bluuebunny/crossref_metadata_2025_split huggingface dataset:
RE-TRAINING IS INEFFECTIVE IN IMPROVING RELIABILITY OF TIBIAL SPINE MEASUREMENTS AND CLASSIFICATION
Authors: Ellis Henry B. , Zynda Aaron J. , Cruz Aristides , Sachleben Brant , Sargent Catherine , Green Daniel , Warnick Drew , Schmale Gregory , Jagodzinski Jason , Rhodes Jason , Mistovich Justin , Fabricant Peter D. , McKay Scott , Yen Yi-Meng , Ganley Theodore 
Published: April 2020

Background: Treatment decisions for patients with tibial spine fractures heavily rely on radiographic measurements. Therefore, it is important to establish reliability of these parameters to assist with standardizing classification and subsequent treatment decisions. Purpose: To improve upon and subsequently validate a proposed measurement system following a live, in-person case review, re-training, and implementation of a new classification of tibial spine fractures. Methods: Following unacceptable classification reliability amongst the tibial spine research interest group when using the original Meyers & McKeever (M&M) classification, a one-hour, live, in-person case review (n=10) of tibial spine fractures with collective agreement on measurements and classification was performed. Based on discussion, a modification of the original M&M classification was developed to specifically define verbiage that lead to unacceptable variance in the original reliability testing. These included a quantitative definition of posterior hinge and the presence of comminution (Figure 1). New reference guidelines were provided to each reviewer demonstrating specific measurements and modified M&M classification prior to subsequent case review along with a new set of randomized, de-identified images. Forty subjects were included, determined as a precedent based on previous reliability studies. Data were analyzed using kappa and ICC for categorical and continuous variables, respectively. Results: Overall, data from 6 surgeon raters were included on a total of 40 cases. Amongst these raters, all variables demonstrated poor interobserver reliability: maximal posterior displacement (ICC=0.23, 95% CI=0.11-0.38), modified M&M classification (Cohen’s Kappa=0.25), amount of comminution (Cohen’s Kappa=0.27), and recommended treatment (Cohen’s Kappa=0.19). Conclusion: Reliability of radiographic measurements and a modified classification for tibial spine fractures remains unacceptable even amongst a group of surgeon experts. A new classification schema may be needed to help reliably guide treatment decisions for patients with tibial spine fractures. [Figure: see text]
LATERAL ELBOW OVERUSE INJURIES IN PEDIATRIC FEMALE GYMNASTS: A COMPARISON OF RADIAL HEAD STRESS FRACTURES AND CAPITELLAR OCD
Authors: Wyatt Charles W. , Searls William C. , Zynda Aaron J. , Ellis Henry B. , Wilson Philip L. 
Published: April 2020

Background: Radial head stress fractures (RHSF) and capitellar osteochondritis dissecans (OCD) are rare and may be seen in pediatric gymnasts. Clinical and radiographic factors correlating with these differential lesions are unclear. Purpose: To describe the clinical presetantion of RHSF and compare the demographic, radiographic, and clinical characteristics of elbows in pediatric gymnasts presenting with RHSF to those presenting with OCD of the capitellum. Methods: An IRB-approved retrospective review of consecutive female gymnasts treated within a pediatric sports medicine practice for either RHSF or capitellar OCD over a 5-year period (1/2014-2/2019) was performed. Gymnasts <18 years old at the time of injury presenting with signs of a radial head stress fracture (Salter-Harris III or IV) or with diagnostic features of capitellar OCD were included. Those with congenital anatomic elbow abnormalities or prior ipsilateral elbow surgery were excluded. Patients were dichotomized into either the RHSF or OCD group; and demographic, radiographic, and clinical characteristics were compared. Statistical analysis was performed using a Mann-Whitney test for continuous variables and a chi-square test for categorical variables. Results: Forty-five patients (9 with bilateral OCD, 1 with bilateral RHSF, and 3 with each lesion in alternate elbows), contributing 58 elbows, met inclusion criteria. Thirty-nine elbows in the OCD group and 19 elbows in the RHSF group were studied. Average age for all gymnasts was 11.58 years (9-16 years), with no difference between groups (OCD: 11.47 vs RHSF: 11.78; p=0.34). No differences in height, weight, BMI, or laterality were noted. Gymnasts presenting with RHSF were competing at a higher level than those with OCD, with 94.74% of RHSF group competing at level 7 or greater compared to 66.67% of OCD patients (p=0.02). Compared to those with OCD, the RHSF group presented more acutely following onset of symptoms (p=0.014), reported significantly more pain with valgus stress (p<0.001), and concurrent medial elbow pain than those with OCD (p<0.01). The RHSF group demonstrated significantly smaller distal humeral width and decreased height of the proximal radial epiphysis, as well as increased valgus angulation of the radial neck shaft angles and distal humeral articular surface (p<0.05). No differences in olecranon or medial epicondyle hypertrophy, or avulsive changes were identified. (Table I) Conclusion: Gymnasts competing at a high competitive level and presenting more acutely may be at risk for RHSF. Additionally, differing anatomy in the lateral elbow may be a predisposing risk factor for RHSF as opposed to OCD and merits further investigation. [Table: see text]
ASSESSMENT OF ACETABULAR COVERAGE IN BORDERLINE ACETABULAR DYSPLASIA: ARE PLAIN RADIOGRAPHIC PARAMETERS ACCURATELY ESTIMATES OF THREE-DIMENSIONAL COVERAGE?
Authors: Graesser Elizabeth , Schwabe Maria , Akers Sean , Pascual-Garrido Cecilia , Clohisy John C , Nepple Jeffrey J 
Published: April 2020

Introduction: Assessment of anterior acetabular coverage is commonly done with measurement of the anterior center edge angle (ACEA) or anterior wall index (AWI). This is particularly important in cases of borderline acetabular dysplasia where it may influence treatment decisions. However, the ACEA and AWI has been poorly validated. Purpose: The purpose of the current study was to investigate the correlation between plain radiographic measurements and three-dimensional femoral head coverage on low-dose CT in borderline acetabular dysplasia. Methods: Seventy consecutive hips with borderline acetabular dysplasia (LCEA 20-25°) were included in the current study. Radiographic evaluation was performed prospectively including LCEA, acetabular inclination, and AWI on AP pelvis radiographs, and ACEA on false profile radiographs. The mean LCEA was 22.1±1.4°, while the mean acetabular inclination was 10.3±3.3. All patients underwent low-dose pelvic CT assessment for preoperative planning. The radial acetabular coverage was calculated according to the standardized clock-face position [measured at 12:00 (lateral), 1:00, 2:00, 3:00 (anterior), and 4:00] as described by Larson et al. Statistical analysis determined the correlation between ACEA and radial coverage. Results: The mean ACEA in the group was 25.3±5.8° (range 10.1-43.9), with 16% having ACEA≤20° and 50% having ACEA≤25°. The mean radial coverages were 63.5%±1.7 (12:00), 60.7%±2.2 (1:00), 50.8%±3.2 (2:00), 37.0%±3.3 (3:00), and 27.9%±3.1 (4:00). The ACEA had poor correlation with radial coverage at all positions from 12:00 to 4:00 (range –0.068-0.173). The AWI had moderate correlation with radial coverage at 3:00 (PCC 0.499) and 4:00 (PCC 0.573). Comparing hips with an ACEA <20° versus >20°, there was no difference between the mean radial acetabular coverage at any position 12:00-4:00 (p=0.18-0.95). Comparing hips with an ACEA <25° versus >25°, there was no difference between the mean radial acetabular coverage at any position 12:00-4:00 (p=0.12-0.71). No significant difference in AWI was present between subgroups with normal and deficient radial coverage from 12:00 to 4:00 (p=0.09-0.72). Discussion: The current study demonstrates poor correlation of the ACEA measurement with true anterior femoral head coverage as evaluated at clock-face positions from 12:00 to 4:00. The AWI demonstrated moderate correlation for 3:00-4:00 coverage but fails to differentiate hips with normal and deficient coverage. In the setting of borderline acetabular dysplasia, anterior and anterolateral femoral coverage should be assessed via low-dose CT rather than ACEA or AWI.
DEFINING THE BORDERLINE HIP: HIGH VARIABILITY IN ACETABULAR COVERAGE AND FEMORAL DEFORMITY
Authors: Graesser Elizabeth , Schwabe Maria , Pascual-Garrido Cecilia , Clohisy John C , Nepple Jeffrey J 
Published: April 2020

Introduction Borderline acetabular dysplasia is radiographically defined as a lateral center edge angle (LCEA) of 20-25 degrees. It is well accepted that some borderline hips have instability while others have primarily impingement. The optimal management of borderline dysplasia is challenging and particularly complex due to the anatomic variability that exists among patients but has not been well characterized. Purpose The purpose of this current study was to investigate the variability in hip deformity present on low-dose CT in a cohort of patients with symptomatic borderline acetabular dysplasia. Methods Seventy consecutive hips with borderline acetabular dysplasia undergoing surgical treatment were included in the current study. Radiographic evaluation included LCEA, acetabular inclination, anterior center edge angle (ACEA), and alpha angles on AP, Dunn, and frog views. All patients underwent low-dose pelvic CT for preoperative planning. Femoral deformity was assessed with femoral version, alpha angle (measured at 1:00 increments), and maximum alpha angle. Radial acetabular coverage was calculated according to standardized clock-face positions [measured from 8:00 (posterior) to 4:00 (anterior)] and defined as normal, under-coverage, or over-coverage relative to 1 SD from the mean of normative values. Results The mean LCEA was 22.1±1.4, while the mean acetabular inclination was 10.3±3.3. The mean ACEA in the group was 25.3±5.8 (range 10.1-43.9), with 16% having an ACEA ≤ 20 and 50% having an ACEA ≤ 25. The mean femoral version was 17.9° (range -4° to 59°). The mean maximal alpha angle was 57.2° (range 43° to 81°) with 61.4% greater than 55°. Lateral coverage (RAC at 12:00) was deficient in 74.1% of cases. Anterior coverage (RAC at 2:00) was highly variable with 17.1% under-coverage, 72.9% normal, and 10.0% over-coverage. Posterior coverage (RAC at 10:00) was also highly variable with 30.0% under-coverage, 62.9% normal, and 7.1% over-coverage. The three most common patterns of coverage were: isolated lateral under-coverage (31.4%), normal coverage (18.6%), and lateral and posterior under-coverage (17.1%). Discussion Patients with borderline acetabular dysplasia demonstrate highly variable three-dimensional deformities including anterior, lateral, and posterior acetabular coverage, femoral version, and alpha angle. Comprehensive deformity characterization in the population is important to guide diagnosis and treatment decisions.
SHOULD WE FEAR THE BORDERLINE DYSPLASTIC HIP?: EXTERNAL VALIDATION OF THE FEAR INDEX IN THE SETTING OF BORDERLINE ACETABULAR DYSPLASIA
Authors: Schwabe Maria , Clohisy John C , Pascual-Garrido Cecilia , Graesser Elizabeth , Nepple Jeffrey J 
Published: April 2020

Introduction: The Femoro-Epiphyseal Acetabular Roof (FEAR) index has recently been proposed as a useful tool in identifying hips with instability in the setting of borderline acetabular dysplasia. Beck et al. were the first to describe this parameter and demonstrated a FEAR index as the angle between a line connecting the most medial and lateral part of the sourcil and a line connecting the most medial and lateral part of the straight central third of the physeal scar. Purpose: The purposes of the current study were 1) external validation of intra-observer and inter-observer reliability and 2) to determine the correlation/association of FEAR with a clinical diagnosis of instability. Methods: The current study was a retrospective review of patients diagnosed with borderline acetabular dysplasia by a single surgeon. The study period included January 2008-April 2017 and identified patients with LCEA 20°-25°, via prospectively collected radiographic measurements in a hip preservation database. Inclusion criteria were treatment with either hip arthroscopy or PAO, LCEA of 20°-25°, and 14-40 years of age. Patients were excluded if they had a Tӧnnis grade ≥2, prior ipsilateral hip surgery, residual deformities from SCFE or Perthes. Demographics and radiographic measurements were recorded. Two individuals read all radiographs after obtaining an intra observer reliability of 97% and inter observer reliability of 88%. Sensitivity and specificity were calculated for FEAR predicting instability. A t-test was used to assess correlation of LCEA, acetabular inclination (AI), and ACEA with FEAR. Results: A total of 186 patients were included, FEAR was unable to be assessed in 5% of hips because of inability to visualize the proximal femoral physeal scar. Of the remaining 176 hips, 18% of hips had a FEAR index >5°. FEAR positive mean was 7.6°±2.8° (range=5.1°-17.5°) and FEAR negative mean was –6.9°±6.4° (range=-29.4°-3.7°). Results of FEAR predicting instability was sensitivity=33% (23/70), specificity=92% (98/106), PPV=74% (23/31), and NPV=67% (98/145). The mean AI was significantly high in FEAR(+) hips (AI mean=11.2° and FEAR(-) AI mean=9.5°; p=0.005). No difference in LCEA or ACEA was seen relative to the presence of FEAR. Discussion: In the current study, a positive FEAR index was generally indicative of the presence of clinical instability. However, the FEAR index was poorly sensitive to hip instability with 67% hips diagnosed with instability having a negative FEAR index.
PEAK LOWER EXTREMITY SOCCER INJURIES OCCUR IMMEDIATELY FOLLOWING GROWTH IN ADOLESCENTS: AN EPIDEMIOLOGIC REVIEW OF EMERGENCY DEPARTMENT VISITS
Authors: Wright Aidan P. , Zynda Aaron J. , Chung Jane S. , Wilson Philip L. , Ellis Henry B. , Miller Shane M. 
Published: April 2020

BACKGROUND: Soccer has become the most popular youth sport in the world. Within the last decade, there has been limited epidemiologic research on pediatric soccer-related injuries based on sex and age. PURPOSE: To examine trends associated with soccer injuries presenting to emergency departments and to describe differences in injury pattern and location based on sex and age during periods of growth. METHODS: An epidemiologic study was conducted utilizing publicly accessible data from the National Electronic Injury Surveillance System (NEISS). The NEISS compiles Emergency Department (ED) data on all injuries presenting to the approximately 100 participating network hospitals in the United States. Information on all soccer-related injuries occurring in ages 7-19 from January 2009 – December 2018 was extracted and summary statistics were calculated. RESULTS: Approximately 54,287 pediatric soccer-related injuries were identified. The average age for all injuries was 13.3 years, and males (60.50%) presented more often than females (39.50%). Concussions and head injuries (15.57%) were most commonly reported overall, with a greater percentage occurring in females than males (17.44% vs. 14.35%). The ankle (15.3%) was the second most common injury location with females also presenting more commonly than males (18.71% vs. 13.62%). Age and sex-based evaluation noted peaks in lower extremity injuries in females younger than in males. Both ankle (F=13-15 years, M=15-17 years) and knee (F=14 years, M=16 years) injuries peaked at ages coinciding with recognized sex-based lower extremity skeletal maturity (Figure 1). CONCLUSION: Peak pediatric soccer-related ankle and knee injuries presenting to emergency departments occur at different ages in females and males and appear to, on average, coincide with maturation (age 14 in females and 16 in males). Lower extremity injuries significantly increase nearing the completion of lower extremity growth, and may indicate appropriate timing for differential sex-specific injury prevention programs within soccer. [Figure: see text]
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN ≤21 YEAR OLDS: PATELLAR VERSUS HAMSTRING TENDON AUTOGRAFTS
Authors: Tauberg Brandon , Sever Ronen , Kirschner Noah , Hanstein Regina , Fornari Eric D. 
Published: April 2020

Background: Bone-patellar tendon-bone (BTB) and hamstring tendon (HS) are commonly used grafts for anterior cruciate ligament reconstruction (ACLR). The optimal graft choice for ACLR remains unclear. We evaluated clinical and self-reported outcomes of patients who underwent ACLR with use of a BTB autograft or double-bundle HS autograft/allograft-augmented HS autograft (HS hybrid). Hypothesis/Purpose: No significant differences in outcomes exist between graft choices. Methods: Retrospective review of prospectively collected data from patients aged ≤21 years who underwent primary ACLR with BTB or HS autograft/hybrid by one fellowship-trained orthopaedic surgeon and a minimum of 6 months follow-up. Demographics, injury characteristics, concomitant injuries, surgical and radiographic parameters were recorded. Clinical and patient self-reported outcomes (Tegner-Lysholm, pediIKDC, KOOSChild) were compared at 6-months, 1-year and latest follow-up. Results: A total of 109 subjects were included; 59 had a HS graft (55 HS autograft, 4 HS hybrid) and 50 a BTB autograft. Patients were between 13 and 21 years old at ACLR and had a follow-up of 1.5 ±1 year. Baseline comparison of demographic, injury and surgical parameters is presented in Table1.1. Graft rupture occurred in 10 patients (9.2%; 9 males and 1 female) at an average of 2 years after initial ACLR; 8 graft ruptures occurred in the HS group (13.6%, none in HS hybrids) and 2 in the BTB group (4%) (p=0.105). Parameters increasing the likelihood of a re-tear were older age at ACLR (HR: 2.348, p<0.005), a >1-year delay to surgery (HR: 4.105, p=0.048) and a concomitant chondral injury (HR: 5.476, p=0.038) (Cox proportional hazards model, Table1.2). Arthrofibrosis developed in 4 BTB patients (8%) at an average of 6 months after initial ACLR, but not in HS patients (p= 0.041). At most recent follow-up, patellofemoral pain was present in 15 (28%) HS and 5 (10%) BTB patients (p= 0.027) and a contralateral ACL tear had occurred in 4 patients (3.7%). No differences were seen between graft groups for knee range of motion, Lachman testing, leg raise, ligament stability and subjective scores - Tegner-Lysholm, pediIKDC, KOOSChild (p>0.05 for each comparison at 6-months, 1-year and most recent follow-up). Conclusion: In patients <21 years undergoing ACLR, BTB autograft lead to fewer graft ruptures, however, was associated with a higher rate of arthrofibrosis. Older age at surgery, a delay to surgery and chondral injuries increased the likelihood of re-tear. However, failure rates were low, and we observed no differences between graft types in terms of laxity and patient self-reported outcomes. Tables/Figures: [Table: see text][Table: see text]
COMPARISON OF CONTINUOUS ADDUCTOR CANAL AND FEMORAL NERVE BLOCKS FOR ANALGESIA AND SPORTS READINESS AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN ADOLESCENT PATIENTS
Authors: Holland Erica L. , Robbins Robin , Low Daniel K-W. , Bosenberg Adrian , Bompadre Viviana , Schmale Gregory A. 
Published: April 2020

Background: Continuous femoral nerve blocks (cFNB) have become a popular method for post-operative analgesia for patients undergoing anterior cruciate ligament reconstruction (ACLR). However, early weight-bearing and the return of quadriceps function favor a motor sparing block, such as a continuous adductor canal nerve block (cACB). Hypothesis/Purpose: We retrospectively compared cACB to cFNB in adolescent patients undergoing ACLR, assessing early post-operative pain scores, narcotic usage, and patient satisfaction; and return of quadriceps function and sports readiness at six months post-surgery. We hypothesized that cACB compared to cFNB would result in in a greater likelihood of sports readiness at six months without having compromised analgesia in the early post-operative period. Methods: We retrospectively reviewed a consecutive series of adolescent patients who underwent ACLR between January 2016 and September 2018 and received either a cACB or cFNB for post-operative pain management. Patient demographic and surgical data, post-operative pain scores, opioid consumption, satisfaction and complications, dates and results of the Return to Sports (RTS) evaluations were collected from the medical record. Comparisons of categorical and continuous variables between groups were made using the χ 2 test, Spearman correlation test, and one-way ANOVA with Bonferroni adjustment. Results: Ninety-one patients (53 with cFNB, 38 with cACB) were reviewed for post-operative analgesia outcomes and quadriceps function at six months and beyond. Analysis of demographic and surgical data revealed no difference in the make-up of the two groups. There were no significant differences between groups in the total oxycodone use PODs 1-3 ( p = 0.213), daily post-operative pain scores ( p > 0.25), or satisfaction with the blocks ( p = 0.93). There was no difference in time to RTS nor in the percentage of patients who achieved a 90% limb symmetry index for quadriceps strength when comparing the two groups at the six-month mark and beyond ( p = 0.384). Conclusions: We found no difference in post-operative analgesic requirements and high satisfaction in both groups when comparing patients who underwent ACLR with hamstring autograft with a cACB to those who underwent a similar procedure with a cFNB. Readiness for return to sports and return of quadriceps function at six months and beyond does not appear to vary with regional technique, either cACB or cFNB, employed at surgery.