bluuebunny/crossref_metadata_2025_split huggingface dataset:
MAPPING COMPRESSIVE AND TENSILE STRAINS OF THE PATELLAR TENDON IN OSGOOD-SCHLATTER DISEASE USING ULTRASOUND ELASTOGRAPHY
Authors: Rizzone Katherine , Weyand Grace E. , Richards Michael S. , Kuo Catherine K. , Buckley Mark R. 
Published: March 2019

Background Osgood-Schlatter Disease (OSD) impacts millions of young athletes every year, yet its biomechanical etiology remains unclear. It’s been postulated that increased growth velocity in children elevates tension within the patellar tendon, placing distal strain on the tibial tubercle, causing anterior knee pain, but this process has not been previously elucidated. The purpose of this study was to evaluate axial tensile and transverse compressive strains in adolescent patellar tendons during exercise to identify differences between those with and without OSD using a cumulative strain, ultrasound elastography measurement method [REF: Chimenti et al 2016]. Methods Axial tensile and transverse compressive strains of the patellar tendon in eight adolescents with OSD and ten adolescents without OSD were quantified from ultrasound elastography images. Multiaxial strains of the patellar tendon were assessed as the participant performed two different exercises: 1) participant seated with leg fully extended, participant bends knee, followed by a return to initial extended position; (2) participant standing performs a squat and then returns to initial standing position. Participants’ disease severity was clinically assessed using the VISA-P and Cincinnati knee scale. Results Mean age was 13.1 years (+/- 2.7), 39% were male (63% of OSD group). There was no statistically significant difference in patellar tendon tensile strains during the seated knee flexion and squat positions between groups (p = 0.99, p = 0.83 respectively). The OSD group had significantly less tendon compression compared to the non-OSD group during both the knee flexion (p <0.01), and squat exercises (p <0.05). Conclusions/Significance Adolescents with OSD had lower transverse compressive strains in the patellar tendon as compared to adolescents without OSD. In contrast, tensile strains were not increased in children with OSD. These findings appear to contradict the tension hypothesis postulating that OSD is caused by increased patellar tendon axial tension associated with rapid bone growth, Instead, impingement from the tibia leading to transverse tendon compression may lead to an adaptive stiffing the patellar tendon, However, further research is needed to confirm this hypothesis. While OSD is a common cause of knee pain in growing athletes that frequently leads to loss in participation, its etiology is unclear, making development of effective treatment approaches difficult. This study highlights differences in multiaxial patellar tendon strains in adolescents with OSD which may help direct future research on management strategies.
RETURN TO SPORT PHYSICAL PERFORMANCE TESTING IN CHILDREN - BUILDING POPULATION NORMS
Authors: Myers Heather , Magill John , Esposito Valentine , Messer Michael , Lentz Trevor , Riboh Jonathan 
Published: March 2019

Purpose/Hypothesis: Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction in children is associated with a much higher risk (˜30%) of subsequent ACL injury than in adults. In adults, delaying RTS until objective physical performance test (PPT) criteria are met reduces re-injury rates. However, normative data on PPTs in children is missing, limiting their utility in this high-risk population. Designing age-specific pediatric guidelines for RTS is therefore a critical area of investigation. Number of Subjects: 63 Materials/Methods: We designed a prospective observational study of 130 healthy pediatric athletes (ages 6 - 18 years, 5 males and 5 females of each age). Each athlete underwent a series of 10 functional tests assessing balance (Y-Balance Test, stork test, stork test on Bosu ball), strength (single leg squat, single leg hop) and composite neuromuscular control (single leg squat on Bosu ball, clockwise and counterclockwise quadrant hop, 6 m timed hop and triple crossover hop). Demographic data including sex, chronologic age, Pubertal Maturity Observational Score (PMOS), height, weight, and body mass index (BMI). Testing order was randomized to reduce confounding from fatigue. Our primary hypothesis was that PPT results would vary predictably with chronologic age. For each PPT, multivariable linear regression was performed including age, sex, PMOS, BMI and testing order as independent variables. Standard “growth curves” for each test were then built based on age and sex. Results: Sixty-three athletes (29 male, 34 female) have completed testing so far (48% enrollment). Mean age was 10.7 +/- 3.2 years (range 6 - 18). Mean PMOS was 3.2 +/- 3.1 (range 0 - 9). PMOS was strongly correlated with chronologic age (Pearson’s? = 0.83), therefore PMOS was excluded as a predictor variable in regression models to avoid multicollinearity. Chronologic age was an independent predictor of all PPT results (p < 0.05 in all cases). There was a learning effect for the Bosu Stork test, with athletes doing this test later in the sequence performing better (ß = 2.47, 95% CI 0.74 - 4.19, p = 0.006). Female sex was an independent predictor of a shorter triple crossover hop distance (ß = -74.1, 95% CI -106.9 to -41.2, p < 0.0001). Balance tests showed the least linear relationships with age. The stork test had a clear ceiling effect by age 10 in females and 13 in males. The Bosu Stork test showed wide variability at all ages. Conclusion: Chronologic age is a strong, typically linear predictor of commonly used PPTs in children. The PMOS did not add additional predictive value. Clinical Relevance: The normative data generated in this study help understand normal neuromuscular development, and provide a foundation for creating age-specific RTS scores.
SLAP TEARS IN THE PEDIATRIC PATIENT: WHO IS TREATING THEM AND WHERE?
Authors: Agatstein Lauren , Brown Matthew J. , Friel Nicole , Haus Brian 
Published: March 2019

BACKGROUND: Although rare in comparison to adult cohorts, superior labral anterior to posterior (SLAP) tears do occur in children and adolescents. Previous publications have focused on the varied surgical treatments of SLAP tears in pediatric hospitals but have not stratified treatments by surgeon training or hospital setting. The objective of this study is to evaluate the demographics of patients under the age of 18 undergoing SLAP surgery as well as to evaluate the influence of hospital setting (hospital self-designation as pediatric vs. non-pediatric) and the trends of treatment choice (debridement versus repair) over a period of time. METHODS: The California statewide outpatient database (OSHPD) was queried for all patients under 18 years old who underwent a SLAP debridement or repair in the state of California between 2008 and 2016. The effect of age, hospital setting (pediatric versus adult hospital), gender, insurance type, race, and year of service were assessed using logistic regression. RESULTS: A total of 1,349 patients under age 18 years underwent surgery for a SLAP tear between 2008 and 2016. SLAP repair was performed in 83.8% of patients while SLAP debridement was performed in 16.2% of patients. 80.9% of patients were treated at non-children’s hospitals and 19.1% were treated at children’s hospitals. At non-children’s hospitals, 161 (14.7%) had SLAP debridement and 931 (85.3%) had SLAP repair. At children’s hospitals, 57 patients (22.2%) had SLAP debridement and 200 (77.8%) had SLAP repair. The odds of having a SLAP repair over SLAP debridement decreases by a factor of .58 (p < 0.01) when patients have surgery at a children’s hospital versus at a non-children’s hospital. Age, gender, race, and insurance type were not statistically significant in predicting whether patients underwent SLAP repair versus debridement. Analysis of each individual year of service over the study period from 2008 to 2016 revealed the odds of having a SLAP repair over debridement increased each year by a factor of 1.1 (p < 0.001). CONCLUSIONS: The majority of surgeries treating SLAP tears in patients under the age of 18 are performed in non-pediatric hospitals. However, previous literature reporting on outcomes of SLAP surgery on patients under 18 is based in tertiary care pediatric centers,, which is likely not representative of this patient population. We hypothesize that this discrepancy may be due to shoulder surgeries more often being performed by sports medicine trained orthopedic surgeons who are not tied to operating in pediatric hospitals. Further, the yearly increased rate of SLAP repair over debridement is likely due to the prevailing knowledge in the orthopedic sports literature that repair is preferable to debridement in younger patients.
SIGNIFICANT NATIONWIDE VARIATION EXISTS IN OPIOID PRESCRIPTION RATES AMONGST PEDIATRIC PATIENTS WITH ACL INJURIES: A RETROSPECTIVE COHORT STUDY
Authors: Anandarajan Dharman , Talwar Divya , Wells Lawrence 
Published: March 2019

Background: Prescription opioid rates have been found to vary on a county and state level. We aim to find if significant hospital-level and regional-level variation in opioid prescription rates exists in a pediatric orthopedic setting. Methods: We conducted a retrospective cohort study of children ages 10-18 who sustained an ACL injury between 2012-2016, from 39 hospitals throughout the United States, found through the Pediatric Health Information System. Patients were divided into four regions according to the regional census of hospital admission, and demographics were recorded. Primary outcomes were hospital-level variation in opioid prescription rates using a mixed effects linear regression model to compare mean differences in average opioid prescription rate. Results: 11,452 pediatric patients were analyzed for regional-level variation in opioid prescription rates. Of those patients 7,879 were analyzed for hospital-level variation in opioid prescription rates based on if the hospital of incidence had a sample size of at least 250 patients over the five-year span (16 of the 43 hospitals fit this criteria). The most common demographics were patients ages 16-18 (n=5,613; 49.01%), white (n=6,588; 57.53%), and male (n=5,905; 51.56%). The 11,452 patients were divided into four regions: (1) Northeast (n=2,409; 21.04%), (2) Midwest (n=2,499; 21.82%), (3) South (n=3,869; 33.78%), and (4) West (n=2,675; 23.36%). After adjustment, significant variation in opioid prescription rates was found to exist at both a hospital-level using a random intercept and random slope model (-2LL=17882.381, p<.05) and at a regional-level by comparing mean differences in average opioid prescription rate (p<.05). Conclusions: Significant variation of opioid prescription rates exists at both a hospital-level and a regional-level over the last five years in a pediatric orthopedic setting. The findings of this study build off previous findings from the Centers for Disease Control, which found significant variation existed in opioid prescription rates on a state-wide level. Given the recent guidelines proposed by the CDC to control and limit prescription opioids (as of March 2016), future studies finding the impact of the guidelines on variation of prescription rates in a pediatric orthopedic setting could be beneficial. [Table: see text][Figure: see text]
QUADRICEP TENDON TURNDOWNS FOR MPFL RECONSTRUCTION: AN ANATOMICAL DIFFERENCE BETWEEN THE ORIGINS OF THE QUADRICEP TENDON AND MPFL ON THE PATELLA
Authors: Rustad Audrey , Anchustegui Nicolas G. , Troyer Stockton , Shea Cooper , Dingel Aleksei , Ganley Theodore J. , Shea Kevin 
Published: March 2019

Background: Quadriceps tendon (QT) turndowns are an alternative method for medial patellofemoral ligament (MPFL) reconstruction, with several distinct advantages: 1. Avoids the use of patella bone tunnels, which have been associated with patella fracture, 2. Avoids the use of separate incision for hamstring tendon harvest, and 3. Avoids the use of allograft tissue, which adds a significant cost. The disadvantage of the Quad Tendon graft is that the most distal reflection point on the patella may not duplicate the patella origin of the native MPFL. The purpose of this study was to determine whether a QT graft for MPFL reconstruction is anatomically analogous to the native MPFL origin in a skeletally immature population. Methods: Three skeletally immature cadaveric knee specimens (ages 10 and 11, 11) were dissected to reveal the MPFL and QT origins on the patella. The proximal and distal extent of the MPFL was marked on the medial border of the patella. The medial aspect of the quad tendon was reflected as far as possible in both a medial and distal position on the patella, to function as the MPFL graft. The distance was measured between the midpoint of the patellar origin of the MPFL in the coronal plane, and the most distal aspect of the patellar origin of the reflected quad tendon. Results: In the 10, 11, and 11 year-old specimens, the distance between the midpoint of MPFL patellar origin and the QT patellar origin was 3.4 cm, 4.3, and 3.7 mm. In all cases, the QT reflected origin was at least 7 mm anterior to the to native MPFL origin on the medial border of the patella. Conclusion: A disparity exists between the patellar origin of the MPFL and the patellar origin of the quad tendon, with the patellar origin of the MPFL being more medial, more distal, and more posterior than the reflected patellar origin of the QT graft. Surgeons performing MPFL reconstructions may find this anatomically valuable as they attempt to duplicate the normal anatomy of the patella stabilizers during surgical reconstruction. While the QT remains a good graft choice for MPFL reconstruction, attachment of the QT graft at the native origin of the MPFL may better reproduce the anatomy of the MPFL. Figures: [Figure: see text][Figure: see text]
SPORT SPECIALIZATION IS A RISK FACTOR FOR OVERUSE, BUT NOT ACUTE, LOWER EXTREMITY INJURIES: A PROSPECTIVE STUDY
Authors: Bell David , Biese Kevin M. , Post Eric G. , Schaefer Dan , McGuine Timothy A. , Kliethermes Stephanie , Brooks Alison , Watson Andrew 
Published: March 2019

BACKGROUND: Sport specialization is often associated with intense, high volume training, which may result in injury – especially overuse injuries. However, there is limited prospective research investigating these relationships. Additionally, previous research has focused on adolescents older than 12 years of age with no data available in younger cohorts, who may be more susceptible to repetitive stress. Therefore, the purpose of this study is to determine if sport specialization is associated with increased risk of overuse and acute lower extremity injuries in middle school aged athletes. METHODS: A total of 281 children (113 females (40%), age=12.1±1.2years; range 10-14 years of age) completed an online survey with their parents for 39 weeks. The study was conducted during the 2017-2018 academic year with a baseline survey conducted the first week of September. Weekly surveys were sent to respondents via Qualtrics with the final weekly survey in June of 2018. The baseline survey consisted of 1) demographic information, 2) injury history in the previous 12 months, 3) a sport specialization scale which classified individuals in low, moderate, and high levels of specialization, and 4) sport participation volume (months per year in primary sport). The weekly surveys asked participants to report and musculoskeletal injury they sustained during sport participation. Participants were included in the analysis if they completed at least 80% of the total surveys. Multivariable logistic regression analyses were utilized to examine associations between specialization category (reference category: low) and prospective injury categories, while adjusting for differences in age, sex, and previous injury history. RESULTS: Respondents reported 57 acute and 32 overuse lower extremity injuries during the observation period. Highly specialized athletes had significantly greater odds of reporting a prospective lower extremity overuse injury than subjects in the low specialization group (OR: 3.78, 1.02-12.90, p=0.03), even after adjusting for sex, age, and previous injury history. However, specialization was not a risk factor for acute lower extremity injuries (OR: 2.20, 0.72-6.77, p=0.17). CONCLUSION: Highly specialized middle school athletes are nearly 4 times greater risk of developing an overuse injury compared to low specialization athletes. Younger athletes may be more susceptible to injuries at younger ages. Thus, adolescent athletes should avoid specialization when possible.
VARIATION IN PREFERRED TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN THE SKELETALLY IMMATURE: WHERE DO WE STAND?
Authors: Patel Neeraj M. , Talathi Nakul S. , Talwar Divya , Fabricant Peter D. , Kocher Mininder S. , Ganley Theodore J. , Lawrence J. Todd 
Published: March 2019

Purpose: Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear. The goal of this study was to identify preferred techniques in skeletally immature patients of various ages and analyze differences in operative strategy based on surgeon and practice demographics. Methods: An electronic survey was administered to members of the Pediatric Research in Sports Medicine society, a cohort of experienced surgeons who perform a high volume of pediatric ACL reconstructions. The survey presented a scenario of a patient who had a physical exam and imaging consistent with an acute, isolated ACL tear. The respondent was asked to select their preferred reconstruction technique for females and males at consecutive skeletal ages from 8 to 15 years. Surgeon and practice demographic information was recorded. Univariate analysis was followed by stepwise multinominal logistic regression to control for confounders. Results: Eighty-eight of 103 surgeons (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 in females and 11 to 14 in males. The modified MacIntosh was the most frequently utilized from ages 8 to 10. An all-epiphyseal technique was preferred over a broader age range in males than females, with peak utilization at age 11 in both. A partial trans-physeal (hybrid) technique was preferred in slightly older patients, with peak utilization at age 12 in females and 13 in males. The trans-physeal technique was most widely used at age 13 and up in females and 14 and up in males. The impact of fellowship training on technique preference was statistically significant for males ages 11-13 and females 11 and 12 (p<0.05 for all). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports training preferred the modified MacIntosh. Conclusions: The preferred ACL reconstruction technique for skeletally immature patients varied considerably, especially in the 11-13 year-old age range, highlighting a lack of consensus among orthopedic surgeons for the optimal ACL reconstruction strategy in skeletally immature patients. Surgeon’s fellowship training was significantly associated with their preferred surgical technique.
10-MINUTE 3D MRI IN CHILDREN WITH ACUTE KNEE TRAUMA: ARTHROSCOPY-BASED DIAGNOSTIC ACCURACY FOR THE DIAGNOSIS OF INTERNAL DERANGEMENT
Authors: Klyce Walter , Fritz Jan , Ahlawat Shivani , Thawait Gaurav , Raithel Esther , Lee R. Jay 
Published: March 2019

Background Magnetic resonance imaging (MRI) is often indicated in the diagnosis of pediatric knee trauma, but using traditional MRIs in children can be time-consuming, require anaesthesia, and sometimes cause discomfort. Recently, 3D turbo spin echo (TSE) MRIs with isotropic datasets have been found to reduce acquisition times substantially, but they have been little-studied in pediatric patients. The purpose of our study was to determine the arthroscopy-based diagnostic performance of 10-minute isotropic 3D TSE MRI for the detection of internal derangement in children with acute knee trauma. Methods Institutional review board approval was obtained for prospective data collection, and informed consent and assent were obtained from all parents and children, respectively. The final study group consisted of 60 children (38 boys, 22 girls; 11 (2-16) years-of-age) with acute knee trauma who underwent 10-minute isotropic 3D prototype CAIPIRINHA SPACE MRI at 3 T and subsequent arthroscopic knee surgery. Two fellowship-trained musculoskeletal radiologists retrospectively evaluated the MRI studies independently and resolved discrepancies through consensus. Outcome variables included image quality, motion artifacts, meniscal abnormalities, cruciate ligament tears, and cartilage lesions. Statistical analysis included the diagnostic performance of MRI with arthroscopy as the reference standard and inter-reader agreements using kappa statistics. Results All studies were suitable for diagnostic interpretation with good-to-very-good image quality and little-to-no motion degradation in the majority of cases. The sensitivities/specificities/accuracies of MRI were 0.93/0.93/0.93 for 15/60 (25%) medial meniscal tears, 0.95/0.90/0.92 for 21/60 (35%) lateral meniscal tears, 0.83/1.0/0.92 for 10/60 (17%) discoid menisci, 1.0/0.95/0.98 for 16/60 (27%) anterior cruciate ligament tears, 1.0/0.95/0.98 for 2/60 (3%) posterior cruciate ligament tears, 1.0/1.0/1.0 for 5/60 (8%) osteochondritis dissecans lesions, and 0.71/0.97/0.84 for 48 (13%) defects in 360 cartilage segments. The inter-reader agreements were overall good-to-very-good (kappa, 0.730 -1.00). Conclusion 10-minute isotropic 3D TSE MRI of the knee is feasible in children with acute knee trauma and yields high diagnostic accuracies for the diagnosis of internal knee derangement. Accuracies for the detection of meniscal tears, discoid menisci, anterior and posterior cruciate ligament tears, osteochondritis dissecans lesions, and cartilage defects ranged from 84-100%. Using previously published protocols for pediatric 2D MRI knee exams with total acquisition times of 25 minutes as a benchmark for traditional MRI, a 10-minute protocol could increase the efficiency by a factor of two or more, and thus substantially improve the availability of MRI and timely care for children with acute knee trauma. [Table: see text]