Changes in sports injuries to children between 1983 and 1998: comparison of case series

Time to return to school following ACL reconstruction: influence of the COVID-19 pandemic

INTRODUCTION

ACL reconstruction is commonly performed in school-aged patients for whom missed time from school can have an impact on their education. Additionally, the COVID-19 pandemic has led to different ways of accessing school content. We sought to determine how many days of school school-aged patients should expect to miss following ACL reconstruction and how the availability of remote learning during the COVID-19 pandemic affected this.

METHODS

We evaluated 53 ACL reconstruction patients in grades 7-12 undergoing surgery during the school year. Demographic, medical, and educational information were collected. Patients were placed into 1 of 2 cohorts: Group A (surgery before the COVID-19 pandemic) or Group B (surgery during the COVID-19 pandemic). We calculated days missed from school after surgery until return to either virtual or in-person school.

RESULTS

Overall, patients returned to school after missing an average of 4.4 (SD, 3.0) days of school after ACL reconstruction surgery. Patients in Group A missed an average of 5.5 (SD, 2.9) school days, while patients in Group B missed an average of 2.3 (SD, 1.4) school days (p <.001). Eighty-nine percent of Group B patients first returned to school utilizing a virtual option. Among those returning virtually, these patients missed an average of 1.9 (SD, 0.9) school days.

CONCLUSIONS

A virtual distance learning option results in fewer missed days of school post ACL reconstruction. When given this option, school-aged patients can expect to return to school within two days post-op. Otherwise, patients should expect to miss about one week of in-person schooling. In this regard, the COVID-19 pandemic has positively impacted educational opportunities for students post-surgery, and physicians should advocate for continuing virtual options for students receiving medical treatment.

Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases

BACKGROUND

Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents.

METHODS

A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms.

RESULTS

Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019.

CONCLUSIONS

Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries.

LEVEL OF EVIDENCE

This is a level III retrospective study.

Is There a Role for Cartilage Imaging in Athletes?

This article reviews implications for cartilage imaging in athletes in the setting of (1) acute chondral injury diagnosis, (2) evaluation and follow-up of conservative and surgical therapy, and (3) evaluation of cartilage as a surrogate for meniscal function and joint stability. Focal knee cartilage defects are common in athletic populations. Athletes with articular cartilage injury may initially be able to return to sport with conservative therapy; however, a reduction of athletic ability and progression to osteoarthritis is expected in athletes with untreated severe chondral injury. For diagnostic and pre- and postsurgical evaluation purposes, morphological magnetic resonance (MR) assessment of the articular cartilage with high-resolution protocols is crucial. Although not widely implemented for clinical use, compositional MR techniques have great potential for monitoring the development and progression of biochemical and microstructural changes in cartilage extracellular matrix before gross morphological changes occur.

The Locations of Anterior Cruciate Ligament Tears in Pediatric and Adolescent Patients: A Magnetic Resonance Study

BACKGROUND

Recently, a resurgence of interest has been noted in anterior cruciate ligament (ACL) preservation in pediatric and adolescent patients. Different tear types, defined by their tear location, require different preservation techniques: proximal and distal avulsion tears can be treated with arthroscopic primary repair, whereas primary repair with biological scaffold has been proposed for midsubstance tears. The goal of this study was to assess the distribution of different tear types in pediatric and adolescent patients, as these are currently unknown.

METHODS

A retrospective search in an institutional radiographic database was performed for patients under 18.0 years undergoing knee magnetic resonance imaging (MRI) for ACL tears between June 2005 and June 2016. Patients with reports of chronic tears, partial tears, and multiligamentous injuries were excluded.Tear locations were graded using MRI as: proximal avulsion (distal remnant length >90% of total length; type I), proximal (75% to 90%; type II), midsubstance (25% to 75%; type III), distal (10% to 25%; type IV), and distal avulsion (<10%; type V).

RESULTS

A total of 274 patients (59% girls; mean±SD age, 15.1±2.1 y; range, 6.9 to 18.0 y) were included. Frequency of type I tears was 15%, type II 23%, type III 52%, type IV 1%, and type V 8% (of which 7% had bony avulsion).Prevalence of tear types varied with age. At age 6 to 10 years, 93% were type V (bony) avulsion tears. At age 11 to 13 years, 32% were type I, 16% type II, 32% type III, and 16% type V. At age 14 to 17 years, type III tears were more common (57%) than type I (14%), type II (25%) and type V (2%) tears.

CONCLUSIONS

It was noted that the ACL was torn at different locations depending on the patients' age. These data provide more information on the potential application for ACL preservation in pediatric and adolescent patients. Future studies correlating these findings with arthroscopy are needed before using MRI for preoperative planning of ACL preservation surgery.

LEVEL OF EVIDENCE

Diagnostic level III.

TFCC Lesions in Children and Adolescents: Open Treatment

BACKGROUND

There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique.

METHODS

Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated.

RESULTS

The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair.

CONCLUSIONS

This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes

BACKGROUND

Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity.

METHODS

A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded.

RESULTS

In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment.

CONCLUSIONS

Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

LEVEL OF EVIDENCE

Level IV.

Accelerated Return to Sport After Osteochondral Autograft Plug Transfer

Background:

Previous studies have reported varying return-to-sport protocols after knee cartilage restoration procedures.

Purpose:

To (1) evaluate the time for return to sport in athletes with an isolated chondral injury who underwent an accelerated return-to-sport protocol after osteochondral autograft plug transfer (OAT) and (2) evaluate clinical outcomes to assess for any consequences from the accelerated return to sport.

Study Design:

Case series; Level of evidence, 4.

Methods:

An institutional cohort of 152 OAT procedures was reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent a physician-directed accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. Clinical outcomes were assessed using International Knee Documentation Committee (IKDC) and Tegner scores as well as assessment of level of participation on return to sport.

Results:

Return-to-sport data were available for all 20 athletes; 13 of 20 athletes (65%) were available for clinical evaluation at a mean 4.4-year follow-up. The mean time for return to sport for all 20 athletes was 82.9 ± 25 days (range, 38-134 days). All athletes were able to return to sport at their previous level and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The mean postoperative IKDC score was 84.5 ± 9.5. The mean Tegner score prior to injury was 8.9 ± 1.7; it was 7.7 ± 1.9 at final follow-up.

Conclusion:

Competitive athletes with traumatic chondral defects treated with OAT managed using this protocol had reduced time to preinjury activity levels compared with what is currently reported, with excellent clinical outcomes and no serious long-term sequelae.

Paediatric ACL repair reinforced with temporary internal bracing

PURPOSE

Instability following non-operative treatment of anterior cruciate ligament (ACL) rupture in young children frequently results in secondary chondral and/or meniscal injuries. Therefore, many contemporary surgeons advocate ACL reconstruction in these patients, despite the challenges posed by peri-articular physes and the high early failure rate. We report a novel management approach, comprising direct ACL repair reinforced by a temporary internal brace in three children.

METHODS

Two patients (aged 5 and 6 years) with complete proximal ACL ruptures and a third (aged seven) with an associated tibial spine avulsion underwent direct surgical repair, supplemented with an internal brace that was removed after 3 months.

RESULTS

Second-look arthroscopy, examination and imaging at 3 months confirmed knee stability and complete ACL healing in all cases. Normal activities were resumed at 4 months, and excellent objective measures of function, without limb growth disturbance, were noted beyond 2 years.

CONCLUSION

ACL repair in young children using this technique negates the requirement and potential morbidity of graft harvest and demonstrates the potential for excellent outcome as an attractive alternative to ACL reconstruction, where an adequate ACL remnant permits direct repair.

LEVEL OF EVIDENCE

IV.

Return to Sport After Articular Cartilage Repair in Athletes' Knees: A Systematic Review

PURPOSE

To perform a systematic review of cartilage repair in athletes' knees to (1) determine which (if any) of the most commonly implemented surgical techniques help athletes return to competition, (2) identify which patient- or defect-specific characteristics significantly affect return to sport, and (3) evaluate the methodologic quality of available literature.

METHODS

A systematic review of multiple databases was performed. Return to preinjury level of sport was defined as the ability to play in the same or greater level (i.e., league or division) of competition after surgery. Study methodologic quality for all studies analyzed in this review was evaluated with the Coleman Methodology Score.

RESULTS

Systematic review of 1,278 abstracts identified 20 level I-IV studies for inclusion but only 1 randomized controlled trial. Twenty studies (1,117 subjects) were included. Subjects (n = 970) underwent 1 of 4 surgeries (microfracture [n = 529], autologous chondrocyte implantation [ACI, n = 259], osteochondral autograft [n = 139], or osteochondral allograft [n = 43]), and 147 were control patients. The rate of return to sports was greatest after osteochondral autograft transplantation (89%) followed by osteochondral allograft, ACI, and microfracture (88%, 84%, and 75%, respectively). Osteochondral autograft transplantation and ACI had statistically significantly greater rates of return to sports compared with microfracture (P < .001, P < .01; Fisher exact test).

CONCLUSIONS

Athletes may return to sports participation after microfracture, ACI, osteochondral autograft, or osteochondral allograft, but microfracture patients were least likely to return to sports. The athletes who had a better prognosis after surgery were younger, had a shorter preoperative duration of symptoms, underwent no previous surgical interventions, participated in a more rigorous rehabilitation protocol, and had smaller cartilage defects.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Anterior cruciate ligament injuries: diagnosis, treatment, and prevention

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

Epidemiology of adolescent rugby injuries: a systematic review

OBJECTIVE

Despite recent increases in the volume of research in professional rugby union, there is little consensus on the epidemiology of injury in adolescent players. We undertook a systematic review to determine the incidence, severity, and nature of injury in adolescent rugby union players.

DATA SOURCES

In April 2009, we performed a computerized literature search on PubMed, Embase, and Cochrane Controlled Trials Register (via Ovid). Population-specific and patient-specific search terms were combined in the form of MEDLINE subject headings and key words (wound$ and injur$, rugby, adolescent$). These were supplemented with related-citation searches on PubMed and bibliographic tracking of primary and review articles.

STUDY SELECTION

Prospective epidemiologic studies in adolescent rugby union players.

DATA SYNTHESIS

A total of 15 studies were included, and the data were analyzed descriptively. Two independent reviewers extracted key study characteristics regarding the incidence, severity, and nature of injuries and the methodologic design.

CONCLUSIONS

Wide variations existed in the injury definitions and data collection procedures. The incidence of injury necessitating medical attention varied with the definition, from 27.5 to 129.8 injuries per 1000 match hours. The incidence of time-loss injury (>7 days) ranged from 0.96 to 1.6 per 1000 playing hours and from 11.4/1000 match hours (>1 day) to 12-22/1000 match hours (missed games). The highest incidence of concussion was 3.3/1000 playing hours. No catastrophic injuries were reported. The head and neck, upper limb, and lower limb were all common sites of injury, and trends were noted toward greater time loss due to upper limb fractures or dislocations and knee ligament injuries. Increasing age, the early part of the playing season, and the tackle situation were most closely associated with injury. Future injury-surveillance studies in rugby union must follow consensus guidelines to facilitate interstudy comparisons and provide further clarification as to where injury-prevention strategies should be focused.

Anatomic landmarks utilized for physeal-sparing, anatomic anterior cruciate ligament reconstruction: an MRI-based study

BACKGROUND

Anterior cruciate ligament (ACL) injury and reconstruction in the skeletally immature patient are becoming more common. The purpose of this study was to develop a reproducible anatomic ACL reconstruction technique, based on intra-articular and extra-articular landmarks, that reliably produces a femoral tunnel of adequate length and diameter while avoiding the distal femoral physis.

METHODS

Magnetic resonance images (MRIs) of one hundred and eighty-eight children (age range, six to seventeen years) were evaluated. Two extra-articular landmarks, the femoral insertion of the popliteus tendon and the lateral femoral epicondyle, and one intra-articular landmark, the central portion of the femoral footprint of the ACL, were identified. Computer software was used to plot these landmarks in all three planes and to draw lines representing two potential femoral tunnels. The first line connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, and the second connected the center of the ACL femoral footprint with the lateral femoral epicondyle. The length of each tunnel, the shortest distance from the center of each tunnel to the distal femoral physis, and the height of the lateral femoral condyle from the physis to the chondral surface and to the base of the cartilage cap were calculated. A three-dimensional MRI reconstruction was used to confirm that placement of a femoral tunnel with use of the chosen landmarks would avoid the distal femoral physis.

RESULTS

The mean distance from the center of the preferred ACL tunnel, which connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, to the distal femoral physis was 12 mm, independent of sex (p = 0.94) or age, and the shortest distance was 8 mm. The length of this proposed tunnel averaged 30.1 mm in the boys and 27.4 mm in the girls (p &lt; 0.001), and it averaged 25.4 mm at an age of six years and 29.7 mm at an age of seventeen years. The mean distance from the center of the alternative tunnel, which connected the center of the ACL femoral footprint with the lateral epicondyle, to the distal femoral physis was 8.8 mm in the boys and 8.9 mm in the girls (p = 0.55). The mean length of this alternative tunnel was 34.3 mm in the boys and 31.6 mm in the girls (p &lt; 0.001).

CONCLUSIONS

Drilling from the center of the ACL femoral footprint to the insertion of the popliteus tendon would have resulted in a mean tunnel length of 27 to 30 mm, and it would have allowed the safe placement of a femoral tunnel at least 7 mm in diameter in a patient six to seventeen years old. The center of the ACL femoral footprint and the popliteus insertion are easily identifiable landmarks and will allow safe, reproducible, anatomic ACL reconstruction in the skeletally immature patient.

Sport injuries in adolescents

In spite of the wide range of injuries in adolescents during sports activities, there are only a few studies investigating the type and frequency of sport injuries in puberty. However, this information may help to prevent, diagnose and treat sports injuries among teens. 4468 injuries in adolescent patients were treated over a ten year period of time: 66,97% were boys and 32.88% girls. The most frequent sports injuries were football (31.13%) followed by handball (8.89%) and sports during school (8.77%). The lower extremity was involved in 68.71% of the cases. Knee problems were seen in 29.79% of the patients; 2.57% spine and 1.99% head injuries. Injuries consisted primarily of distortions (35.34%) and ligament tears (18.76%); 9,00% of all injuries were fractures. We found more skin wounds (6:1) and fractures (7:2) in male patients compared to females. The risk of ligament tears was highest during skiing. Three of four ski injuries led to knee problems. Spine injuries were observed most often during horse riding (1:6). Head injuries were seen in bicycle accidents (1:3). Head injuries were seen in male patients much more often then in female patients (21:1). Fractures were noted during football (1:9), skiing (1:9), inline (2:3), and during school sports (1:11). Many adolescents participate in various sports. Notwithstanding the methodological problems with epidemiological data, there is no doubt about the large number of athletes sustain musculoskeletal injuries, sometimes serious. In most instances, the accident does not happened during professional sports and training. Therefore, school teachers and low league trainer play an important role preventing further accidence based on knowledge of individual risk patterns of different sports.It is imperative to provide preventive medical check-ups, to monitor the sport-specific needs for each individual sports, to observe the training skills as well as physical fitness needed and to evaluation coaches education.

Characteristics of martial art injuries in a defined Canadian population: a descriptive epidemiological study

BACKGROUND

The martial arts have emerged as common activities in the Canadian population, yet few studies have investigated the occurrence of associated injuries on a population basis.

METHODS

We performed such an investigation and suggest potential opportunities for prevention. The data source was 14 years (1993 to 2006) of records from the Kingston sites of the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP).

RESULTS

920 cases were identified. Incidence rates were initially estimated using census data as denominators. We then imputed annual injury rates per 10000 using a range of published estimates of martial arts participation available from a national survey. Rates of injury in males and females were 2300 and 1033 per 10000 (0.3% participation) and 575 and 258 per 10000 (1.2% participation). Injuries were most frequently reported in karate (33%) and taekwondo (14%). The most common mechanisms of injury were falls, throws and jumps (33%). Fractures (20%) were the most frequently reported type of injury and the lower limb was the most common site of injury (41%).

CONCLUSIONS

Results provide a foundation for potential interventions with a focus on falls, the use of weapons, participation in tournaments, as well as head and neck trauma.

Mechanical loading, cartilage degradation, and arthritis

Joint tissues are exquisitely sensitive to their mechanical environment, and mechanical loading may be the most important external factor regulating the development and long-term maintenance of joint tissues. Moderate mechanical loading maintains the integrity of articular cartilage; however, both disuse and overuse can result in cartilage degradation. The irreversible destruction of cartilage is the hallmark of osteoarthritis and rheumatoid arthritis. In these instances of cartilage breakdown, inflammatory cytokines such as interleukin-1 beta and tumor necrosis factor-alpha stimulate the production of matrix metalloproteinases (MMPs) and aggrecanases (ADAMTSs), enzymes that can degrade components of the cartilage extracellular matrix. In order to prevent cartilage destruction, tremendous effort has been expended to design inhibitors of MMP/ADAMTS activity and/or synthesis. To date, however, no effective clinical inhibitors exist. Accumulating evidence suggests that physiologic joint loading helps maintain cartilage integrity; however, the mechanisms by which these mechanical stimuli regulate joint homeostasis are still being elucidated. Identifying mechanosensitive chondroprotective pathways may reveal novel targets or therapeutic strategies in preventing cartilage destruction in joint disease.

Articular Cartilage Injury in Athletes

Articular cartilage lesions in the athletic population are observed with increasing frequency and, due to limited intrinsic healing capacity, can lead to progressive pain and functional limitation over time. If left untreated, isolated cartilage lesions can lead to progressive chondropenia or global cartilage loss over time. A chondropenia curve is described to help predict the outcome of cartilage injury based on different lesion and patient characteristics. Nutriceuticals and chondroprotective agents are being investigated as tools to slow the development of chondropenia. Several operative techniques have been described for articular cartilage repair or replacement and, more recently, cartilage regeneration. Rehabilitation guidelines are being developed to meet the needs of these new techniques. Next-generation techniques are currently evaluated to optimize articular cartilage repair biology and to provide a repair cartilage tissue that can withstand the high mechanical loads experienced by the athlete with consistent long-term durability.

Return to sports participation after articular cartilage repair in the knee: scientific evidence

BACKGROUND

Articular cartilage injury in the athlete's knee presents a difficult clinical challenge. Despite the importance of returning injured athletes to sports, information is limited on whether full sports participation can be successfully achieved after articular cartilage repair in the knee.

HYPOTHESIS

Systematic analysis of athletic participation after articular cartilage repair will demonstrate the efficacy of joint surface restoration in high-demand patients and help to optimize outcomes in athletes with articular cartilage injury of the knee.

STUDY DESIGN

Systematic review.

METHODS

A comprehensive literature review of original studies was performed to provide information about athletic participation after articular cartilage repair. The athlete's ability to perform sports postoperatively was assessed by activity outcome scores, rate of return to sport, timing of the return, level of postoperative sports participation, and the continuation of athletic activity over time.

RESULTS

Twenty studies describing 1363 patients were included in the review, with an average follow-up of 42 months. Return to sports was possible in 73% overall, with highest return rates after osteochondral autograft transplantation. Time to return to sports varied between 7 and 18 months, depending on the cartilage repair technique. Initial return to sports at the preinjury level was possible in 68% and did not significantly vary between surgical techniques. Continued sports participation at the preinjury level was possible in 65%, with the best durability after autologous chondrocyte transplantation. Several factors affected the ability to return to sport: athlete's age, preoperative duration of symptoms, level of play, lesion size, and repair tissue morphology.

CONCLUSION

Articular cartilage repair in the athletic population allows for a high rate of return to sports, often at the preinjury level. Return to sports participation is influenced by several independent factors. The findings provide pertinent information that is helpful for the clinical decision-making process and for the management of the athlete's postoperative expectations.

The effects of timing of pediatric knee ligament surgery on short-term academic performance in school-aged athletes

BACKGROUND

Orthopaedic injuries negatively affect the academic lives of children.

HYPOTHESIS

The timing of anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstructions affects academic performance in school-aged athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2. Methods Records of patients < or = 18 years old who underwent ACL or MPFL reconstructions from 2001-2007 were reviewed retrospectively. Subjects had been administered a unique questionnaire to evaluate school life in the immediate postoperative period as well as International Knee Documentation Committee (IDKC), Lysholm, and Kujala knee-specific questionnaires. Patients were in 1 of 3 study cohorts: group A (surgery during school year), group B (surgery during school holiday), and group C (surgery during summer break).

RESULTS

There were 62 subjects (53 ACL and 12 MPFL reconstructions). A higher proportion of patients in group A required being driven to school (88.5%) than groups B (63.6%) or C (64.7%) (P < .05). A lower proportion of patients in group A returned to school immediately after surgery (3.8%) than groups B (36.4%) or C (88.2%) (P < .005). Among children who had never failed a test before surgery, a higher proportion of patients in group A failed a test (36.4%) after return to school than groups B (0%) or C (0%) (P < .05). Patients in group C had higher mean Likert scores (4.5) than groups A (3.8) or B (3.7) (P = .05) in response to the question "my grades suffered in my classes." Delay in surgery was negatively correlated with IKDC, Lysholm, and Kujala questionnaire scores (P < .05).

CONCLUSION

In school-aged athletes with ligamentous knee injuries receiving operative treatment, surgery on a school day causes more academic difficulties than surgery during a holiday or summer break. Academic benefits of delaying surgery during the school year must be weighed against potentially worse outcomes encountered with prolonged surgical delay.

High-impact athletics after knee articular cartilage repair: a prospective evaluation of the microfracture technique

BACKGROUND

Knee articular cartilage injuries in athletes present a therapeutic challenge and have been identified as an important cause of permanent disability because of the high mechanical joint stresses in athletes.

PURPOSE

To determine whether microfracture treatment of knee articular cartilage injuries can return athletes to high-impact sports and to identify the factors that affect the ability to return to athletic activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-two athletes who regularly participated in high-impact, pivoting sports before articular cartilage injury were treated with microfracture for single articular cartilage lesions of the knee. Functional outcome was prospectively evaluated with a minimum 2-year follow-up by subjective rating, activity-based outcome scores, and the ability for postoperative participation in high-impact, pivoting sports.

RESULTS

At last follow-up, 66% of athletes reported good or excellent results. Activity of daily living, Marx activity rating scale, and Tegner activity scores increased significantly after microfracture. After an initial improvement, score decreases were observed in 47% of athletes. Forty-four percent of athletes were able to regularly participate in high-impact, pivoting sports, 57% of these at the preoperative level. Return to high-impact sports was significantly higher in athletes with age <40 years, lesion size <200 mm(2), preoperative symptoms <12 months, and no prior surgical intervention.

CONCLUSION

Microfracture is an effective first-line treatment to return young athletes with short symptomatic intervals and small articular cartilage lesions of the knee back to high-impact athletics.

Gender differences in adolescent injury characteristics: A population-based study of hospital A&E data

OBJECTIVES

To investigate patterns of adolescent home/leisure injury serious enough to require hospital attendance.

STUDY DESIGN

Population-based analysis of data collected by the Home and Leisure Accident Surveillance System (HASS/LASS).

METHODS

Study subjects were 0-17 year old residents of Airdrie and Coatbridge, Lanarkshire, Scotland, who attended Monklands Hospital Accident and Emergency (A&E) Department with a home/leisure injury during calendar years 1996-1999. Male to female relative risk ratios (M:F RRRs) for A&E attendance, fracture and hospital admission, stratified into sports and non-sports injuries, were calculated. Sports injuries were further analysed by specific sports and by whether the sports activity was organized or informal. Data were analysed in age groups corresponding to children's stage of schooling.

RESULTS

The M:F RRR for non-sports A&E attendances remained constant throughout childhood (1.35, 95% CI 1.30-1.39 in 0-17 year olds), whilst that for sports attendances increased sharply with age (2.50, 95% CI 0.89-7.02 in 0-4 year olds, increasing to 8.11, 95% CI 6.27-10.51 in 16-17 year olds). Of sports injury attendances, 50.3% were football-related. Football was overwhelmingly the main cause of boys' sports injury in both the organized and informal sports injury categories. When football injuries were excluded from the analysis, the widening teenage gender gap in injury risk disappeared. There was no significant gender difference in teenagers' rates of A&E attendance for injuries sustained during compulsory school physical education (PE), suggesting a dose-response relationship between sports participation and injury risk.

CONCLUSIONS

This study found significant gender inequalities in adolescent injury risk, which were largely attributable to boys' football injuries. Focusing prevention efforts on making football safer would, then, be a sensible strategy for reducing the overall burden of adolescent injury and for reducing sex inequalities in injury risk; however further research is needed to understand how the risks differ between organized and informal football. These findings are also interesting because of what they suggest about teenage girls' lack of participation in sport and habitual physical activity. This is clearly of public health concern because of the links between physical inactivity and a range of health problems.

Jump-land characteristics and muscle strength development in young athletes: a gender comparison of 1140 athletes 9 to 17 years of age

BACKGROUND

Many authors have speculated that altered neuromuscular control and strength of the lower extremity are responsible for the gender disparity in knee ligament injury rates.

HYPOTHESIS

Significant increases in normalized quadriceps and hamstrings strength and limb symmetry on single-legged hop test occur with age. No gender differences in strength occur until age 14 years, after which boys generate greater peak torques than do girls. Age and gender do not influence lower limb alignment on a drop-jump test.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We studied the effects of age and gender in 1140 athletes, 9 to 17 years old, on muscle strength and neuromuscular control during functional activities. Isokinetic quadriceps and hamstrings strength was measured at 300 deg/s. Limb symmetry was assessed with single-legged hop tests. A video drop-jump test determined lower limb alignment in the coronal plane.

RESULTS

Extension peak torques significantly increased with age; maximum strength was noted in girls at age 13 years and in boys at age 14 years (P < .001). Although maximum flexion strength occurred in boys at age 14 years (P < .001), girls had only slight increases from ages 9 to 11 years (P = not significant). Boys aged 14 to 17 years had significantly greater normalized isokinetic strength than did age-matched girls. No age or gender effects existed in limb alignment on the drop-jump test or limb symmetry on single-legged hop testing.

CONCLUSION

Maximum hamstrings strength was noted in female athletes by age 11 years, compared with age 14 years in male athletes, and a distinct lower limb valgus alignment existed in the majority of all athletes on landing. The absence of a gender difference in lower limb alignment on landing suggests other factors may be responsible for the gender disparity in knee ligament injury rates.

Pediatric distal radius fractures and triangular fibrocartilage complex injuries

Management of distal radius fractures is guided by the pattern and location of injury, degree of deformity, and expectations of bony remodeling based on the amount of remaining skeletal growth.Indications for surgical treatment include unstable or irreducible fractures, open fractures, floating elbow injuries, and neurovascular or soft-tissue compromise precluding cast immobilization. Patients and families should be counseled regarding the potential for post-traumatic distal radial growth arrest following physeal fractures. In these cases, epiphysiodeses, ulnar shortening osteotomies, or corrective radial osteotomies may be performed, depending on the pattern of arrest,degree of deformity, and remaining skeletal growth.TFCC tears may be the source of ulnar-sided wrist pain in children and adolescents, though symptoms and physical examination findings maybe subtle. Patients who have persistent pain and functional limitations despite activity modification and therapy are candidates for surgical treatment. Appropriate repair of peripheral TFCC tears with correction of concomitant wrist pathology restores normal wrist anatomy, alleviates pain, and allows for return to functional activities.

The causes and consequences of injury in students at UK institutes of higher education

BACKGROUND

Injuries are the leading cause of mortality and also an important cause of permanent disability in young people living in developed countries. This study aimed to inform injury prevention programmes by assessing the incidence of injury and disabling injury, and identifying factors predicting injury in students at institutes of higher education, an under-researched group with regard to injury studies.

METHODS

Secondary analysis of data obtained from a postal questionnaire survey of 1208 students at three institutions in the UK.

RESULTS

Eighteen percent (222/1208) of students reported at least one injury requiring medical attention in the last year. Males and younger students were at greater risk, as were those who reported 'seeking out risky activities because they enjoyed potential danger'. Seventy-nine percent of reported injuries caused some degree of, at least temporary, disability. Four percent of students reported an injury in the last year that interfered with studies, work or other regular daily activities for at least 1 month. Team sports increased the risk of injury by a factor of 2.5 independently of age, gender and risk-taking attitudes. Sport/physical activity injuries were much more likely to be disabling than injuries attributable to other causes.

CONCLUSIONS

There is a need for injury prevention programmes among students at institutes of higher education. Programmes need to disseminate the risk of disabling injury, particularly that attributable to participation in sport/physical activity. There is an urgent need for those working on injury prevention to collaborate with those working on other aspects of health promotion to define the net health gain from participation in sport/physical activity and to develop coherent public health messages.

Assessment of lower limb neuromuscular control in prepubescent athletes

BACKGROUND

Although neuromuscular indices have been extensively studied in adolescents and adults, limited data exist for prepubescent children.

HYPOTHESIS

No differences exist between prepubescent boys and girls in lower limb strength, symmetry on single-legged hop testing, and limb alignment during drop-jump testing.

STUDY DESIGN

Cross-sectional study (prevalence); Level of evidence, 1.

METHODS

The authors tested 27 female and 25 male athletes who were aged 9 to 10 years and matched for both body mass index and years of organized sports participation. In a drop-jump screening test, the distance between the right and left hips, knees, and ankles was measured as an indicator of lower limb axial alignment in the coronal plane. The distance between the knees and ankles was normalized by the hip separation distance. Quadriceps and hamstrings strengths were measured isokinetically at 180 deg/s. Lower limb symmetry was determined from 2 single-legged hop function tests.

RESULTS

Boys demonstrated greater mean absolute and normalized knee and ankle separation distances on the drop-jump test. Even so, 76% of boys had a normalized knee separation distance of 60% or less of the hip separation distance, as did 93% of girls, indicating a distinctly valgus alignment. There were no differences between the sexes in quadriceps and hamstrings peak torques, hamstrings/quadriceps ratio, time to peak torque, total work, or lower limb symmetry values.

CONCLUSIONS

A high percentage of the prepubescent athletes studied had a distinctly valgus lower limb alignment during the drop-jump test and a lack of lower limb symmetry during the hop tests. These same indices have been hypothesized to increase the risk for knee ligament injuries in older athletes. Neuromuscular training may be needed to address these issues in children.

Injuries during physical activity in school children

During the spring of 2001, 1975 children, from grades 3, 6 and 9 participated in a nationwide, multidisciplinary collaboration study. The students came from randomly selected classes throughout Sweden, representing different geographical and socio-economic areas. The aim of this study was to collect and evaluate self-reported injuries and associated factors during various physical activities as recalled retrospectively for 3 months by the students. Every sixth student (n=299 or 16%) reported 306 injuries. Twice as many girls than boys were injured during physical education class. Ninth-grade students reported relatively more injuries during organized sports than during physical education class and leisure activities. There were no age or gender differences in incidence rate during leisure activities. Most injuries were minor, as 70% were back in physical activity within a week. Half of the students (50%) reported that they previously had injured the same body part. Primary care of the injured student was, with the exception of a family member, most often carried out by the physical education teacher or coach, which accentuates the importance of continuous sports medicine first aid education for this group.

Soccer injury in the lower extremities

Information about soccer injuries is required to develop prevention and rehabilitation programmes. Most soccer injuries occur in the lower extremities. This type of injury is reviewed here. Definitions of injury, injury rate, injury percentage, mechanism of injury, anatomical region of injury, type of injury, and severity of injury are summarised. In each section, a description and summary of the data are provided. Finally, the limitations of the studies and suggestions to improve the investigation of soccer injuries are provided.

Functional outcome of knee articular cartilage repair in adolescent athletes

BACKGROUND

Limited information exists about the treatment of full-thickness articular cartilage lesions of the knee in adolescent athletes.

PURPOSE

To evaluate the functional outcome and athletic activity after articular cartilage repair in the knees of adolescent athletes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty adolescent athletes with full-thickness articular cartilage lesions of the knee were treated with autologous chondrocyte transplantation. Functional outcome was evaluated by subjective patient outcome rating, knee activity scores, and level of athletic participation.

RESULTS

At a mean of 47 months after autologous chondrocyte transplantation, 96% of adolescents reported good or excellent results with significant increases in postoperative Tegner activity scores and Lysholm scores. Ninety-six percent returned to high-impact sports and 60% to an athletic level equal or higher than that before knee injury. Return to preinjury sports correlated with shorter preoperative symptoms and a lower number of prior operations. All adolescents with preoperative symptoms < or =12 months returned to preinjury-level athletics, compared to 33% with preoperative intervals longer than 12 months.

CONCLUSION

Treatment of full-thickness articular injuries of the knee in adolescent athletes with autologous chondrocyte transplantation yields a high rate of functional success at a mean follow-up of 47 months. The rate of return to demanding athletic activities is higher in cases in which the preoperative duration of symptoms is 12 months or less.

Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study

OBJECTIVE

The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors.

METHODS

The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively.

RESULTS

During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics.

CONCLUSIONS

Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.

Parental safety concerns--a barrier to sport and physical activity in children?

OBJECTIVE

To examine the extent to which parents and carers perceive injury and safety risks as serious enough to prevent or discourage their children, aged 5-12 years, from participating in sports/physical activity and to identify factors that influence these perceptions.

METHODS

An analysis of the 2001 New South Wales Child Health Survey.

RESULTS

More than one-quarter of parents/ carers of active children aged 5-12 years reported discouraging or preventing children from playing a particular sport (34.7% for boys and 16.6% for girls) because of injury and safety concerns. In boys, the most frequently discouraged sport was rugby league (23.2%), followed by rugby union (7.5%) and Australian rules football (2.8%). Among girls, the most frequently discouraged activities were rollerblading (2.7%), rugby league (2.3%) and soccer (2.1%). Multivariate analysis shows that factors independently associated with parents' decision to prevent/discourage their child from engaging in sport/physical activity include their child's age and gender, language spoken at home, presence of disability, and the respondent's relation to the child.

CONCLUSIONS AND IMPLICATIONS

Efforts need to be made to modify some sports/ activities, such as football codes, in order to minimise injury and to ensure that children continue enjoying their favourite activity well into adulthood. Guidelines designed to promote physical activity among children and young adolescents need to take into account parental concerns regarding the associated risk of injury.

Looking for the evidence: a systematic review of prevention strategies addressing sport and recreational injury among children and youth

OBJECTIVES

To examine evidence on the effectiveness of current injury prevention strategies in selected sport and recreational activities, determine the applicability of the evidence to children and youth and discuss the implications related to policy, programming and future research.

METHODS

Research questions and relevance criteria were developed a priori. Potentially relevant studies were located through electronic and hand searches. Two independent assessors assessed articles for first relevance and then quality. Relevant articles were abstracted and synthesised for activities that had three or more relevant articles.

RESULTS

A total of 21,499 articles identified through database and manual searching yielding 117 that met inclusion criteria. The majority of the studies (93 or 89%) involved eight activities: baseball, basketball, cycling, football, ice hockey, rugby, alpine skiing and soccer. Children and youth were identified as the specific target group in 45% of the studies and another 12% included children in their sample. Studies addressed a range of intervention strategies and varied on quality of evidence.

CONCLUSIONS

Surprisingly few well-designed and controlled studies investigating strategies to prevent injuries were found and an even smaller number evaluated strategies to reduce injury in children and youth. As governments in developed countries continue to focus on increasing physical activity among children and youth, thought must be given to the issue of risk of injury and the relative lack of evidence of effective preventive measures.

Acute Injury of the Articular Cartilage and Subchondral Bone:A Common but Unrecognized Lesion in the Immature Knee

OBJECTIVE

We studied the prevalence of injuries of the articular cartilage and subchondral bone after acute trauma in skeletally immature knees using high-resolution MRI.

MATERIALS AND METHODS

We reviewed knee MRIs of 126 young children and adolescents suspected to have internal knee derangement, including 82 with open physes and a control group of 44 who were skeletally mature. High-resolution proton density and T2-weighted pulse sequences were used in all patients. The prevalence of common injuries in the two groups was compared using chi-square analysis. Levels of interobserver agreement for evaluation of chondral lesions in the skeletally immature group were determined using the kappa statistic.

RESULTS

In the skeletally immature group, chondral lesions were the most prevalent injuries (prevalence = 0.34, p = 0.009) followed by meniscal and anterior cruciate ligament injuries (prevalence = 0.23 and 0.24, respectively). No significant difference in the prevalence of chondral injury before and after physeal closure was seen (p = 0.45). There was no significant difference in the prevalence of anterior cruciate ligament injuries between the two groups, but meniscal injuries were more prevalent in the skeletally mature patients (prevalence = 0.41, p = 0.037). Interobserver agreement for chondral injuries in the group with open physes was good (weighted kappa = 0.45-0.51).

CONCLUSION

The most common injuries occurring as a result of acute trauma to the immature knee were chondral. In patients with open physes, chondral injuries were significantly more prevalent than anterior cruciate ligament and meniscal injuries.