classified as non-specialized. There were no significant difference in low back injury history between the specialized female figure skaters (25.6%, 21/82) and non-specialized female figure skaters (24.0%, 12/52, p=0.836).

CONCLUSION/SIGNIFICANCE:

The majority of female figure skaters in this cohort were classified specialized, and almost all female figure skaters participated in figure skating more than 8 months of the year. Although no association with low back injury was found based on status of specialization, more research is needed including effects of training volume on injury risk in female figure skaters.
PHYSICAL LITERACY IN ELEMENTARY PHYSICAL EDUCATION: A SURVEY OF FUNDAMENTAL MOVEMENT SKILL PRACTICE PATTERNS
Authors: Butler Lauren S. , Gupta Apeksha , DeVerna Amie , Moore James G. , Latz Kevin , Davelaar Cassidy Foley , Sugimoto Dai ,   PRiSM Injury Prevention Research Interest Group
Published: April 2020

Background:

Pediatric physical inactivity is a major public health concern. According to the 2017 State of Play report, only 24% of youth meet the recommended physical activity (PA) dosage. Previous studies identified fundamental movement skill (FMS) proficiency as a predictor of physical literacy and PA. Mastery of FMS requires direct instruction and practice; however, it is unknown how well FMS are implemented in physical education (PE).

Hypothesis/Purpose:

To describe FMS practice patterns in the elementary PE curriculum. We had two hypotheses: 1) Fewer PE teachers provide comprehensive FMS instruction in later curriculum (grades 4-6) compared to early curriculum (grades 1-3) and 2) Fewer PE teachers teach FMS with direct instruction methods in later curriculum compared to early curriculum.

Methods:

A cross sectional survey design was used. PE teachers (grades 1-6) were recruited via electronic mail from various U.S. regions from January 2018 to March 2019. An electronic questionnaire was developed to ask about timing of FMS teaching and method of instruction. Additional questions were asked about methods used to evaluate FMS proficiency, including use of a standardized assessment of gross motor development, referrals and remediation recommended for children who appeared to be falling behind, and perceived barriers to FMS instruction. Chi-square tests (p<0.05) were employed.

Results:

We collected 87 responses with approximately 9% from West, 42% from Midwest, and 49% from South regions. Among all responses, 54% of PE teachers taught all FMS and 40% taught all FMS with direct instruction. Approximately, 66 % taught all FMS for grades 1-3 compared to 42% for grades 4-6 (p<0.0001). Regarding instruction methods, 47% of teachers for grades 1-3 utilized direct instruction to teach all FMS compared to 27% for grades 4-6 (p=0.0007). Only 3.7% of teachers used a standardized assessment of gross motor development to evaluate FMS proficiency. For children who appeared to be falling behind, 6.7% of teachers reported accepting the child’s “best effort” in participation. Only 7.3% reported referring to an exercise program and no PE teacher sought a healthcare referral. Time was reported as the greatest barrier to improving a child’s FMS competency in 52.4% of responses.

Conclusion:

Results suggests that fewer PE teachers teach all FMS in late elementary PE curriculum compared to early curriculum. Additionally, fewer teachers utilize direct instruction methods to teach skills in late elementary curriculum. With time reported as the greatest barrier, a more efficient screening tool to evaluate FMS competency may be needed.
A NECK STRENGTH TRAINING PROTOCOL IN HIGH SCHOOL FOOTBALL PLAYERS FOR CONCUSSION RISK REDUCTION
Authors: Rotto Torsten , Kraus Emily , Fredericson Michael
Published: April 2020

Background:

Increased neck strength may be a protective factor for reducing concussions in youth athletes. However, little research exists regarding validated neck strength training methods among this demographic.

Purpose:

To determine whether a 7-week neck strength training period is sufficient to achieve significant gains in neck strength and size amongst high school football players. Additionally, to assess if increased neck strength influences concussion outcomes.

Methods:

This study enrolled 54 male high school football players, ages 14-17, in a 7-week strength training protocol in which neck exercises were incorporated into preseason strength and conditioning workouts (figure 1). Pre- and post-neck strength was assessed in four directions: forward flexion (FF), extension (EXT), right lateral flexion (RLF) and left lateral flexion (LLF). Strength was measured as maximal isometric head pressure applied into a pre-inflated sphygmomanometer cuff (figure 2). Concussion totals from the subsequent 2018 season were compared with totals from the 2017 and 2016 seasons per data obtained from the team’s athletic trainer.

Results:

Fifty athletes in total were analyzed; 4/54 athletes did not complete final testing due to scheduling conflicts. A two sample t-test of neck circumferences revealed a statistically significant increase of 0.37 cm from pre- to post-neck strength training (p=0.0025, figure 3). Single sample strength t-test analysis (corrected for cuff pre-inflation) demonstrated a statistically significant post-test strength increase of 19.8% (FF), 11.0% (EX), 18.8% (RLF), and 18.0% (LLF) (p<0.001, figure 3). The team suffered 4 concussions in the 2018 season, 2 of which were sustained by athletes who did not participate in preseason neck training, compared to 12 concussions in 2017 and 7 concussions in 2016 (figure 3).

Conclusion

This study demonstrates that increases in neck size and strength can be achieved amongst high school athletes using easily implemented training methods during a 7-week preseason training period. The additional observation of reduced concussion outcomes is not conclusive, though these initial results are promising. Additional research is needed to investigate the potential of neck strengthening in modifying concussion risk. Funding provided by the Stanford Medical Scholars Fellowship Program

[Figure: see text][Figure: see text][Figure: see text]
AMBULATORY SURGERY TRENDS IN PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: WHERE’S IT HAPPENING AND HOW MUCH CAN WE SAVE?
Authors: Meza Blake C. , Ganley Theodore J. , Adams Alexander J. , Sankar Wudbhav N. , Flynn John M. , Shah Apurva S.
Published: April 2020

Background:

Benefits of ambulatory surgery include more efficient operations, lower cost, and patient preference. The national frequency of anterior cruciate ligament (ACL) reconstruction in children has increased three-fold compared other pediatric orthopaedic procedures, a trend that is likely attributable to an increased rate of ACL tears associated with year-round training and competition in young athletes.

Hypothesis/Purpose:

The goal of this study was to utilize the Pediatric Health Information System (PHIS) to analyze the national trends towards ambulatory surgery for ACL reconstruction procedures and quantify the cost savings associated with the trend.

Methods:

The PHIS database was queried using Common Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and 10) codes for ACL reconstruction from 2009-2017. Patient information including gender, age at surgery, region (Northeast, South, Midwest, West) and hospital cost data for each procedure was collected. Cases were classified as ambulatory or non-ambulatory (inpatient or observation). Annual rates of ambulatory surgery were calculated for each procedure regionally for hospitals with cases included in each year of the query. The Consumer Price Index (CPI) was used to adjust procedural costs for inflation. Ambulatory and non-ambulatory costs were analyzed with the Wilcoxon Signed-Rank test. Trends in rates of ambulatory surgery were compared using joinpoint regression and annual percent change (APC).

Results:

A total of 21,582 cases of ACL Reconstruction were identified from 33 different children’s hospitals from 2009-2017. More than half (50.3%) of the patients were female, and the average age at surgery was 15.4 years (± 2.1 years). The overall rate of ambulatory pediatric ACL reconstructions across the United States increased by 14.7% (APC 1.6%, 95% C.I. 0.8-2.4, p<0.01) from 2009 to 2017. Overall, this trend was most significant in the West (APC 2.0%, 95% C.I. 1.2-2.7, p<0.01), however in more recent years (2012-2017), there has been a similar significant increase in ambulatory pediatric ACL reconstruction in the South (APC 3.0%, 95% C.I. 1.7-4.3, p<0.01). The mean difference in median procedural cost between ambulatory and non-ambulatory ACL reconstructions was $3,145 ($13,866 vs. $10,721, p<0.01). This corresponds to national annual savings of 4.1% associated with the shift towards ambulatory surgery.

Conclusions:

From 2009-2017, there was a national trend towards performing pediatric ACL reconstruction in the ambulatory setting, which was accompanied by an annual 4.1% procedural cost savings. The feasibility of ambulatory surgery for other common pediatric orthopaedic surgeries should be explored in order to reduce healthcare costs.

[Figure: see text]
A COMPARISON OF THE MARX ACTIVITY RATING SCALE AND THE HOSPITAL FOR SPECIAL SURGERY PEDIATRIC FUNCTIONAL ACTIVITY BRIEF SCALE
Authors: Marom Niv , Xiang William , Heath Madison R. , Boyle Caroline , Fabricant Peter D. , Marx Robert G.
Published: April 2020

Background:

The Marx Activity Rating Scale (MARS) and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) are both validated activity scales. While the MARS examines greatest physical activity level within the last year, the HSS Pedi-FABS assesses the greatest level of physical activity within the last month.

Purpose:

To determine whether the different time frames used in MARS and HSS Pedi-FABS affect scores on common items in both scales, and if so, to determine whether age or injury status affect this difference.

Methods:

The MARS and 4 analogous items on the HSS Pedi-FABS were administered sequentially in random order to patients being evaluated at two sports surgeons’ clinic for knee injuries in addition to their healthy companions in order to enroll an uninjured comparison group. Responses to each question were scored from 0-4 for a maximum overall score of 16. Participant demographics were also recorded. Paired and independent sample t-tests were used to determine mean differences between the two scales and between healthy and injured adults and children, respectively.

Results:

The final cohort included 88 participants of which 47% were children (ages 10-17) and 51% had a knee injury. All participants except for healthy adults scored significantly lower on the HSS Pedi-FABS than the MARS (p < 0.05, Table 1). On the HSS Pedi-FABS activity scale, healthy participants scored significantly higher than injured participants (p<0.01), but there were no significant differences based on age, Figure 1A. Conversely, on the MARS scale, children scored higher than adults (p≤0.001), but there were no significant differences based on injury, Figure 1B.

Conclusion:

Physical activity level is significantly different when evaluated by either MARS or its analogue portion of HSS Pedi-FABS. Because the only difference between the scales is the timeframe, the lower scores on the Pedi-FABS than the MARS are likely due to seasonal changes in activity which are not captured in the MARS. Because the Pedi-FABS analyzes a shorter window, it is more likely to capture acute changes in physical activity due to a recent injury than the MARS scale while the MARS scale is better suited for examining general physical activity unaffected by seasonality. Understating the differences between these scales can guide clinicians in using them appropriately when evaluating patient activity level.

Tables: [Table: see text] Figures: [Figure: see text]
LOW DOSE CT SCAN FOLLOWING PERIACETABULAR OSTEOTOMY: ASSESSMENT OF REDUCTION AND CORRELATION WITH RADIOGRAPHIC MEASURES
Authors: DeVries Clarabelle , Nepple Jeffrey J , Fowler Lucas , Akers Sean , Pashos Gail , Harris Michael , Clohisy John C
Published: April 2020

Introduction:

Periacetabular osteotomy (PAO) has become a favored treatment for symptomatic acetabular dysplasia worldwide. Nevertheless, the parameters for optimal correction to avoid residual instability or iatrogenic impingement have not been defined.

Purpose:

The purposes of this study were (1) to assess the ability of PAO to correct femoral head coverage to normal ranges as measured by 3D CT scan and (2) to determine if postoperative radiographic parameters of dysplasia are accurate markers of optimal acetabular correction.

Methods:

A total of 43 hips (in 38 patients, mean 27.7 years, 88.4% female) were enrolled in this prospective cohort study at minimum 1 year after PAO. Postoperative femoral head coverage was assessed via low-dose CT and compared to normative data of asymptomatic hips from the literature. Anterior (3:00-1:15), lateral (1:00-11:00), and posterior (11:25-9:00) sector coverage was defined by averaging the coverage at 15 minute increments in each zone. Postoperative radiographs were utilized to measure lateral center edge angle (LCEA), anterior wall index (AWI), posterior wall index (PWI), and anterior center edge angle (ACEA). Good correction for each sector was defined as coverage from 1 SD below mean to 2 SD above mean.

Results:

Postoperatively, the anterior sector was normalized in 84% of hips, lateral sector in 84% of hips, and posterior sector in 86% of hips. Sixty-seven percent of hips were corrected to normative range in all three sectors and 19% were corrected in two sectors (86% in at least two sectors). LCEA and PWI showed the highest correlation with lateral and posterior sector coverage with Pearson’s correlation coefficients of 0.67 and 0.71 (p < 0.001), respectively. Weaker correlations were found between anterior coverage and the AWI and ACEA coverage (-0.16 and 0.15, respectively). Good correction was best correlated with the following target values for acetabular correction: LCEA 28°, AI 1°, AWI 0.37, ACEA 32°, and PWI 1.0.

Conclusion:

PAO can effectively normalize femoral head coverage compared to normative data. Good correction of each sector coverage ranged from 84-86% of cases. The proposed set of radiographic parameter targets were found to be reliable markers of femoral head coverage.
THE EFFECT OF A BODY CHECKING RULE CHANGE ON HEAD IMPACT BIOMECHANICS IN BANTAM ICE HOCKEY ATHLETES
Authors: Combs Patricia R. , Ford Cassie B. , Teel Elizabeth F. , Wasserman Erin B. , Cools Michael J. , Mihalik Jason P.
Published: April 2020

Background:

Body checking is the most common injury mechanism in ice hockey. Rule changes have sought to mitigate body checking exposure among youth players. In 2011, USA Hockey changed the legal body checking age from Pee Wee (11/12-year-olds) to Bantam (13/14-year-olds). Interestingly, Bantam players with checking experience during Pee Wee had a lower concussion risk relative to Bantam players without checking experience in a sample of Canadian youth hockey players. Understanding the head impact biomechanics underlying these findings could further elucidate the consequences of this rule change.

Purpose:

To determine the association between Pee Wee checking exposure and head impact biomechanics in a cohort of Bantam players.

Methods:

We prospectively collected data on Bantam ice hockey players during the 2006/07-2009/10 seasons and the 2012-2013 season. The 2006/07-2009/10 cohort (n= 61, age=13.9±0.5 years, height=168.2±8.7 cm, mass=59.9±10.4 kg) was allowed to body check (BC) as a Pee Wee player. The 2012-2013 cohort (n=15, age=13.3±0.4 years, height=167.5±7.4 cm, mass=57.5±8.6 kg) was not permitted to body check (NBC) as a Pee Wee player. Over the course of each season, head impacts were measured using in-helmet accelerometers. Only head impacts with linear acceleration ≥10 g were included in our analysis. Main outcome measures were mean linear acceleration (g) and rotational acceleration (rad/s2). Levene’s tests assessed equality of variance between groups. We employed mixed effects models to assess group differences in mean linear and rotational acceleration between BC and NBC groups.

Results:

The BC and NBC groups did not differ in height (t74=0.28, p=0.78) or mass (t74=0.84, p=0.40). When assessing group differences in head impact biomechanics, the NBC experienced significantly greater linear acceleration (F1,74=4.36, p=0.04) and greater rotational acceleration (F1,74=21.2, p<0.001) relative to the BC group. On average, the NBC group experienced 23.1 ± 0.87 g linear acceleration and 1993.5 ± 68.4 rad/s2 rotational acceleration compared to the BC group, which experienced 21.2 ± 0.30 g linear acceleration and 1615.9 ± 45.2 rad/s2 rotational acceleration.

Conclusions:

Bantam ice hockey players without body checking experience during their Pee Wee years experienced greater average linear and rotational acceleration relative to players with Pee Wee body checking experience. While removing body checking from Pee Wee ice hockey may reduce short-term injury risk, these athletes may demonstrate more high-risk head impact biomechanics when legally allowed to body check. Future research should continue to examine the influence of policy changes on head impact biomechanics and injury risk in youth ice hockey.

[Figure: see text]
SELF-REPORTED PHYSICAL ACTIVITY IN SPECIALIZED AND UNSPECIALIZED YOUTH
Authors: Young Julie A. , Valasek Amy E , Onate James
Published: April 2020

The benefits of physical activity cross all domains of health. Unfortunately, many children are not meeting the current American College of Sports Medicine recommendations of 60 minutes of moderate to vigorous physical activity (MVPA) 7 days a week. This is especially deleterious since physical activity patterns during childhood may carryover to adulthood. Research has also shown that participating in one sport may increase the risk of injury. The purpose of this study was to examine self-reported exercise levels in children reporting to a tertiary sports medicine clinic over a three year period. Subjects were asked “How many minutes of moderate to vigorous physical activity per day?” and “How many days per week do you participate in moderate to vigorous physical activity”. Minutes per week of MVPA was calculated. Age, sex, and current sports and recreational activities were recorded. There were 7427 unique patients (53% female) with an average age of 13.8±2.6. The average minutes per day of exercise was reported as 85.6±44.4, average days per week was 4.4±1.6 and minutes per week was 410.8±266.9. Females reported less minutes per day (83.5 vs. 87.8, p<.001), less days per week (4.2 vs 4.7, p<.001) and less minutes per week (384.1 vs 440.2, p<.001) than males. On average, females reported 56 minutes less activity per week than their male counterparts. There were 3618 participants who only reported one activity and were categorized as specialized in a single physical activity. Those that specialized in a single activity were significantly older (14.1 vs 13.4, p<.001). There were no significant differences between reported minutes per day between specialized and unspecialized athletes (85.8 vs 85.2, p=.57). Those who specialized in one activity reported more days per week (4.6 vs 4.2. p<.001) and more minutes per week (423.8 vs 397.0, p=.001) than unspecialized athletes. Research has consistently shown that females are less active than males. Those who specialized in one activity participated in more minutes per week of activity, mainly through participating in more days of physical activity. Children should be encouraged to participate in a variety of activities on a daily basis to ensure they receive the benefits of physical activity.
MAGNETIC RESONANCE QUANTIFICATION OF MENISCUS VASCULARITY IN PEDIATRIC VERSUS ADULT KNEES
Authors: Lin Kenneth M. , Gadinsky Naomi E. , Klinger Craig E. , Dyke Jonathan P. , Rodeo Scott A. , Green Daniel W. , Fabricant Peter D. , Helfet David L. , Shea Kevin G. , Lazaro Lionel E.
Published: April 2020

Background:

Despite advances in surgical techniques, implant technology, and biological augmentation, one innate limitation to meniscus healing is lack of vascularity. Ability to quantify meniscal vascularity has been limited with previous techniques, and minimal data exists describing differential vascular zones in the skeletally immature meniscus.

Purpose/Hypothesis:

The objective of this study is to use quantitative contrast-enhanced magnetic resonance imaging (MRI) to compare meniscal vascularity in pediatric cadaveric specimens to adults. We hypothesize that the developing meniscus has greater and more uniform vascularity throughout all zones.

Methods:

We utilized 10 fresh-frozen human cadaveric knees (5 immature knees, age 0-6 months; 5 mature knees, age 34-67 years). Gadolinium-enhanced MRI was performed using a previously established vascularity quantification protocol. Regions of interest corresponding to peripheral and central zones of the meniscus were identified on pre-contrast coronal images, and signal enhancement (normalized against background tissue) was compared between pre-and post-contrast images (Figure 1).

Results:

Quantitative MRI demonstrated increased perfusion in the peripheral zones compared to the central zones (2.3:1 in immature knees and 3:1 in mature knees) in the medial and lateral menisci separately, and both menisci aggregated. Overall, the medial and lateral menisci had similar levels of perfusion in all specimens (45.9% ± 8.3% medial vs. 54.1% ± 8.3% lateral in immature knees; 50.5% ± 11.3% medial vs. 49.5% ± 11.3% lateral in mature knees). Immature specimens demonstrated greater overall normalized meniscal signal uptake, with the 0-month specimen demonstrating the greatest proportional signal enhancement.

Conclusion:

While blood flow to peripheral zones is greater than to central zones in both immature and adult menisci, younger menisci receive proportionally greater overall blood flow compared to adults, including greater blood flow to the inner zone, challenging the conventional wisdom of the central zone being avascular. As younger patients become increasingly active in sports, thorough understanding of the immature meniscus is required. Greater overall vascularity, including centrally, to the developing meniscus suggests improved healing potential following injury, and further encourages meniscal preservation when possible.

[Figure: see text][Figure: see text]
PATIENT REPORT OUTCOME MEASURE USE FOR CONCUSSION AMONG HIGH SCHOOL ATHLETIC TRAINERS
Authors: McLeod Tamara Valovich , Hattrup Nicholas , Root Hayley J.
Published: April 2020

Background:

Recent recommendations suggest incorporating patient-report outcome measures (PROMs) into concussion assessment batteries. Utilizing PROMs provides information on the patient’s perspective and how the concussion may influence the patient’s health status. Past studies evaluating PROM use among athletic trainers (ATs) found varying practices and barriers to implementation. However, there is limited data on use of PROMs in managing concussion among adolescent patients.

Hypothesis/Purpose:

To describe the use of PROMs as part of concussion assessment and treatment practices of ATs working in middle and high school settings.

Methods:

An online survey regarding concussion treatment perceptions and practices was distributed to a convenience sample of 5000 ATs through the NATA Survey Research Program. The survey included personal and institutional demographics, healthcare provider access and referral practices, perceptions of concussion treatment, clinical practice characteristics of concussion treatment and PROM use. The survey was pilot tested and validated in a sample of ATs prior to distribution. Analysis of the PROM section was conducted using descriptive statistics (percentages, frequencies) for this study.

Results:

The survey was accessed by 304 ATs (6.1% access rate) and completed by 153 ATs (58.3% completion rate). Of those, 27.2% (n=57) were employed in the middle school or high school setting and were analyzed for this study. Just over half of respondents had <10 years of experience (52.7%, n=30). Only 35.1% (n=20) of ATs reported they use PROMs as part of their clinical management of concussion. Of those who use PROMs, 75% (n=15) indicated that they use them always or almost always. The most commonly used generic PROMs were the Short Form 12 or 36 (25%, n=5) and Patient Reported Outcomes Measurement Information System (25%, n=5) and the most common specific PROMs were the Headache Impact Test (45%, n=9) and Dizziness Handicap Inventory (15%, n=3). Figure 1 shows the level of self-reported confidence of those utilizing PROMs. Barriers for PROM use included it being too time consuming (24.6%, n=14/57), lacking a support structure (15.8%, n=9/57), and not familiar with PROMs (14%, n=8/57). Close to one-fourth (22.8%, n=13/57) of respondents would be willing to use PROMs, but lacked time.

Conclusion:

While the use of PROMs is recommended in the evaluation and treatment of adolescent athletes, just over one-third of ATs providing care to these patients, use PROMs. Educational efforts for ATs should look to increase their familiarity and confidence when using PROMs for concussion while suggesting strategies to incorporate PROMs into practice.

[Figure: see text]
DESCRIPTIVE STUDY OF INJURIES IN MIDDLE SCHOOL CROSS COUNTRY RUNNERS
Authors: Wu Alexander , Ackerman Kate , Barrack Michelle , Tenforde Adam
Published: April 2020

Background:

High school athletes participating in cross-country sports are at increased risk of overuse injuries. Little is known in younger athletes including those participating in running during middle school regarding prevalence of injuries or related risk factors. The objective of this study was to assess the frequency of sports-related injuries in middle school cross-country runners.

Methods:

This was a retrospective online survey study of middle school cross-country runners. Middle school cross-country coaches from middle school teams in the Boston area sent letters of invitation via email to the parents of their athletes to participate in an optional, anonymous online survey administered in REDCap. Participants received a $5 gift card for their time. The online survey included demographic information, weight, height, training variables, daily dietary patterns, and injury history. We conducted univariate and bivariate analyses while stratifying for sex.

Results:

A total of 101 subjects completed the survey, 47% (n=48) were female. Mean age was 12.5 years [SD 0.94], and 24% (n=24) were in sixth grade, 39% (n=39) in seventh grade, and 38 % (n=38) in 8th grade. The mean BMI for girls was 17.9 kg/m2 and for boys 18.24 kg/m2. The self-reported race/ethnicity was white in 72% (n=72), Asian in 22% (n=22), Latino in 5% (n=5), and black in 1% (n=1). Mean weekly mileage during the cross-country season was 15.2 miles [SD 7.6]. Of female subjects, 17% (n=8) reported that they were diagnosed with a bone stress injury (BSI) due to running, compared to 2% (n=1) of male subjects, p=0.009. The injured bones in females included the tibia (n=1), fibula (n=1), navicular (n=1) and metatarsal bones (n=6). The injured bone in the male was a sacral fracture. Compared to those without injury, runners with BSIs did not have observed differences in calcium or vitamin D intake; no differences were observed related to ball sport or other forms of strengthening exercises. A total of 63 non-fracture injuries occurred from running, with females (18%) more likely to have sprained ankles than males (6%, p=0.47).

Conclusions/Significance:

Running-related injuries are relatively common in middle school cross-country runners. In middle school, female runners are more likely to sustain running related BSIs than male runners. Efforts to prevent overuse stress injuries in middle school runners should be considered.

[Table: see text]
GRAFT CHOICE FOR ACL RECONSTRUCTION IN YOUNG ACTIVE PATIENTS – USE OF QUADRICEPS TENDON AUTOGRAFT INCREASED LIKELIHOOD OF MEETING RETURN TO PLAY CRITERIA AT 6 MONTHS POST SURGERY
Authors: Gregory Bonnie , Magill John , Meyers Heather , Pietrosimone Laura , Le Daniel , Reinke Emily , Riboh Jonathan
Published: April 2020

Background:

ACL graft tears and contralateral injuries are problematic in pediatric sports medicine, with a combined incidence of 25-35%. Recent publications have highlighted a high failure rate with hamstring autografts in young patients, while others have suggested lower failure rates with quadriceps autografts. However, little is known about the possible reasons for this difference.

Hypothesis:

We hypothesized that the use of quadriceps soft tissue autografts would lessen post-operative neuromuscular deficits compared to other autografts, and therefore, young athletes would achieve objective return to sport (RTS) criteria more rapidly.

Methods:

A retrospective review of consecutive patients who underwent ACL reconstruction by a single surgeon and completed a comprehensive series of physical performance tests (PPTs) at 6 months post-surgery was conducted. A chart review of demographic and surgical data was completed. Patients performed nine common PPTs; limb symmetry index (LSI) was established and LSI> 90% was used as the cut-off for passing each individual test. Athletes met RTS criteria if they achieved LSI>90% on at least 8 of 9 tests. Multivariate linear and logistic regressions were performed to assess the effect of age (dichotomous; pediatric (<16 years) versus skeletally mature), gender, graft type, concomitant meniscal surgery, and time post-op, on the number of tests an individual could pass and the likelihood of passing the battery of PPTs, respectively.

Results:

The cohort of 68 young, active patients (mean age= 18.9 years +/- 7.5; 56% pediatric; 46% female; graft type: 63% BTB, 16% hamstring, 15% quadriceps, 6% ITB) were tested at a mean 6.7 months +/- 1.9. Overall, 35% of patients “passed” the battery of PPTs. Upon logistic regression, age and concomitant meniscal surgery were poor predictors of “passing.” In contrast, use of quadriceps was a strong predictor of passing (OR 14.1, 95% CI 2.4-83, p=0.003, compared to BTB). Upon linear regression, use of quadriceps was again a strong predictor of the number of individual PPTs passed (b=1.8, 95% CI 0.33-3.3, p=0.02, compared to BTB). No other demographic variables predicted “passing” or number of individual PPTs passed.

Conclusion:

Young, active patients undergoing ACL reconstruction with quadriceps autograft are 14 times more likely to meet RTS criteria at 6 months post-op than similar patients with BTB, hamstring or ITB autograft. This may provide valuable insight into the decreased failure rates suggested with the quadriceps autograft. Additionally, this study confirms the majority of these high-risk, young athletes do not meet RTS criteria at 6 months post-operatively.
OPEN OSTEOCHONDRAL AUTOGRAFT TRANSFER RESULTS IN MORE FREQUENT REOPERATION THAN OPEN ALLOGRAFT TRANSFER IN THE PEDIATRIC KNEE
Authors: Hall Tyler B. , Hyman Max J. , Patel Neeraj M.
Published: April 2020

Background:

Osteochondral autograft (OAU) and allograft (OAL) transfer are surgical options for sizeable articular cartilage lesions in the knee. In the pediatric population, there is little data on the patients undergoing these procedures or evidence to support one technique over another. Specifically, the rate of reoperation in these young patients is unknown.

Hypothesis/Purpose:

The purpose of this study is to compare the rate of reoperation in children and adolescents undergoing OAU or OAL of the knee in a nationally representative population.

Methods:

The Pediatric Health Information System, a national database consisting of 49 children’s hospitals, was queried for all patients undergoing open or arthroscopic OAU and OAL between 2012 and 2018. Demographic information was collected for each subject as well as data regarding subsequent reoperations, readmissions, and returns to the emergency department. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.

Results:

A total of 732 subjects with a mean age of 15.4±2.4 years were included in the analysis. Of these, 393 (53.7%) initially underwent OAL (273 open, 120 arthroscopic) and 339 (46.3%) underwent OAU (137 open, 202 arthroscopic). The overall reoperation rate was 144/732 (19.7%) at a median of 198 days (range 17-1604 days) after the index operation. This rate was similar between OAL and OAU. In 18 subjects (2.5%), OAU, OAL, or autologous chondrocyte implantation (ACI) was performed at the time of revision surgery. When analyzing only open procedures, 25.5% of open OAU patients underwent a repeat procedure compared to 16.5% of open OAL patients (p=0.03). After adjusting for other factors in a multivariate model, those who initially underwent open OAU had 1.7 times higher odds of requiring a future reoperation than an open OAL patient (95% CI 1.1-2.8, p=0.04). There was no difference in the rate of repeat surgery among arthroscopic procedures or when comparing open to arthroscopic operations.

Conclusion:

While 19.7% of children and adolescents undergoing OAU or OAL eventually require repeat surgery, the rate at which revision OAU, OAL, or ACI is performed is 2.5%. Patients undergoing open OAU have 1.7 times higher odds of ultimately requiring a reoperation than those undergoing open OAL, even when adjusting for confounding factors.
LATERAL FEMORAL CONDYLE OSTEOCHONDRITIS DISSECANS: DOES WEIGHTBEARING ZONE LOCATION PREDICT HEALING?
Authors: Huang Sharon G. , Zhou Liang , Wagner K. John , Gee Shawn , Wilson Philip L. , Ellis Henry B.
Published: April 2020

Background:

Osteochondritis dissecans (OCD) is a focal, idiopathic alteration of subchondral bone with potential for instability and disruption of adjacent articular cartilage that may result in premature (early secondary) osteoarthritis.

Purpose:

The purpose of this study was to evaluate differences in clinical, radiographic, and treatment outcomes in weightbearing (WB) versus non-weightbearing (NWB) lateral femoral condyle (LFC) OCDs.

Methods:

An IRB-approved retrospective review of 62 patients with LFC OCD lesions, 26 of which were weightbearing and 36 non-weightbearing (defined as Cahill and Berg sagittal zones B and C, respectively), treated at a single institution between 2004 and 2019 was performed. All participants were 18 years of age or younger at the time of diagnosis. Demographic and clinical characteristics, radiographic features, treatment modalities, and outcomes were evaluated. Continuous variables were analyzed using a Mann-Whitney test and a Kruskal-Wallis test when comparing across various groups. A Chi-square test was used to compare categorical variables.

Results:

The study cohort consisted of 40 (64.5%) male and 22 (35.5%) female participants, with an average age at diagnosis of 12.86 ± 2.74 years, and an average follow-up of 24 months. WB and NWB LFC OCDs had no differences in symptom chronicity or the presence of mechanical symptoms. NWB lesions were more likely to present with distinct ossification of the progeny bone segment (70.0% vs. 25.0%; p = 0.044) and were deeper lesions (MRI sagittal depth 7.11 vs. 5.96; p = 0.046). Across a variety of treatment modalities, NWB lesions were significantly more likely than WB lesions to demonstrate full radiographic healing at final follow-up (52.8% vs. 24.0%; p = 0.033). There was no difference in the likelihood of initial non-operative versus operative treatment selection or in the outcomes of non-operative treatment between the two lesion types. Additionally, OCDs in either zone were equally likely to be pain-free at final follow-up.

Conclusion:

Lateral femoral condylar OCD lesions in weightbearing and non-weightbearing zones have similar clinical presentation. However, lesions in non-weightbearing zones demonstrate improved radiographic healing at final follow-up. These data may aid in clinical decision-making and counseling during treatment of children and adolescents presenting with lateral femoral condylar OCD.

[Figure: see text]
ASSOCIATION BETWEEN SADNESS AND SYMPTOM SEVERITY IN PEDIATRIC AND ADOLESCENT PATIENTS WITH HIP PAIN
Authors: Wagner K. John , Tigabu Kirubel , Sabatino Meagan J. , Richard Heather M. , Podeszwa David A. , Sucato Daniel J. , Ellis Henry B.
Published: April 2020

Background:

Patient-reported outcome measures (PROMs) are used by hip surgeons to assess treatment outcomes.

Purpose:

The purpose of this study was to evaluate patient-reported sadness and its association with perceived pain, symptoms, and clinical disease severity in patients with hip pain.

Methods:

A review of prospectively collected PROMs from patients presenting with hip pain was performed. PROMs were completed at baseline, one year, and two years post-treatment. Those who reported feeling ‘downhearted and blue’ sometimes, often, or always on a baseline SF-12 (SAD) were compared to those who did not (NOT SAD). A subset of patients diagnosed with femoroacetabular impingement (FAI) was analyzed to assess radiographic and intraoperative disease severity between the groups. Radiographic measures consisted of baseline alpha angle and lateral center edge angle. Intraoperative disease severity of the femoral head, labrum, acetabulum, and capsule was determined by an orthopaedic surgeon using a standardized 1-3 ranking system. A Mann-Whitney Test was used to compare groups.

Results:

Of 378 participants, the mean age was 15.3 (range 7-19) and 64.6% were female. Sixty-four participants (16.9%), of which 78.1% were female (p=0.013 compared to male) reported feeling SAD at baseline. SAD participants scored worse on the HOOS at baseline (55.8 vs. 66.1, p<0.001), with significantly lower scores on every subscale (Table 1). Additionally, SAD participants demonstrated worse perceived outcomes one year post-treatment. While not significant, SAD participants also demonstrated a trend towards lower HOOS scores two years post-treatment (Table 1). Of 121 participants diagnosed with FAI (mean age 15.8; 72.7% female), SAD participants reported worse quality of life (29.1 vs. 44.5, p<0.001), pain (52.2 vs. 60.1, p=0.049), physical function (59.7 vs. 68.8, p=0.028), and scored lower overall on the HOOS at baseline (53.8 vs. 62.0, p=0.023). However, SAD participants did not demonstrate worse radiographic or intraoperative disease severity (Table 2). One year post-treatment, SAD participants reported worse pain on the HOOS (68.0 vs. 87.6, p=0.033). There were no significant differences between the SAD and NOT SAD groups at two years post-treatment, but lower scores were noted (Table 1).

Conclusion:

The question of feeling ‘downhearted or blue,’ perhaps a symptom of underlying depression, may be associated with patient reported symptom severity at baseline and one year post-treatment. However, no differences were found in radiographic or intraoperative disease severity of hip impingement between the SAD and NOT SAD groups, indicating that symptoms of underlying depression may be a risk factor for poor treatment outcomes.

[Table: see text][Table: see text]
OSTEOCHONDRAL LESIONS OF THE TALUS: FACTORS PREDICTIVE OF CARTILAGE INTEGRITY
Authors: Perkins Crystal A , Erickson John , Braithwaite Kiery , Busch Michael T , Willimon S. Clifton
Published: April 2020

Background:

The integrity of articular cartilage in patients with osteochondral lesions of the talus (OLTs) guides treatment. The ability to predict cartilage integrity in OLTs, as previously published for OCD of the knee1, would be beneficial. The purpose of this study is to evaluate the association of radiographic and MRI findings and articular cartilage integrity at the time of ankle arthroscopy for OLTs.

Methods:

A single-institution retrospective review identified patients 19 years of age and younger with operative treatment of OLTs from 2010 – 2017. Demographics and intra-operative findings at the time of ankle arthroscopy were identified by chart review. Radiographs were assessed for physeal status, OLT location, and Berndt and Hardy grade. MRIs were reviewed for OLT size and location, modified Kramer grade, and cartilage status.

Results:

53 patients with 54 OLTs and a mean age of 13.6 years (range 7 – 19 years) were included. OLTs were located in the posteromedial talus in 39 patients (72%). Physeal status was closed/closing in 32 patients (59%) and open in 22 patients (41%). On MRI, the cartilage was predicted to be disrupted in 40 patients (74%) and intact in 14 patients (26%). At the time of ankle arthroscopy, the cartilage was found to be disrupted in 38 OLTs (70%) and intact in 16 OLTs (30%). Table 1 lists variables predictive of cartilage integrity. [Table: see text] MRI classification of cartilage integrity was 95% sensitive and 75% specific for arthroscopic integrity, with 11% misclassification. In the 16 patients less than 13 years, MRI perfectly predicted arthroscopic cartilage integrity. In patients with open physes, MRI sensitivity was 92% and specificity 100%. In patients with closing/closed physes, MRI sensitivity was 89% and specificity 50%. Receiver operator curve characteristics of a model to predict arthroscopic cartilage integrity combining MRI cartilage integrity, physeal status, and radiographic grade has an AUC of 0.955.

Conclusions:

Physeal status, radiographic grade, MRI grade, and cartilage integrity on MRI are independent predictors of cartilage integrity at the time of ankle arthroscopy for patients with OLTs. Overall, MRI has 95% sensitivity and 75% specificity for cartilage integrity at the time of arthroscopy, which improves to near 100% sensitivity and specificity in patients with open physes. A model combining MRI cartilage integrity, physeal status, and radiographic grade has the highest predictability of intra-operative cartilage integrity. SIegaSll E, Faust JR, Herzog MM, Marshall KW, Willimon SC, Busch MT. Age predicts disruption of the articular surface of femoral condyles in knee OCD: can we reduce usage of arthroscopy and MRI? J Pediatr Orthop 2018;38:176-180.