bluuebunny/crossref_metadata_2025 huggingface dataset:
Financing Constraints and Investment Efficiency in Canadian Real Estate and Construction Firms: A Stochastic Frontier Analysis
Authors: Luo Hang (Robin) , Islam Abu Reza Mohammad , Wang Rui
Published: July 2021

This article models the behavior of 179 listed and unlisted real estate and construction firms (RECFs) in Canada to study how financial constraints impact the investment efficiency of these real estate firms during the 2004–2020 period. Investment efficiency is interpreted here as the ability and ease of a firm to convert investment opportunities into actual investments. The results show that Canadian RECFs are strongly dependent on two sources of financing: equity financing and debt financing. Equity financing helped ease financing constraints due to a cash flow increase but was unlikely to decrease the uncertainty of follow-up financing of investments of these companies. This study constructed an investment efficiency index (IEI) for all 179 RECF firms. The results showed an investment rate loss of approximately 62% of the RECF firms due to financing constraints during the above period. The IEI of RECFs in Canada has demonstrated a descending pattern, and the investment efficiency level slipped from 0.47 to 0.40 from 2004 to 2020. Furthermore, a regional analysis demonstrates that compared with the RECFs located in Ontario, the investment efficiency indices of RECFs in Quebec and British Columbia were more volatile. Small RECFs demonstrated a very steady trend in investment efficiency during the sample period, which was completely different from the patterns displayed by large and medium RECFs.
Ghana’s Competitive Clientelism and Space for Long-Term Stable Policies
Authors: Odijie Michael Ehis , Imoro Mohammed Zayan
Published: July 2021

Given the close election results and the winner-takes-all nature of politics in Ghana, researchers have argued that the two parties are now characterized by a high degree of vulnerability, which in turn provides strong incentives for ruling elites in both parties to find strategies to ensure their political survival. This results in the distribution of state resources to political supporters and short-termism, which weakens the possibility of building a broad political consensus on any national development issues. Using the case of Ghana’s Right to Information Bill, this article will argue that there are conditions under which elite commitment to long-term development could be fostered and sustained in competitive clientelist political settings like Ghana.
Obesity and Work-Related Injuries Among Farmers in Kentucky, Tennessee, and West Virginia
Authors: Hunsucker Sharon , Reed Deborah B.
Published: July 2021

Background

Obesity is a recognized risk factor for work-related injuries (WRI). Despite the inherent safety hazards associated with farm work, research on obesity among farmers is limited giving little guidance to occupational health providers on obesity as a risk factor in farm WRI. This study evaluated the association between obesity and farm WRI.

Methods

Cross-sectional data were collected from farmers ( n = 100) in Kentucky, Tennessee, and West Virginia. Data included a survey (demographic data, farm factors, health indicators, occurrences of work-related injuries consistent with the definition of Occupational Safety and Health Administration [OSHA] recordable injuries) and direct anthropometric measures (height, weight, and waist circumference). Logistic regression was used to model any work-related injury, injuries consistent with the definition of OSHA recordables (herein called OSHA-recordable injuries), and recurrent injuries occurring during farm work performance on body mass index (BMI) and waist circumference.

Findings

Twenty-five percent of the participants reported any injuries, and 18% reported OSHA-recordable injuries. Farmers with a BMI ≥30 kg/m2 had 3 times the risk for OSHA-recordable injuries and 5 times the risk for recurrent injuries. No significant relationship was identified between waist circumference and farm WRI.

Conclusion

This study provides evidence that increased BMI is a safety risk for farmers. Prospective studies with a larger sample are needed. Occupational health nurses and providers should educate farmers on the potential safety risk of obesity and implement weight management programs addressing obesity in farmers.
Can We Extrapolate SINS Score to Evaluate Instability in Spinal Tuberculosis?
Authors: Pithwa Yogesh Kishorkant , Sinha Roy Vikrant
Published: July 2021

Study Design:

Prospective Observational Study.

Objectives:

To assess the feasibility of utilizing SINS score, originally suggested for neoplastic conditions, to assess structural instability in spinal tuberculosis.

Methods:

Patients with an established diagnosis of spinal tuberculosis were included in the study. Based on SINS scoring, patients classified as those with “indeterminate stability” were managed with or without surgery based on other parameters including neurological status, severity of pain, medical comorbidities, etc.

Results:

Eighty [39 males, 41 females] patients prospectively evaluated with mean age 46.74 ± 17.3 years. Classification done into stable [n = 7], indeterminate [n = 45] and unstable [n = 28] groups based on SINS scoring. All the patients in unstable group were treated with surgical stabilization whereas none in the stable group required surgical stabilization. In the indeterminate group, 26 patients underwent surgical stabilization, while 19 treated non-operatively. Major determinants predisposing to surgical intervention in “indeterminate group” were pain [14 of 26 patients] and neurological status [11 of 26 patients]. Mean follow-up 38.5 ± 22.61 months with minimum follow-up being 24 months. Preoperative VAS score for pain improved from median of 9/10 to 1/10 following surgery [ P < .0001]. In the non-operative group, the improvement was from median score of 6/10 to 1/10 [ P < .0001]. Preoperative ODI improved in non-operative and operative group from median of 42% and 70%, respectively to 10% and 12%, respectively in the postoperative period [ P < .0001 for both groups].

Conclusions:

SINS scoring can be a helpful tool in surgical decision-making even in spinal tuberculosis. Further refinement of the score can be done with a larger, multicenter study.
Wound Botulism in Black Tar Heroin Injecting Users: A Case Series
Authors: Raza Nadia , Dhital Sandhya , Espinoza Valerie Elise , Jariwal Roopam , Chiu Chien-Wai , Valdez Michael , Heidari Arash , Petersen Greti , Sabetian Katayoun
Published: July 2021

The incidence of wound botulism in injection drug users has increased since the introduction of black tar heroin. Many species of the Clostridium genus, most commonly Clostridium botulinum, Clostridium baratii, and Clostridium butyricum, have been associated with wound botulism. Patients often present with progressive bulbar weakness, including dysphagia, cranial nerve palsies, and loss of speech, in addition to symmetrical descending weakness of the upper extremities that may progress to the chest and lower extremities. In this article, we present 3 cases of wound botulism, in which the patients presented with bulbar weakness and were treated with botulism antitoxin heptavalent. The time to antitoxin administration and its effect on the patients’ clinical courses is compared.
LCL IN A SINGLE CORONAL SLICE – A NOVEL SIGN FOR IDENTIFYING ACL DEFICIENT PATIENTS AND PREDICTING RISK OF FUTURE GRAFT FAILURE
Authors: Mitchell Brendon C. , Siow Matthew Y. , Chambers Henry G. , Pennock Andrew T. , Parvaresh Kevin , Edmonds Eric W.
Published: July 2021

Background:

The ACL deficient knee is predisposed to anterior translation and internal rotation of the tibia.

Hypothesis/Purpose:

To show that knee deformity in an ACL deficient knee will produce a more vertical orientation of the lateral collateral ligament (LCL), allowing for the entire length of the LCL to be visualized on a single coronal slice (coronal LCL sign) on MRI, and that this sign is indicative of a greater risk for graft failure after ACL reconstruction.

Methods:

Charts were retrospectively reviewed to create 3 separate cohorts: normal ACL and no pathology involving the collateral ligaments (control cohort), ACL reconstruction without evidence for graft rupture, and ACL reconstruction with graft failure. Tibial translation and femorotibial rotation were measured on MRI, and posterior tibial slope was measured on lateral knee radiographs. Imaging was reviewed for the presence of the coronal LCL sign.

Results:

Deficient ACL (n=153) compared with intact ACL (n=70) was associated with significantly greater displacement regarding anterior translation (5.8mm internal rotation vs 0.3mm external rotation, p<0.001, respectively) and internal rotation (5.2 degrees vs. -2.4 degrees, p<0.001, respectively). The coronal LCL sign was present in a greater percentage of ACL deficient patients than intact ACL controls (68.6% vs. 18.6%, p<0.001, respectively) and associated with greater anterior tibial translation (7.2mm vs. 0.2mm vs., p<0.001) and internal tibial rotation (7.5 degrees vs 2.4 degrees, p=0.074). Multivariate analysis revealed the coronal LCL sign was significantly associated with an ACL tear (OR 12.8, p<0.001). Of the 153 ACL deficient cohort, 114 had no graft failure patients and 39 experienced graft failure. Mean follow-up time was 3.5 years (2 – 9.4 years). Coronal LCL sign was associated with graft failure (p=0.013), with an odds ratio of 4.3 for graft failure (p=0.003). Comparison of pre- and post-ACL reconstruction MRI in the graft failure cohort demonstrated reduced internal rotation, p= 0.00, but no change in coronal LCL sign (p=0.922).

Conclusion:

Our study shows that the coronal LCL sign correlates with the presence of an ACL tear and functions as a surrogate for the extent of axial and sagittal deformity. Further, we show that tibia internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Whereas, the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). [Table: see text][Figure: see text]
ARE SPORTS INJURIES THE MOST COMMON CAUSE OF MOREL-LAVALLEE LESIONS IN THE PEDIATRIC POPULATION?
Authors: Kushare Indranil , Ghanta Ramesh Babu , Wunderlich Nicole A.
Published: July 2021

Background:

Traumatic internal degloving injury i.e. Morel-Lavallée lesion (MLL) develops as a result of blunt trauma with tangential shear forces. In the pediatric population, these have been described only as small case reports till date. Purpose: To describe the largest case series of lower extremity Morel-Lavallée lesion (MLL) in the pediatric population, to determine its etiology (especially its relationship to sports), treatment and outcomes.

Methods:

Retrospective study of patients <18 years presenting to a tertiary children’s hospital with MLL between 2013-2019. Demographics, clinical data, imaging features, treatment and outcomes data was collected. Descriptive statistical analysis was conducted.

Results:

38 patients (21 males, 17 females) having MLL with mean age 14.6 years were classified into 2 groups- hip/thigh MLL (9 patients) and lower leg MLL (29) (Table 1.1). Most common cause of lower leg MLL was sports injury (79%). Most commonly implicated sports in MLL were football and baseball(24% each). Associated injuries were seen in 9 (23%) patients. Radiographs done in 58% of patients showed no bony abnormalities. Imaging modality of choice was MRI for lower leg MLLs (72%) and US for hip/thigh MLL (67%)(Fig.1.2). MLL size was larger for hip/thigh MLL (168 cm3) as compared to leg MLL (38.6 cm3). 25 (65.8%) of MLLs were treated with conservative management,12 (31.5%) with minimally invasive methods and 1(2.6%) needed surgical management. 2/9 (22.2%) of the associated injuries required operative management. 2/38 (5%) patients were given prophylactic antibiotics. 72.4% Lower leg MLLs were treated with conservative management while intervention was needed more in hip/thigh MLLs (55.6%). Patients returned to activities at 14.3 weeks for hip/thigh MLL;9.1 weeks for lower leg MLL. 24 patients with adequate documentation demonstrated lower extremity functional score (LEFS) and pain level of 74/80 (92.5%) and 0.7/10 respectively at mean 12.5 months follow-up. Leg cellulitis was seen as a complication in one patient.

Conclusion:

The largest case series on MLL exclusively in the pediatric population suggests that they are more common in knee/leg region region and usually caused by sports injuries which is notably different as compared to adult population. Most pediatric injuries are treated conservatively, especially sports related MLLs. Although return to activities takes longer for hip/thigh injuries, majority of patients regain satisfactory functionality post-injury. [Table: see text][Figure: see text]
NEURAXIAL ANESTHESIA FOR HIP ARTHROSCOPY IS ASSOCIATED WITH DECREASED IMMEDIATE POSTOPERATIVE PAIN SCORES AND OPIOID REQUIREMENTS COMPARED TO GENERAL ANESTHESIA
Authors: Turner Elizabeth H. G. , Whalen Christopher J. , Beilfuss Matthew A. , Hetzel Scott J. , Schroeder Kristopher M. , Spiker Andrea M.
Published: July 2021

Background:

Hip arthroscopy is most commonly performed utilizing general anesthesia. Studies in hip and knee arthroplasty have shown an association between neuraxial anesthesia and lower rates of perioperative adverse events, lower post-operative pain scores, and lower dosing of postoperative systemic analgesics when compared to general anesthesia. A direct comparison between neuraxial and general anesthesia in hip arthroscopy has not previously been investigated.

Hypothesis/Purpose:

We sought to identify the immediate post-operative differences in opioid use, pain scores, and post-anesthesia care unit (PACU) length of stay (LOS) after hip arthroscopy related to the type of anesthesia used for the surgical procedure.

Methods:

Patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with labral tears by a single surgeon at an academic center between October 2017 and July 2019 were retrospectively reviewed. The primary outcome was PACU opioid administration, measured by morphine equivalents (MEQ). Secondary parameters included total LOS, post-incision LOS, PACU LOS and PACU arrival/discharge pain scores. Analyses conducted were t-tests, Wilcoxon rank sum tests, or chi-square tests.

Results:

A total of 129 patients met inclusion criteria for this study; 54 males and 75 females, with an average age of 28 (±10.1) years. 52 (40.3%) had general anesthesia and 77 (59.7%) had neuraxial anesthesia, including spinal, epidural, and combined spinal-epidural anesthesia which were intermixed throughout the study period. Intraoperative and PACU opioid administration demonstrated a significant difference in medians. Neuraxial methods required a lower MEQ in both the operating room (30.0 vs 53.9, p = 0.001) and PACU (18.2 vs 31.2, p = 0.002). Neuraxial anesthesia had lower median PACU arrival and discharge pain scores (0.0 vs. 5.0, p = 0.001, 3.0 vs. 4.0, p = 0.013). There was no statistically significant difference in post-incision LOS, or traction time. General anesthesia was associated with a longer PACU phase 1 time (1.0 vs. 1.3 hrs, p = 0.005). No major adverse events such as death, disability, or prolonged hospitalization occurred in either group.

Conclusion:

Neuraxial anesthesia use in routine hip arthroscopy was associated with lower immediate postoperative pain scores, lower intraoperative and immediate postoperative opioid requirements, and may be associated with shorter anesthesia recovery time without any major adverse events when compared to general anesthesia.

Tables

[Table: see text][Table: see text]
PHYSICAL THERAPISTS’ PERCEPTIONS OF ADOLESCENT IDIOPATHIC SCOLIOSIS TREATMENT
Authors: Davelaar Foley , Sugimoto D
Published: July 2021

Background:

Few studies have demonstrated the benefit of physical therapy in the treatment of adolescent idiopathic scoliosis (AIS), alone or in conjunction with bracing or surgery. To our knowledge, there is no consensus in pediatric physical therapists who treat AIS patients.

Purpose:

To identify the optimal physical therapy practices for AIS including; weekly frequency, session length, treatment duration, clinical interventions, therapeutic goal-setting, and outcome measures from pediatric physical therapists’ perspectives.

Methods:

A 40-question validated survey, The Analysis of the Schroth Method in Adjunct to Physical Therapy Services for Treatment of AIS, was distributed to pediatric physical therapists across the country via the Academy of Pediatric Physical Therapy electronic newsletter and via dissemination by the Injury Prevention Research Interest Group from Pediatric Research in Sport Medicine. REDCap was used to collect and organize responses. The responses were analyzed by a descriptive statistics using percentages (%).

Results:

Sixty-five responses were obtained. The majority of physical therapists, 78.5%, were Doctors of Physical Therapy (DPT), treating 1-5 AIS patients a week (69.2%), and 18.8% had Schroth certification. Preferred treatment frequency was twice a week (41.5%) for a duration of 60 minutes (53.8%), over the course of 3-5 months (44.6%). The top three common clinical interventions were; core and trunk stability enhancement (90.8%), abdominal strengthening (83.1%) and postural correction (80.0%). The three most common therapeutic goal-setting parameters were activity based (78.5%), quality of life measure based (56.9%), and therapy participation based (50.8%). Additionally, for outcome measures, patient reported outcome was the most common objective measurement (78.5%), followed by pain (63.1%), manual muscle testing (46.2%), range of motion (44.6%), cobb angle (27.7%), scoliometer readings (26.2%) and Adam’s forward bend test (10.8%). Therapists often monitored progress with completed surveys by patients. However, patients’ ability to return to activity was the most common marker of improvement (72.3%). Patient’s scoliosis was often being treated in another manner aside from PT (46.2%), and many patients had medical conditions in addition to scoliosis (52.3%).

Conclusion:

According to our data, pediatric physical therapists believe that patients with AIS can benefit from physical therapy treatments addressing core and trunk stability, abdominal strengthening, and postural correction. Ideal treatment sessions would occur twice a week for 60 minutes over a period of 3-5 months. Objective measurements can be monitored to ensure improvements in quality of life, pain, strength, range of motion and curvature of the patient’s spine. Acknowledgements The Injury Prevention Research Interest Group from Pediatric Research in Sports Medicine and Suzanne M. McCahan, PhD
COMMUNITY IMPACT FOR CLINICALLY INTEGRATED ATC PROGRAM IN A SPORTSMEDICINE PRACTICE
Authors: Grambo Laura , Rivero Samantha , Harbacheck Katie , Boyd Christine , Keefer Shaun , Klein Eric , Vuong Brian , Ford-Hemann Carolyn , Larson Scott , D’Alpe Cameron , Frick Steve , Shea Kevin
Published: July 2021

Background:

Health Systems routinely make investments in clinically driven outreach programs to build for future community needs, improve health outcomes, and serve their community mission. Many community sports programs have limited access to sports medicine care, including access to athletic trainers.

Hypothesis/Purpose:

The primary purpose of this study was to evaluate the impact of a clinically integrated Certified Athletic Trainer (ATC) Community Sports Outreach Program, by evaluating the outreach into the community, sports clubs, schools, covered events.

Methods:

The ATC Community Outreach Program monitored key metrics over a 3 and 1/2-year period. Metrics included the partnerships developed with local clubs and schools, number of athletes covered in each organization, games covered and hours spent supporting organizations. Categories were divided into fiscal years (FY) running from September to August. Fiscal Year 2016 was calculated from January – August, as it was the first year of the program. The percentage of growth of the amount of games covered was calculated from the adjacent FY.

Results:

Over the first 3 and 1/2 years (FY2016-FY2019), the number clubs, schools, programs covered grew from 10, 19, 25, to 31 from FY2016 - FY2019. Number of athletes from 7,363, 12,552, 15,104, to 19,794 from FY2016 - FY2019. The number of community outreach events grew from 6, 11, 57, to 190 from FY2016 - FY2019 (Table/Figure 1.1). The percentage of growth of games covered grew from 183%, 518% to 333% between FY2016 and FY2019.

Discussion/Conclusion:

Building, maintaining a sports medicine practice is a complex undertaking, and represents a significant investment for the health system and community. In many communities, access to sports medicine care for athletes is very limited. A clinically integrated ATC program can generate a significant impact on the community by building relationships with local sports clubs/schools and improving sports medicine care access to young athletes.

Tables/Figures:

[Table: see text][Figure: see text]
LIMITED INTER-RATER RELIABILITY IN ANTEROLATERAL LIGAMENT DETECTION IN PEDIATRIC KNEE MRIS
Authors: Williams Brendan A. , Mehta Nishank , Ganley Theodore J. , Lawrence J. Todd , Kim Sung H. , Nguyen Jie C.
Published: July 2021

Background:

Despite the rapidly expanding anterolateral ligament (ALL) literature base, little has focused on the reliability of its detection on MRI. This is especially important in the pediatric population where the scarcity of pediatric cadaveric specimens hinders the accurate estimation of its prevalence.

Purpose:

The purpose of this study was to assess the visibility of ALL on common MRI pulse sequences and to calculate the inter-rater reliability among multiple expert readers in a cohort of normal pediatric knee MRIs.

Methods:

A series of 3T pediatric knee MRIs obtained from 8/2018-4/2019 were reviewed to identify patients without significant knee pathology. Knee laterality, age, gender, and regional physeal status were also recorded. One orthopedic surgeon, 1 pediatric musculoskeletal (MSK) radiologist, and 1 adult MSK radiologist, independently reviewed each MRI pulse sequence (T1-weighted, PD-weighted, and PD-weighted fat-suppressed images) separately, to determine the presence or absence of the 3 parts of the ALL (femoral, tibial, and meniscal proper). Inter-rater reliability was calculated using Fleiss’ Kappa (K).

Results:

Inclusion criteria were met for 75 patient knees with a mean age of 12.7±3.42y (3-19) and a greater proportion of females (57.3%). The distribution of regional physeal status was: Open-48.0%, Closing-29.3%, and Closed-22.7%. Inter-rater reliability was slight to fair (K: 0.141-0.340) for visualizing any specific ALL component on a unique MRI sequence (Table 1). For visualizing a specific attachment on any MRI sequence, there was slight to moderate agreement (K: 0.018-0.411). Visualizing any ALL attachment on any MRI sequence also yielded slight agreement (K: 0.190). Inter-rater reliability between specialities (i.e. Ortho vs. MSK Radiology) did not differ substantially from group findings. No single study sequence demonstrated enhanced reliability for all ALL components.

Conclusion:

The reliability of ALL detection on MRI across multiple clinicians was slight to moderate for all components in this cohort of normal 3T pediatric knee MRIs. No single sequence was consistently better for ALL detection agreement. This is in contrast with previous work showing substantial agreement among raters and describing PD-weighted imaging as preferable for viewing the ALL. Experience in musculoskeletal imaging did not confer improved agreement. Establishing diagnostic reliability should be a prerequisite for use of an imaging finding in the research or clinical setting. Existing literature drawing conclusions from ALL findings on MRI may need to be interpreted with caution if reliability testing is not described.

[Table: see text]
CONCOMITANT MENISCECTOMY RESULTS IN REDUCED RETURN TO SPORT COMPARED TO MENISCUS REPAIR IN PRIMARY PEDIATRIC ACL RECONSTRUCTION
Authors: Williams Brendan A. , Wright Maggie L. , Bram Joshua T. , Maguire Kathleen J. , Patel Neeraj M. , Ganley Theodore J.
Published: July 2021

Background:

Meniscus repair has demonstrated favorable outcomes when performed with ACL reconstruction (ACLR). However, literature comparing meniscal tear patterns, treatments, and outcomes among pediatric patients remains limited.

Purpose:

The aim of this study is to evaluate the impact of surgical technique on patient outcomes, in primary pediatric ACLR with associated meniscal pathology. We secondarily examined patient factors and tear characteristics on these outcomes.

Methods:

This is a retrospective cohort study from 2014-2016 of pediatric ACL reconstruction patients who underwent concurrent surgical management of a meniscus tear. Predictors included patient demographics, injury mechanism, meniscal tear characteristics and surgical treatments. Clinical outcomes including return to sport (RTS), meniscus or ACL graft re-tear, and return to surgery were assessed via patient cross-sectional survey. Criteria for RTS were based on standardized postoperative rehabilitation protocols. Univariate and multivariate analyses were used to examine the relationship between studied predictors with the likelihood of RTS and other outcomes.

Results:

Inclusion criteria were met by 123 patients with an average follow-up time of 2.5 ± 0.7 years. RTS was achieved by 80.8% of patients while 17.1% of patients had a subsequent knee surgery within the studied timeframe. Univariate analysis of factors associated with successful RTS are shown in Table 1. While patients failing to RTS were shown to have delayed surgical intervention in univariate testing, multivariate analysis identified that patients who underwent meniscectomy were less likely to RTS than those who underwent meniscal repair (OR=2.690, 95% CI 1.044-6.930, p=0.040). Patients with an initial contact mechanism of injury were also demonstrated to be more likely to return to the OR for any reason (OR=13.443, CI 1.736-104.108, p=0.013) in multivariate modeling.

Conclusion:

In one of the few large cohorts of pediatric ACL reconstructions with concomitant meniscus surgery, this study adds to our understanding of a potentially modifiable factor (meniscus repair) in the surgical treatment of ACL injury with concaminant meniscus tear. Although no differences were seen in rates of meniscus or graft re-tear when comparing treatments, patients who underwent meniscal repair were more likely to return to sport than patients treated with meniscectomy. While these findings may reflect the quality of the torn meniscal tissue and severity of injury, it further emphasizes the importance of meniscal preservation not just for long term joint quality, but also for short term function in active pediatric patients.

[Table: see text]
SPORTS SPECIALIZED YOUTH ATHLETES EXHIBIT LOWER RISK QUALITY OF MOTION THAN NON-SPECIALIZED ADOLESCENTS
Authors: Heath Madison R. , Janosky Joseph , Pegno Angelo , Schachne Jonathan M. , Fabricant Peter D.
Published: July 2021

Background:

Quality of motion and neuromuscular balance are noted predictors of acute injury risk. Early sports specialization and extremely high activity levels have been linked to high risk of injury, especially overuse injury.

Purpose:

The purpose of this study is to investigate for any relationships between quality of physical movement, quantity of physical activity, and degree of sports specialization in a healthy cohort of children and adolescents.

Methods:

Healthy children between the ages 10 and 18 completed the HSS Pedi-FABS to assess quantity of physical activity and the Jayanthi scale to assess degree of sports specialization. Quality of motion was assessed using motion analysis sensors (DorsaVi, Kew, Australia) during 5 repetitions of 4 different jumping and squatting motions (Table 1). For each repetition, one point was given for low risk of injury anterior or medial/lateral motion, for a maximum score of 2 per leg. Quality of motion scores were summed for a maximum score of 100 per participant. Specialization level was dichotomized as high specialization with a Jayanthi scale score of 2 or 3 and low specialization with a score of 1 or 2. Independent samples t-tests were used to compare high vs. low specialization participants on physical activity quantity and overall quality of motion. A Pearson correlation was used to determine the relationship between quantity of physical activity and quality of motion.

Results:

Final analyses included 147 participants (72% male) with a mean age of 13.4 ± 2.2 years. For the entire cohort, the mean Pedi-FABS score was 22.9 ± 6.8, the mean quality score was 25.5 ± 13.5 and 73% were highly specialized. Participants that were highly specialized displayed low risk motion more frequently than participants with low sport specialization (27.6 ± 14.0 vs 19.8 ± 10.1, p < 0.01; Table 2). Highly specialized participants had significantly higher activity levels (24.6 ± 5.9 vs 18.1 ± 6.9, p < 0.001). Additionally, quality of motion was moderately correlated with physical activity level (r = 0.349, p < 0.001).

Conclusion:

Overall quality of motion as in jump-landing tasks in healthy children was better in highly specialized participants. Taken together with existing literature, although early specialization may put young athletes at risk for overuse injuries, highly sports specialized youth athletes may be at lower risk for acute injury. Future research should explore associations between sports specialization, physical activity, save movement patterns, and athletic injuries.

[Table: see text][Table: see text]
INITIAL CLINICAL PRESENTATION OF PEDIATRIC PATIENTS WITH PSYCHOLOGICAL DISORDERS FOLLOWING CONCUSSION
Authors: Worrall Hannah M. , Miller Shane M. , Cullum C. Munro , Chung Jane S.
Published: July 2021

Background:

There is limited evidence regarding the impact of pre-existing psychological disorders on the initial clinical presentation in pediatric patients following concussion.

Hypothesis/Purpose:

To examine differences in clinical symptom measures between pediatric patients with a history of depression and/or anxiety and no history of psychological disorder (PD) following a concussion.

Methods:

Data were prospectively collected from participants enrolled in the North Texas Concussion Network Registry (ConTex) between August 2015 and March 2020. Participants aged 5-18 years diagnosed with a concussion were included. Demographic variables and a range of clinical measures from initial presentation were reviewed, including SCAT-5 Symptom Log, Patient Health Questionnaire (PHQ-8), Generalized Anxiety Disorder (GAD-7) scale, and Brief Resiliency Scale (BRS). Participants were separated into four groups based on self-reported prior diagnosis: depression, anxiety, depression+anxiety, and no PD.

Results:

A total of 1770 participants were included: 50 with depression, 82 with anxiety, 84 with both, and 1554 with no history of PD. There was no significant difference in age, sex, prior concussion history, or time to presentation between the depression and no PD group, or between the anxiety and no PD group. A significant difference was found between the depression+anxiety group and no PD group in the following variables: age (15.11±1.8 vs 13.68±2.61 years, p<0.001), prior concussion history (40.5% vs 23.9%, p=0.001), and time to presentation (31.47±25.82 vs 19.85±26.33 days, p=0.01). Additionally, there were more females in the depression+anxiety group than the no PD group (71.4% vs 47.8%, p<0.001). The depression, anxiety, and depression+anxiety groups had significantly higher rates of learning disorders than the no PD group (40%, 47.6%, 46.4% vs 16.4%, all p<0.001). A significant difference in SCAT-5 symptom severity scores between the depression, anxiety, and depression+anxiety groups compared to the no PD group was found. The PD groups all reported higher GAD-7 and PHQ-8 scores and lower BRS scores compared to the no PD group. The depression+anxiety group had the highest symptom severity, GAD-7, and PHQ-8 scores along with the lowest BRS score. Table 1.1 summarizes these significant findings.

Conclusion:

Differences were seen in participants with a history of depression and/or anxiety at initial clinical presentation, including history of learning disability, SCAT-5 symptom severity scores, and common screening tests for depression, anxiety, and resiliency compared to those without a history of PD. Understanding these differences at initial presentation may urge providers to engage multidisciplinary teams early in facilitating patient recovery.

Tables/Figures:

[Table: see text]
ROLE OF PHYSICAL THERAPY IN THE TREATMENT OF POSTERIOR ANKLE IMPINGEMENT IN PEDIATRIC ATHLETES - A PROSPECTIVE STUDY
Authors: Saloom Adam , Purcell Nick , Ruhe Matthew , Gomez Jorge , Santana Jonathan , Kushare Indranil
Published: July 2021

Background:

Posterior ankle impingement (PAI) is a known cause of posterior ankle pain in athletes performing repetitive plantarflexion motion. Even though empirically recommended in adult PAI, there is minimal literature related to the role of conservative physical therapy (PT) in pediatric patients.

Purpose:

To identify patient characteristics and determine if there is a difference in pediatric patients with PAI who were successful with conservative PT and those who were unsuccessful, requiring surgical intervention.

Methods:

Prospective study at a tertiary children’s hospital included patients <18 years diagnosed with PAI and underwent PT. Patients who received PT at an external facility were excluded. Collected data included demographics, initial presentation at PT evaluation, treatment throughout PT, patient presentation at PT discharge, time to return to sport (RTS) from initial PT evaluation (if successful), time to surgery from initial PT evaluation (if unsuccessful). Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were collected. Group comparisons were conducted using independent t-tests or chi-square analyses (alpha level set at .05).

Results:

31 (12 males, 19 females) patients diagnosed with PAI were enrolled with a mean age 12.61 years (range: 8-17). Gymnastics, football, and basketball were the most commonly implicated sports (42% patients). All patients underwent initial conservative PT for an average of 16.24 weeks (9.23 visits ±7.73). 20/31(64.5%) patients failed conservative management and underwent arthroscopic debridement. PAI pathology was predominantly bony in 61.3% and soft tissue 38.7%. Between the successful PT group and unsuccessful PT group, there was no difference in the proportion of athletes/non-athletes (p=.643). Average RTS time for successful group was 11.47 weeks and average time to surgery for unsuccessful group was 17.82 weeks. There were no significant differences in sex (p=.332), age (p=.674), number of PT visits (p=.945), initial weight-bearing status (p=.367), use of manual therapy (p=.074) including manipulation (p=.172) and mobilization (p=.507), sport (p=.272), initial evaluation ankle ROM (p>.05). Initial AOFAS scores for pain, function, alignment, or total were not significantly different (p=.551, .998, .555, .964 respectively).

Conclusion:

The first prospective study in pediatric patients with PAI demonstrates that even though success of PT is not dependent on age, sex, sport or PAI pathology, a notable proportion of patients who undergo PT do not need surgery. Conservative management including PT should be the initial line of management for PAI. PT treatment and surgery (if unsuccessful with PT) allowed patients to return to prior level of activity/sports.

Tables/Figures:

[Table: see text]
EARLY OUTCOMES AFTER SUTURE TAPE REINFORCEMENT OF QUADRICEPS TENDON AUTOGRAFT ACL RECONSTRUCTION IN ADOLESCENT ATHLETES
Authors: Saper Michael
Published: July 2021

Background:

Recently, anterior cruciate ligament reconstruction (ACLR) with suture-tape reinforcement has been popularized for protection of the graft during the revascularization and remodeling phase of incorporation. To date, there are limited short-term data regarding the outcomes of suture tape reinforcement to ACLR. Furthermore, its use with quadriceps tendon autograft (QT) ACLR is limited.

Purpose:

The purpose of this study was to review the early, preliminary results of ACLR in adolescent patients using QT autograft with suture tape reinforcement (QT-SR).

Methods:

A retrospective review was performed of skeletally mature adolescent patients who underwent primary ACLR with all-soft tissue QT-SR since 2018. Surgeries were performed by a single surgeon using an all-inside technique. All patients followed the same standardized rehabilitation protocol. Twelve-month patient-reported outcome measures (PROMs) and complications were analyzed. PROMs included the Pediatric International knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, and the Tegner activity level scale. Psychological readiness was assessed with the ACL-Return to Sport after Injury (ACL-RSI) scale.

Results:

39 patients (24 girls, 15 boys) were identified. The mean age at the time of surgery was 15.7 ± 1.3 years (range, 13-18 years). 82% of patients were high school athletes. Soccer was the primary sport for 48.7% of patients. The mean graft diameter was 9.5 ± 0.4 mm. 51.3% of patients had concomitant meniscus repairs. The mean time to return-to-sport clearance was 10.1 ± 1.4 months. At 12 months, the mean postoperative Pedi-IKDC was 95.6 ± 4.0, the mean Lysholm score was 97.6 ± 3.9, and the mean Tegner score was 8.8 ± 0.9. All PROMs improved significantly compared to the preoperative scores (Pedi-IKDC: p = 0.003, Lysholm: p = 0.006, Tegner: p = 0.003). The mean ACL-RSI was 93.4 ± 4.7. Complications included return to surgery due to postoperative stiffness in two patients. There were no cases of postoperative instability, graft rupture, or contralateral ACL injury.

Conclusion:

QT-SR ACLR results in excellent clinical and patient-reported outcomes in adolescent athletes at 12 months follow-up. The long-term effect of QT-SR remains to be investigated.
FEMORAL NECK BONE STRESS INJURIES IN CHILDREN AND ADOLESCENTS: A LITERATURE REVIEW AND META-ANALYSIS
Authors: Magrini Danielle , Brown Naomi , Nussbaum Eric
Published: July 2021

Background:

Most bone stress injuries (BSI) affect weight-bearing bones of the lower extremity. While femoral neck BSIs (FNBSI) are less common, they occur in the pediatric and adolescent population, accounting for 0.7%-21.1% of all sports-related injuries. A recent publication showed a 4-fold increase in the incidence of pediatric BSI. Literature detailing FNBSI in the pediatric population is limited to small case studies. Recommendations are lacking for imaging protocols and grading of injury.

Purpose:

To assess available evidence-based literature for pediatric and adolescent FNBSI in order to better understand the incidence, risk factors, work up and treatment practices of pediatric and adolescent FNBSI.

Methods:

A systematic review was conducted to find FNBSI studies in the pediatric and adolescent population. Due to a paucity of literature, information was gleaned from adult FNBSI literature, other areas of BSI in pediatric patients and biomedical papers looking at pediatric growth and bone health. Papers discussing potential risk factors to bone health and pediatric, adolescent and collegiate athletes at higher risk for BSI were also included. Regarding meta-analysis: Search terms included “Femoral Neck,” “Bone Stress Injury; Hip,” “Stress Fracture,” “Stress Fracture + Adolescent.” For the meta-analysis, patients under 20 years of age were reviewed and available information documented. Patients were excluded if they had a known metabolic or chronic medical condition that could be the primary reason or main contributor to their BSI.

Results:

A total of 66 fractures (57 patients) were identified, 9 bilateral, ranging from 5-19 years. All but 9 (86%) had compression sided fractures; 4/9 tension sided fractures were displaced. 35% (23/66) occurred in military and 30% (20/66) were athletes. Radiographs were most often initial imaging; 22/55 (40%) of those were abnormal, 4 inconclusive. If initial radiographs were negative (or none obtained), 14/33 had repeat positive x-rays, 15/33 positive BS, 12/33 positive MRI. MRI frequently was used to confirm positive radiographs. 6/57 (11%) patients treated conservatively would go on to require surgical fixation.

Conclusions:

FNBSI is a diagnosis that must be considered in the young, especially when the chief complaint is hip, thigh or groin pain. Radiographs should be the initial diagnostic test, but further imaging is usually necessary to establish the diagnosis and determine a treatment plan. Understanding the specific risk factors to this population is crucial. Further studies in this population are needed to develop a pediatric specific understanding of FNBSI, formulate a proper workup and develop a treatment plan.
DIVERGENT INTERPRETATION OF POST-CONCUSSIVE SYMPTOMS BETWEEN PARENT AND CHILD
Authors: Kieschnick Jennifer , Seagraves Ben , Nieman Holly , Caze Todd
Published: July 2021

Background:

Self-report symptom scales are often given to both parents and the injured child to rate a child’s symptoms following concussion. Previous research has shown that individual symptom reporting may not reflect agreement between parent and child. While total calculated scores may reflect agreement, looking at the total number of items reported may provide more insight into consistency between parent and child symptom rating following concussion.

Purpose/Hypothesis:

To evaluate the degree of divergence in post-concussive symptom reporting between parent and child. It was hypothesized the parent would endorse their child as having more symptoms following their concussion than self-reported by the child.

Methods:

The concussed child and their parent completed the Post-Concussion Symptom Inventory (PCSI), a self-reported concussion symptom scale to document symptoms related to the injury. The concussed child completed the age-appropriate version (8-12 years-old or 13-18 years-old) of the PCSI while the parent reported their perception of symptoms experienced by the child. The parent version of PCSI has 26 items, the adolescent version has 25 items, and the child version has 23 items. The total number of symptoms endorsed were calculated by recoding each symptom as a 0 or 1 variable to account for the item differences on the scales. A difference in total items reported, between parent and child as well as parent and adolescent PCSI, were calculated.

Results:

A total of 36 patients, 15 males and 21 females aged 8-18 (13.8±12.1 years), filled out the PCSI with 10 patients filling out the 8-12 years-old version and 26 filling out the 13-18 years-old version. The 10 parents of children ages 8-12, endorsed 2.9±2.7 more concussion symptoms. Of the 26 parents to adolescents ages 13-18, 1.08±6.28 more concussion symptoms were reported.

Conclusion:

Current results suggest the parents endorse their child experiencing more symptoms following their concussion than what is self-reported by the child. A future study to investigate the impact of parents’ elevated PCSI score(s) (i.e. total score or endorsed items) when compared to patient’s duration of recovery is recommended. This research would provide more comprehensive guidelines for recovery by means of patient and parent education.
PROSPECTIVE EVALUATION OF IN SITU SCREW FIXATION FOR STABLE SLIPPED CAPITAL FEMORAL EPIPHYSIS
Authors: DeVries Clarabelle , Baird Samuel G. , Bomar James D. , Upasani Vidyadhar V.
Published: July 2021

Background:

In situ screw fixation is the standard of care for the treatment of stable slipped capital femoral epiphysis (SCFE), however, recent studies recommend treatment of all slip-related cam deformity to prevent degenerative changes due to femoroacetabular impingement (FAI).

Hypothesis/Purpose:

The purpose of this study was to prospectively evaluate radiographic and patient reported outcomes after in situ screw fixation for stable SCFE with minimum 2-year follow-up.

Methods:

After obtaining IRB approval, we prospectively collected data on all consecutive stable SCFE patients who underwent in situ screw fixation at a single institution. Demographic information, Southwick slip angle (SSA) and alpha angle were recorded. The Hip disability and Osteoarthritis Outcome Score (HOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were collected. Basic descriptive statistics, the Mann-Whitney test, and correlation analysis was performed.

Results:

Forty-four hips in 38 patients with an average pre-op SSA of 41.1±20.0˚ were studied. Cohort characteristics can be found in Table 1. We observed no surgical complications of the index procedure and no cases of avascular necrosis (AVN). Twelve hips (27%) went on to have a secondary procedure (SSA range: 34˚ to 101˚) on average 2.6±2.4 years after the index surgery. These were performed to correct residual deformity, limited hip range of motion, or symptomatic impingement; one patient (2 hips) was referred for total hip arthroplasty due to significant degenerative osteoarthritis at 7.8 years follow-up. There were five complications of the secondary procedures (three implant failures and two mal-positioned implants). Our mean post-op HOOS and WOMAC scores were 84.2±16.8 and 87.8±13.9, respectively. Severe slips were 19.3 times more likely to undergo a secondary procedure than mild and moderate slips (p<0.001), however we found no correlation between slip severity and patient reported outcomes (p>0.6).

Conclusion:

With minimum 2-year follow-up, 27% of patients went on to require a secondary surgery after in situ screw fixation for stable SCFE. Patient reported outcomes did not correlate with slip severity (p>0.6) but were found to be significantly higher in SCFE patients that did not require a secondary procedure (p=0.023). Prophylactic treatment of all slip-related cam deformity was not found to be necessary in this prospective cohort. While in situ screw fixation can be used to safely treat mild to moderate stable slips, patients with moderate to severe stable slips may require secondary surgery and have a higher complication rate with worse patient reported outcomes.

Level 2

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