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Stearns SA, Engmann TF, Francalancia S, Hegermiller K, Bixby S, Mandeville R, d’Hemecourt PA, Micheli LJ, Upton J, Dowlatshahi S. Surgical management of popliteal artery entrapment syndrome. J Orthop 2024; 48:32-37. [PMID: 38059216 PMCID: PMC10696308 DOI: 10.1016/j.jor.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Popliteal artery entrapment syndrome (PAES) is a rare condition in which the popliteal artery becomes compressed by adjacent soft tissue structures causing progressive claudication. Due to its low incidence, this disorder and its surgical management is poorly described in the literature. This study presents our institutional data surrounding PAES management to further optimize care of this syndrome. Methods This retrospective study gathered demographic, surgical, and outcome data of all patients with PAES who underwent surgical decompression at our institution from 2015 to 2022. Patients were identified using CPT and ICD-9/10 codes. Summary statistics were calculated, with Chi-squared and T-test used for subgroup analysis. Results 50 surgical patients with PAES were identified. On average, they were young (mean age: 20.7 years), mostly female (78 %), and predominately white (68 %). The vast majority were physically active, with 13 of the 50 patients being runners (26 %). Medically, the cohort was otherwise healthy, with 74 % reporting no comorbidities. Diagnosis was often delayed, with patients on average seeing 4.5 physicians over 2.0 years prior to arriving at our institution for care. In addition to popliteal artery release, the second most performed procedure was fasciotomy (82 %). Postoperatively, there was significant long-term subjective improvement, with 91 % of patients reporting they would repeat the operation and 65 % reporting improved activity. Conclusion PAES is a rare condition affecting the lower limb that requires a nuanced surgical approach. From diagnosis to outcome, we hope to better inform surgeons of PAES so that these patients may receive the highest quality care.
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Affiliation(s)
- Stephen A. Stearns
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Toni F. Engmann
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stephanie Francalancia
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Katherine Hegermiller
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Bixby
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ross Mandeville
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pierre A. d’Hemecourt
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph Upton
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sammy Dowlatshahi
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Trauma Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Pruneski JA, Heyworth BE, Kocher MS, Tavabi N, Milewski MD, Kramer DE, Christino MA, Yen YM, Micheli LJ, Murray MM, Gilreath L, Kim A, Murray J, Kiapour AM. Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital. Am J Sports Med 2024; 52:77-86. [PMID: 38164668 DOI: 10.1177/03635465231205556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients. HYPOTHESIS There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL). RESULTS Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014). CONCLUSION These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.
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Affiliation(s)
- James A Pruneski
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nazgol Tavabi
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew D Milewski
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa A Christino
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Martha M Murray
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leah Gilreath
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Kim
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Murray
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ata M Kiapour
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Sugimoto D, Micheli LJ, Meehan WP. Lower Extremity Strength Relative to Body Mass in Pediatric Female Athletes: Implications for Anterior Cruciate Ligament Injury. Clin Pediatr (Phila) 2023:99228231216316. [PMID: 38053390 DOI: 10.1177/00099228231216316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
This study compared lower extremity (LE) muscular strength by 3 groups of female athletes using chronological age and consideration of age of peak height velocity (PHV). Isometric quadriceps, hamstrings, and hip abductors strength were assessed from physically active, pediatric females. The body mass normalized isometric strength (N m/kg) was compared by the 3 age groups. There were 388 young female athletes (<10 years [14.2%], 11-14 years [48.7%], and 15-18 years [37.1%]). The body mass normalized LE strength was lower in 11-14 years compared with <10 years (quadriceps [P = .001], hamstrings [P = .001], and hip abductors [P = .037]) as well as in 15-18 years relative to <10 years in quadriceps (P = .001) and hamstrings (P = .001). The analysis results were consistent with both chronological age alone and incorporating effects of age of PHV. In short, body mass normalized LE strength (quadriceps, hamstrings, and hip abductors) of 11-14 years females was lower than <10 years females.
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Affiliation(s)
- Dai Sugimoto
- Faculty of Sport Sciences, Waseda University, Tokyo, Japan
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Department of Orthopaedics and Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- Department of Orthopaedics and Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Perkins CA, Coene RP, Miller PE, Anderson CN, Nunally KD, Parikh SN, Busch MT, Chambers HG, Christino MA, Cordasco FA, Edmonds EW, Fabricant PD, Ganley TJ, Green DW, Heyworth BE, Lawrence JTR, Matava MJ, Micheli LJ, Milewski MD, Nepple J, Pennock AT, Saluan PM, Shea KG, Wall EJ, Willimon SC, Kocher MS. Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study. J Pediatr Orthop 2023; 43:e695-e700. [PMID: 37694605 DOI: 10.1097/bpo.0000000000002495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN Cohort study (diagnosis). METHODS Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE Level III.
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Milewski MD, Traver JL, Coene RP, Williams K, Sugimoto D, Kramer DE, Kocher MS, Micheli LJ, Yen YM, Christino MA. Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231166012. [PMID: 37332533 PMCID: PMC10273787 DOI: 10.1177/23259671231166012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 06/20/2023] Open
Abstract
Background Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process. Purpose To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores. Study Design Prospective cohort study; Level of evidence, 2. Methods Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex. Results A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001). Conclusion This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.
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Affiliation(s)
- Matthew D. Milewski
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica L. Traver
- Department of Orthopedic Surgery, University of Texas, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Ryan P. Coene
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kathryn Williams
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Biostatistics and Research Design Center, ICCTR, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Dennis E. Kramer
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S. Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J. Micheli
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa A. Christino
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Barnes DA, Flannery SW, Badger GJ, Yen YM, Micheli LJ, Kramer DE, Fadale PD, Hulstyn MJ, Owens BD, Murray MM, Fleming BC, Kiapour AM. Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration. Am J Sports Med 2023; 51:413-421. [PMID: 36645042 PMCID: PMC9905304 DOI: 10.1177/03635465221142323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.
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Affiliation(s)
- Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, Larner College of
Medicine, University of Vermont, Burlington, VT, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul D. Fadale
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Michael J. Hulstyn
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Brett D. Owens
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
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Guevel B, Mathew ST, Coene RP, Maguire KJ, Williams KA, Micheli LJ, Milewski MD. Low-Intensity Pulsed Ultrasonography Plus Arthroscopic Drilling Does Not Improve Bone Healing More Than Arthroscopic Drilling Alone in Pediatric Patients With Stable Osteochondritis Dissecans of the Knee. Arthrosc Sports Med Rehabil 2023; 5:e225-e232. [PMID: 36866308 PMCID: PMC9971866 DOI: 10.1016/j.asmr.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 11/09/2022] [Indexed: 01/12/2023] Open
Abstract
Purpose To determine whether adjuvant use of bone stimulation would improve the rate of healing in the operative management of stable osteochondritis dissecans (OCD) of the knee in pediatric patients. Methods This retrospective matched case-control study was performed at a single tertiary care pediatric hospital between January 2015 and September 2018. Patients who underwent antegrade drilling for stable femoral condyle OCD with greater than 2 years' follow-up were included. Preference was for all to receive postoperative bone stimulation; however, some were denied because of insurance coverage. This enabled us to create 2 matched groups of those who received postoperative bone stimulation and those who did not. Patients were matched on skeletal maturity, lesion location, sex, and age at surgery. The primary outcome measure was the rate of healing of the lesions determined by postoperative magnetic resonance imaging measurements at 3 months. Results Fifty-five patients were identified who met the inclusion and exclusion criteria. Twenty patients from the bone stimulator group (BSTIM) were matched to 20 patients from the no bone stimulator group (NBSTIM). Mean age for BSTIM at surgery was 13.2 years ± 2.0 (range, 10.9-16.7) and for NBSTIM at surgery 12.9 years ± 2.0 (range, 9.3-17.3). At 2 years, 36 patients (90%) in both groups went on to clinical healing without further interventions. In BSTIM, there was a mean decrease of 0.9 (±1.8) mm in lesion on coronal width and 12 patients (63%) had overall improved healing; in NBSTIM there was a mean decrease of 0.8 (±3.6) mm in coronal width and 14 patients (78%) had improved healing. No statistical differences in the rate of healing were found between the 2 groups (P = .706). Conclusion In antegrade drilling of stable knee OCD lesions in pediatric and adolescent patients, adjuvant bone stimulator use did not appear to improve radiographic or clinical healing. Level of evidence Level III, retrospective case-control study.
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Affiliation(s)
- Borna Guevel
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, Massachusetts, U.S.A
| | - Stephen T. Mathew
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, Massachusetts, U.S.A
| | - Ryan P. Coene
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, Massachusetts, U.S.A
| | | | - Kathryn A. Williams
- Boston Children’s Hospital, Biostatistics and Research Design Center, ICCTR Boston, Massachusetts, U.S.A
| | - Lyle J. Micheli
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Matthew D. Milewski
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston, Massachusetts, U.S.A.,Harvard Medical School, Boston, Massachusetts, U.S.A.,Address correspondence to Matthew Milewski, M.D., Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedic Surgery, 300 Longwood Avenue, Boston, MA 02115, U.S.A.
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8
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Sanborn RM, Badger GJ, Fleming BC, Kiapour AM, Fadale PD, Hulstyn MJ, Owens BD, Proffen B, Sant N, Portilla G, Freiberger C, Henderson R, Barnett S, Costa M, Chrostek C, Ecklund K, Micheli LJ, Murray MM, Yen YM, Kramer DE. Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure. Am J Sports Med 2023; 51:49-57. [PMID: 36412922 DOI: 10.1177/03635465221137873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.
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Affiliation(s)
- Ryan M Sanborn
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary J Badger
- Department of Medical Biostatistics, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ata M Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Paul D Fadale
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Michael J Hulstyn
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Brett D Owens
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Benedikt Proffen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Nicholas Sant
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Gabriela Portilla
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Christina Freiberger
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Rachael Henderson
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Samuel Barnett
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Meggin Costa
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Cynthia Chrostek
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Kirsten Ecklund
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Martha M Murray
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Menghini D, Kaushal SG, Flannery SW, Ecklund K, Murray MM, Fleming BC, Kiapour AM, Proffen B, Sant N, Portilla G, Sanborn R, Freiberger C, Henderson R, Barnett S, Yen YM, Kramer DE, Micheli LJ. Changes in the Cross-Sectional Profile of Treated Anterior Cruciate Ligament Within 2 Years After Surgery. Orthop J Sports Med 2022; 10:23259671221127326. [PMID: 36263311 PMCID: PMC9575446 DOI: 10.1177/23259671221127326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 11/07/2022] Open
Abstract
Background: The cross-sectional area (CSA) of the anterior cruciate ligament (ACL) and
reconstructed graft has direct implications on its strength and knee
function. Little is known regarding how the CSA changes along the ligament
length and how those changes vary between treated and native ligaments over
time. Hypothesis: It was hypothesized that (1) the CSA of reconstructed ACLs and restored ACLs
via bridge-enhanced ACL restoration (BEAR) is heterogeneous along the
length. (2) Differences in CSA between treated and native ACLs decrease over
time. (3) CSA of the surgically treated ACLs is correlated significantly
with body size (ie, height, weight, body mass index) and knee size (ie,
bicondylar and notch width). Study Design: Cohort study; Level of evidence, 2. Methods: Magnetic resonance imaging scans of treated and contralateral knees of 98
patients (n = 33 ACL reconstruction, 65 BEAR) at 6, 12, and 24 months
post-operation were used to measure the ligament CSA at 1% increments along
the ACL length (tibial insertion, 0%; femoral insertion, 100%). Statistical
parametric mapping was used to evaluate the differences in CSA between 6 and
24 months. Correlations between body and knee size and treated ligament CSA
along its length were also assessed. Results: Hamstring autografts had larger CSAs than native ACLs at all time points
(P < .001), with region of difference decreasing
from proximal 95% of length (6 months) to proximal 77% of length (24
months). Restored ACLs had larger CSAs than native ACLs at 6 and 12 months,
with larger than native CSA only along a small midsubstance region at 24
months (P < .001). Graft CSA was correlated
significantly with weight (6 and 12 months), bicondylar width (all time
points), and notch width (24 months). Restored ACL CSA was significantly
correlated with bicondylar width (6 months) and notch width (6 and 12
months). Conclusion: Surgically treated ACLs remodel continuously within the first 2 years after
surgery, leading to ligaments/grafts with heterogeneous CSAs along the
length, similar to the native ACL. While reconstructed ACLs remained
significantly larger, the restored ACL had a CSA profile comparable with
that of the contralateral native ACL. In addition to size and morphology
differences, there were fundamental differences in factors contributing to
CSA profile between the ACL reconstruction and BEAR procedures. Registration: NCT 02664545 (ClinicalTrials.gov
identifier).
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Affiliation(s)
| | | | | | | | | | | | | | - Ata M. Kiapour
- Ata M. Kiapour PhD, MMSc, Department of Orthopedic Surgery,
Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston,
MA 02115, USA (
)
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10
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Christino MA, Sanborn RM, Miller PE, Milewski MD, Heyworth BE, Kramer DE, Yen YM, Kocher MS, Micheli LJ, O’Brien KH. COVID-Delayed Elective Surgery Has a Negative Effect on Young Sports Medicine Patients. Arthrosc Sports Med Rehabil 2022; 4:e1377-e1384. [PMID: 36033191 PMCID: PMC9402453 DOI: 10.1016/j.asmr.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/13/2022] [Indexed: 10/25/2022] Open
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11
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Zheng ET, Kocher MS, Wilson BR, Hussain ZB, Nunally KD, Yen YM, Kramer DE, Micheli LJ, Heyworth BE. Descriptive Epidemiology of a Surgical Patellofemoral Instability Population of 492 Patients. Orthop J Sports Med 2022; 10:23259671221108174. [PMID: 35859643 PMCID: PMC9289910 DOI: 10.1177/23259671221108174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Patellofemoral instability (PFI) occurs most commonly in pediatric and
adolescent patients, with evolving indications for surgery and changes in
surgical techniques over the past decade. Purpose: To characterize the demographic, clinical, and radiologic characteristics of
a large cohort of patients undergoing PFI surgery and investigate
longitudinal trends in techniques utilized over a 10-year period at a
tertiary-care academic center. Study Design: Case series; Level of evidence, 4. Methods: Electronic medical records of patients younger than 25 years of age who
underwent primary surgery for lateral PFI from 2008 to 2017 at a single
center by 1 of 5 different sports medicine surgeons were retrospectively
reviewed. Demographic, clinical, and radiographic parameters of instability
were analyzed. Routine surgical techniques included medial retinacular
plication/reefing/repair (MRP), medial patellofemoral ligament
reconstruction (MPFLR), tibial tubercle osteotomy (TTO), or a combination
thereof, with or without lateral retinacular release (LR) or lateral
retinacular lengthening (LRL). Exclusion criteria, selected for potentially
altering routine surgical indications or techniques, included
fixed/syndromic PFI, a formally diagnosed collagen disorder, cases in which
a chondral/osteochondral shear fragment underwent fixation or was >1 cm
in diameter, and body mass index >30 kg/m2. Results: Of the 492 study patients (556 knees; 71% female; median age, 15.2 years; 38%
open physes), 88% were athletes, with the most common sports participated in
being soccer, basketball, dance, football, gymnastics, and
baseball/softball. While 91% of the cohort had recurrent dislocations, the
9% with primary dislocations were more likely to have small osteochondral
fractures/loose bodies (P < .001). Female patients were
younger (P = .002), with greater patellar tilt
(P = .005) than male patients. Utilization of MPFLR and
TTO increased significantly over the study period, while use of MRP+LR
decreased. Conclusion: Most patients younger than 25 years of age who underwent PFI surgery were
skeletally immature, female, and athletes and had recurrent dislocations.
The <10% who had primary dislocations and underwent surgery were likely
to have osteochondral fractures. Surgical techniques have changed
significantly over time, with increasing use of TTO and MPFLR, while the use
of MRP+LR/LRL has significantly decreased.
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Affiliation(s)
- Evan T Zheng
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin R Wilson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kianna D Nunally
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Fury MS, Paschos NK, Fabricant PD, Anderson CN, Busch MT, Chambers HG, Christino MA, Cordasco FA, Edmonds EW, Ganley TJ, Green DW, Heyworth BE, Lawrence JTR, Matava MJ, Micheli LJ, Milewski MD, Nepple JJ, Parikh SN, Pennock AT, Perkins CA, Saluan PM, Shea KG, Wall EJ, Willimon SC, Kocher MS. Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review. Am J Sports Med 2022; 50:1430-1441. [PMID: 33984243 DOI: 10.1177/03635465211008656] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. PURPOSE To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. RESULTS A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. CONCLUSION This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. REGISTRATION CRD42019136059 (PROSPERO).
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Affiliation(s)
- Matthew S Fury
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nikolaos K Paschos
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter D Fabricant
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | -
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christian N Anderson
- Tennessee Orthopaedic Alliance, Nashville, Tennessee, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael T Busch
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry G Chambers
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melissa A Christino
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Frank A Cordasco
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel W Green
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - J Todd R Lawrence
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew D Milewski
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shital N Parikh
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Crystal A Perkins
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul M Saluan
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Garfield Heights, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin G Shea
- Department of Orthopedic Surgery, Stanford University, Stanford, California, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric J Wall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel C Willimon
- Children's Healthcare of Atlanta, Children's Orthopaedics of Atlanta, Atlanta, Georgia, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Boston Children's Hospital, Division of Sports Medicine, Department of Orthopaedics, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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13
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Sanborn RM, Badger GJ, Yen YM, Murray MM, Christino MA, Proffen B, Sant N, Barnett S, Fleming BC, Kramer DE, Micheli LJ. Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial. Orthop J Sports Med 2022; 10:23259671211070542. [PMID: 35155707 PMCID: PMC8832603 DOI: 10.1177/23259671211070542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Previous clinical studies have shown that psychological factors have
significant effects on an athlete’s readiness to return to sport after
anterior cruciate ligament (ACL) reconstruction (ACLR). Hypothesis: We hypothesized that patients who underwent bridge-enhanced ACL restoration
(BEAR) would have higher levels of psychological readiness to return to
sport compared with patients who underwent ACLR. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients (median age, 17 years; median preoperative Marx
activity score, 16) with complete midsubstance ACL injuries were randomized
to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33
hamstring and 2 bone--patellar tendon—bone]) and underwent surgery within 45
days of injury. Objective, functional, and patient-reported outcomes,
including the ACL--Return to Sport after Injury (ACL-RSI) scale, were
assessed at 6, 12, and 24 months postoperatively. Results: Patients who underwent the BEAR procedure had significantly higher ACL-RSI
scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2;
P = .008); scores were similar at 12 and 24 months.
Baseline factors independently predictive of higher ACL-RSI scores at 6
months were having a BEAR procedure and participating in level 1 sports
prior to injury, explaining 15% of the variability in the scores. Regression
analysis of baseline and 6-month outcomes as predictors indicated that the
International Knee Documentation Committee (IKDC) score at 6 months
explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC
excluded from the model indicated that decreased pain, increased hamstring
and quadriceps strength in the surgical limb, and decreased side-to-side
difference in anteroposterior knee laxity were significant predictors of a
higher ACL-RSI score at 6 months, explaining 34% of the variability in
scores. Higher ACL-RSI score at 6 months was associated with earlier
clearance to return to sports. Conclusion: Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6
months postoperatively. Better ACL-RSI scores at 6 months were related most
strongly to higher IKDC scores at 6 months and were also associated with
lower pain levels, better muscle recovery, and less knee laxity at 6
months. Registration: NCT02664545 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Ryan M. Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Melissa A. Christino
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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14
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Maguire K, Sugimoto D, Micheli LJ, Kocher MS, Heyworth BE. Recovery After ACL Reconstruction in Male Versus Female Adolescents: A Matched, Sex-Based Cohort Analysis of 543 Patients. Orthop J Sports Med 2021; 9:23259671211054804. [PMID: 34881338 PMCID: PMC8647249 DOI: 10.1177/23259671211054804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/23/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Differences in postoperative recovery after anterior cruciate ligament reconstruction (ACLR) between men and women have been demonstrated in the adult population. Sex-based differences have been incompletely investigated in adolescents, which represent the subpopulation most affected by ACL injury. Purpose/Hypothesis: The purpose of this study was to compare the 6-month postoperative functional recovery after ACLR between adolescent boys and girls. It was hypothesized that significant differences in postoperative strength, dynamic balance, and functional hop test performance would be seen between the sexes. Study Design: Cohort study; Level of evidence, 3. Methods: Included in this study were athletes aged 12 to 19 years with closed or closing growth plates who underwent ACLR with hamstring autograft between May 2014 and May 2018 at a single institution. All athletes had undergone strength and functional testing between 5 and 8 months postoperatively. Exclusion criteria were previous knee surgery (contralateral or ipsilateral knee), concomitant injury/surgery other than meniscal tear/repair, allograft supplementation, and incomplete medical records. The limb symmetry index (LSI) for strength (measured with handheld dynamometer), as well as dynamic Y-balance and functional hop test performance, was compared between groups. To account for differences in physical characteristics between the sexes, 1-way between-group multivariate analysis of covariance was used to analyze the data. Results: Overall, 543 patients (211 boys, 332 girls) were included. There was no significant difference in age, body mass index, incidence of concomitant meniscal pathology, use of regional anesthesia, or time to functional testing between cohorts. Female athletes demonstrated a statistically significantly greater deficit in quadriceps strength LSI compared with male athletes (boys, +3.4%; girls, –2.3%; P = .011). Both male and female athletes demonstrated 33% hamstring strength deficits, with no statistically significant sex-based differences in dynamic balance or functional hop testing. Conclusion: Female athletes demonstrated greater quadriceps strength deficits than male athletes at 6 months after ACLR with hamstring autograft. Severe hamstring strength deficits persisted in both male and female patients at this time point. The correlation of such deficits to risk of ACL retear warrants continued study in the adolescent population and may support a delay in return to sports, which has been suggested in the more recent literature.
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Affiliation(s)
- Kathleen Maguire
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Boston, Massachusetts, USA.,Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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15
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Kiapour AM, Flannery SW, Murray MM, Miller PE, Fleming BC, Sant N, Portilla G, Sanborn R, Freiberger C, Henderson R, Barnett S, Ecklund K, Yen YM, Kramer DE, Micheli LJ, Fleming BC. Regional Differences in Anterior Cruciate Ligament Signal Intensity After Surgical Treatment. Am J Sports Med 2021; 49:3833-3841. [PMID: 34668789 PMCID: PMC8829819 DOI: 10.1177/03635465211047554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Magnetic resonance-based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing. HYPOTHESES (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL). RESULTS For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points (P < .01) but compared with the tibial region only at 6 months (P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points (P < .01) but versus the tibial region only at 6 and 12 months (P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs (P < .01). CONCLUSION The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.
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Affiliation(s)
- Ata M. Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Martha M. Murray
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Patricia E. Miller
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Nicholas Sant
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Portilla
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Boston Children's Hospital Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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James EW, Dawkins BJ, Schachne JM, Ganley TJ, Kocher MS, Anderson CN, Busch MT, Chambers HG, Christino MA, Cordasco FA, Edmonds EW, Green DW, Heyworth BE, Lawrence JTR, Micheli LJ, Milewski MD, Matava MJ, Nepple JJ, Parikh SN, Pennock AT, Perkins CA, Saluan PM, Shea KG, Wall EJ, Willimon SC, Fabricant PD. Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:4008-4017. [PMID: 33720764 DOI: 10.1177/0363546521990817] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. PURPOSE/HYPOTHESIS The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non-English language manuscripts, multiligamentous injuries, and nonclinical studies. RESULTS A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P = .413) or proportion with difference ≥3 mm (P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. CONCLUSION Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.
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Affiliation(s)
- Evan W James
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Brody J Dawkins
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Jonathan M Schachne
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Theodore J Ganley
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Mininder S Kocher
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | -
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Christian N Anderson
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Michael T Busch
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Henry G Chambers
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Melissa A Christino
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Frank A Cordasco
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Eric W Edmonds
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Benton E Heyworth
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - J Todd R Lawrence
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Lyle J Micheli
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Matthew D Milewski
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Matthew J Matava
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Jeffrey J Nepple
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Shital N Parikh
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Andrew T Pennock
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Crystal A Perkins
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Paul M Saluan
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Kevin G Shea
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Eric J Wall
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Samuel C Willimon
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Peter D Fabricant
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
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17
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Redler LH, Sugimoto D, Bassett AJ, Kocher MS, Micheli LJ, Heyworth BE. Effect of Concomitant Meniscal Tear on Strength and Functional Performance in Young Athletes 6 Months After Anterior Cruciate Ligament Reconstruction With Hamstring Autograft. Orthop J Sports Med 2021; 9:23259671211046608. [PMID: 34778471 PMCID: PMC8573495 DOI: 10.1177/23259671211046608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The effect of concomitant meniscal tears, and their associated treatment, on strength and functional recovery after anterior cruciate ligament reconstruction (ACLR) has not been adequately investigated in young populations. Hypothesis: Concomitant meniscal tears, treated with or without repair, would not adversely affect strength, balance, or functional hop test performance at 6 months postoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed return-to-sports (RTS) assessments prospectively collected 6 months after ACLR with hamstring autograft in 165 patients ≤25 years of age. Descriptive, surgical, and RTS testing data were analyzed, and subgroups were compared using analysis of covariance models designed to assess the effects of sex, meniscal tear, and meniscal repair on RTS performance. Results: Included were 115 female (70%) and 50 male (30%) patients with a mean age of 16.4 years (range, 12.3-25 years). Of these patients, 58% had concomitant meniscal tears (59% lateral, 27% medial, 14% lateral + medial), comprising 53% of the female and 70% of the male patients. The authors treated 61% of the tears with repair, with range of motion (ROM) and weightbearing limitations imposed within the first 6 weeks postoperatively, whereas 39% were treated with partial meniscectomy, rasping, or trephination (no ROM or weightbearing restrictions). The mean deficit in hamstring strength at 6 months postoperatively was significantly greater in the meniscal tear group than in those without a tear (32.3% vs 24.6%; P = .028). The meniscal repair group had greater hamstring strength deficits than the group with meniscectomy, rasping or trephination (34.3% vs 26.2%; P = .023). Performance on dynamic balance and functional hop tests was similar among all meniscus subgroups. There were no sex-based effects on any subgroup comparisons. Conclusion: At 6 months postoperatively, both young male and young female patients who underwent ACLR with hamstring autograft demonstrated significant hamstring strength deficits compared with their nonoperative leg. The presence of a meniscal tear and subsequent repair, or its related rehabilitation restrictions, appears to have adverse effects on the postoperative recovery of hamstring strength.
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Affiliation(s)
- Lauren H Redler
- Columbia University Medical Center, Sports Medicine & Shoulder Service, New York, New York, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Faculty of Sports Sciences, Waseda University, Tokyo, Japan
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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18
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Barnett SC, Murray MM, Badger GJ, Yen YM, Kramer DE, Sanborn R, Kiapour A, Proffen B, Sant N, Fleming BC, Micheli LJ. Earlier Resolution of Symptoms and Return of Function After Bridge-Enhanced Anterior Cruciate Ligament Repair As Compared With Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211052530. [PMID: 34778483 PMCID: PMC8581796 DOI: 10.1177/23259671211052530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Bridge-enhanced anterior cruciate ligament repair (BEAR) has noninferior
patient-reported outcomes when compared with autograft anterior cruciate
ligament reconstruction (ACLR) at 2 years. However, the comparison of BEAR
and autograft ACLR at earlier time points—including important outcomes such
as resolution of knee pain and symptoms, recovery of strength, and return to
sport—has not yet been reported. Hypothesis: It was hypothesized that the BEAR group would have higher outcomes on the
International Knee Documentation Committee and Knee injury and
Osteoarthritis Outcome Score, as well as improved muscle strength, in the
early postoperative period. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients aged 13 to 35 years with complete midsubstance
anterior cruciate ligament injuries were randomized to receive a suture
repair augmented with an extracellular matrix implant (n = 65) or an
autograft ACLR (n = 35). Outcomes were assessed at time points up to 2 years
postoperatively. Mixed-model repeated-measures analyses were used to compare
BEAR and ACLR outcomes. Patients were unblinded after their 2-year
visit. Results: Repeated-measures testing revealed a significant effect of group on the
International Knee Documentation Committee Subjective Score
(P = .015), most pronounced at 6 months after surgery
(BEAR = 86 points vs ACLR = 78 points; P = .001). There was
a significant effect of group on the Knee injury and Osteoarthritis Outcome
Score-Symptoms subscale scores (P = .010), largely
attributed to the higher BEAR scores at the 1-year postoperative time point
(88 vs 82; P = .009). The effect of group on hamstring
strength was significant in the repeated-measures analysis
(P < .001), as well as at all postoperative time
points (P < .001 for all comparisons). At 1 year after
surgery, approximately 88% of the patients in the BEAR group and 76% of the
ACLR group had been cleared for return to sport (P =
.261). Conclusion: Patients undergoing the BEAR procedure had earlier resolution of symptoms and
increased satisfaction about their knee function, as well as improved
resolution of hamstring muscle strength throughout the 2-year follow-up
period. Registration: NCT02664545 (ClinicalTrials.gov identifier)
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Affiliation(s)
- Samuel C Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas Sant
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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19
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Lins LAB, Feroe AG, Yang B, Williams KA, Kocher SD, Sankarankutty S, Micheli LJ, Kocher MS. Long-term Minimum 15-Year Follow-up After Lateral Discoid Meniscus Rim Preservation Surgery in Children and Adolescents. J Pediatr Orthop 2021; 41:e810-e815. [PMID: 34411050 DOI: 10.1097/bpo.0000000000001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. The purpose of our study was to examine long-term patient-reported outcomes of lateral discoid meniscus (LDM) treated with meniscal-preserving techniques. METHODS Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and Western Ontario and McMaster University Osteoarthritis Index Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and SD, median and interquartile range (interquartile range), or frequency and percent, as appropriate. RESULTS Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (±SD) age at initial surgery was 10.8 (±3.4) and 30.3 (±3.7) years at final follow-up. The mean (±SD) follow-up time from initial surgery was 19.5 (±2.8) years (range, 16 to 27). Patient-reported outcomes included: International Knee Documentation Committee 77.4±17.2, Lysholm 78.6±21, Western Ontario and McMaster University Osteoarthritis Index 7.6±11.3, Tegner Activity 7 (of 10), and Marx Activity Rating Scale 8 (of 10). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement. CONCLUSIONS Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of LDM. While two thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with objective outcome measures are important to further elucidate the natural history of LDM and understand how rim-preserving procedures may prevent the development of degenerative processes. LEVEL OF EVIDENCE Level IV-case series, prognostic study.
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Affiliation(s)
- Laura A B Lins
- Department of Orthopaedic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Aliya G Feroe
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Brian Yang
- Hospital for Special Surgery, New York City, NY
| | - Kathryn A Williams
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital
| | | | | | - Lyle J Micheli
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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20
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Feroe AG, Hussain ZB, Stupay KL, Kocher SD, Williams KA, Micheli LJ, Kocher MS. Surgical Management of Medial Discoid Meniscus in Pediatric and Adolescent Patients. J Pediatr Orthop 2021; 41:e804-e809. [PMID: 34369475 DOI: 10.1097/bpo.0000000000001906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medial discoid meniscus (MDM) is an exceedingly rare anatomic abnormality that presents similarly to other meniscal pathologies. Symptomatic MDM is typically managed arthroscopically with mixed short-term and long-term outcomes, although the existing knowledge about MDM is limited. The purpose of this study was to describe the presentation and surgical treatment of MDM in pediatric and adolescent patients. METHODS Medical records of 12 knees with MDM in 8 pediatric and adolescent patients treated between 1991 and 2016 were reviewed retrospectively for patient characteristics, clinical manifestations, radiographic findings, operative techniques, and surgical outcomes. RESULTS Of the 446 knees diagnosed arthroscopically with discoid menisci, lateral discoid meniscus was noted in 434 knees (97.3%) and MDM was present in 12 knees (2.7%). The MDM series included 8 patients of mean age 13.8 years (range: 7.8 to 19.8), of which 5 were males (63%), and 4 (50%) had bilateral involvement. Of the 11 knees with available clinical records, all cases presented symptomatically (pain, mechanical symptoms); 10 (91%) had concurrent physical exam findings. On intraoperative examination, discoid morphologies were described as complete in 4/8 knees (50%) or incomplete in 4/8 (50%), with associated instability in 6/12 (50%). Meniscal tears were reported in 9 cases (75%)-primarily, horizontal cleavage tears. Saucerization was performed in 11 knees (92%), with medial meniscal repair in 7 (58%), when indicated. Retear of the medial meniscus occurred in 4/11 knees (36%) at a mean of 25.8 months postoperation; 2 knees required revisions. One knee developed arthrofibrosis and underwent arthroscopic lysis of adhesions. CONCLUSIONS MDM is a rare diagnosis, representing 3% of all discoid menisci, with a nonspecific clinical manifestation. Operative management of symptomatic MDM typically involves saucerization and meniscal repair, when indicated, for concurrent tears. Symptom resolution is common short-term, but long-term outcomes include recurrent meniscal tears. Subsequent observational studies are important to evaluate long-term outcomes, such as arthritic changes, with the advancement of arthroscopic techniques for meniscal preservation. LEVEL OF EVIDENCE Level IV-retrospective case series.
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Affiliation(s)
- Aliya G Feroe
- Department of Orthopaedic Surgery and Sports Medicine
- Harvard Medical School, Boston, MA
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery and Sports Medicine
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | - Kathryn A Williams
- Biostatistics and Research Design Center, ICCTR, Boston Children's Hospital
| | - Lyle J Micheli
- Department of Orthopaedic Surgery and Sports Medicine
- Harvard Medical School, Boston, MA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery and Sports Medicine
- Harvard Medical School, Boston, MA
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21
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Abstract
BACKGROUND Discoid meniscus is a congenital variant, typically involving the lateral meniscus, that comprises a spectrum of meniscal shapes and degrees of instability in an estimated 1% to 15% of the population. The purpose of this study was to describe the clinical and operative course of a large cohort of children and adolescents patients with symptomatic lateral discoid meniscus. METHODS Medical records of 470 knees with symptomatic lateral discoid meniscus in 401 patients ages 18 years or younger diagnosed at a single institution between 1991 and 2016 were reviewed retrospectively for patient characteristics, treatment course (nonoperative and/or operative), and complications. Surgical reports were reviewed in the operative group. RESULTS The series included 401 patients of mean age 11.6 years (range: 1 mo-18.9 y), of which 222 (55%) were female, and 69 (17%) had bilateral involvement. Of 470 knees, 83 (18%) were initially managed nonoperatively. Of these, 32 knees (39%) failed nonoperative management and were converted to surgical treatment at a median of 7.9 months (interquartile range: 4.0-15.1). In total, 419 knees were managed surgically with saucerization (partial meniscectomy) with or without meniscal repair/stabilization; 84 knees (20%) required at least one concurrent nonmeniscal procedure. Discoid meniscus tears were reported in 264/419 knees (63%) intraoperatively; horizontal cleavage tears were most common. Reoperation was required for 66/379 cases (17%) with clinical follow-up, at a median of 19.6 months (range: 9.2-34.9) after index saucerization; 60/379 cases (16%) had ongoing pain and/or mechanical symptoms at final follow-up. CONCLUSION With a failure rate of 39% (32/83 knees), nonoperative management for discoid lateral meniscus frequently convert to surgical treatment. During surgery, meniscus tearing and instability are common and should be anticipated. Postoperatively, 33% (126/379) of knees with clinical follow-up underwent either reoperation, or had ongoing symptoms of the knee at final follow-up. Discoid mensical retear is the most common complication (94%, 62/66) prompting repeat surgery, and should be discussed with families before the index operation. LEVEL OF EVIDENCE Level IV-descriptive case series.
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Affiliation(s)
| | - Frances A Tepolt
- Department of Family Medicine, University of Minnesota, Minneapolis, MN
| | | | - Aliya G Feroe
- Harvard Medical School
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, MA
| | - Lyle J Micheli
- Harvard Medical School
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, MA
| | - Mininder S Kocher
- Harvard Medical School
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, MA
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22
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Micheli LJ, Solomon R, Solomon J, Gearhart M, Parmeter R, Sugimoto D. Posterior Ankle Decompression With Os Trigonum or Stieda Process Resection in Dancers: Case Series Report and Review of the Literature. J Foot Ankle Surg 2021; 60:706-711. [PMID: 33839009 DOI: 10.1053/j.jfas.2020.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/12/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
This case series reports the outcome of posterior ankle decompression and os trigonum or Stieda process resection utilizing an open posterolateral approach in 54 professional, pre-professional, and dedicated recreational dancers. All procedures were performed by a single surgeon at the same facility between 2008 and 2018. The surgical technique is described in detail. Data related to results of the surgery were gathered via follow-up questionnaire and verified by referencing the patients' medical records. Outcomes were self-assessed in terms of categories ranging from excellent through moderate to poor. Eighty-nine percent of the dancers (N = 48 of 54) chose excellent or good, 11% (N = 6) chose moderate, and none selected poor. These results were compared with those achieved in 17 previous studies reporting the use of both open (posterolateral and posteromedial) and arthroscopic/endoscopic techniques in dancers. This comparison found similarly favorable reported outcomes, but also great variation in methodology for determining patient reported outcomes (PROs). While the preferred surgical technique for posterior ankle decompression remains controversial, the open posterolateral approach utilized in this series resulted in high expectation of return to dance with minimal complications. The need for a dancer-specific PRO tool is discussed.
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Affiliation(s)
- Lyle J Micheli
- Director Emeritus, Division of Sports Medicine, Boston Children's Hospital, Boston, MA; Professor of Orthopaedic Surgery, Part Time, Harvard Medical School, Boston, MA
| | - Ruth Solomon
- Professor Emerita, University of California, Santa Cruz, CA; Honorary Fellow, Division of Sports Medicine, Boston Children's Hospital, Boston, MA.
| | - John Solomon
- Editor-in-Chief, Journal of Dance Medicine & Science, Soquel, CA
| | - Marina Gearhart
- Program/Research Coordinator, Division of Sports Medicine, Children's Hospital, Boston, MA; ARFID Program
- Department of GI/Nutrition, Boston Children's Hospital, Boston, MA
| | - Rebecca Parmeter
- Director of Research, Sports Medicine Division, The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Walthan, MA
| | - Dai Sugimoto
- Research Statistician, Sports Medicine Division, The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Walthan, MA
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Kowalczyk AD, Geminiani ET, Dahlberg BW, Micheli LJ, Sugimoto D. Pediatric and Adolescent Figure Skating Injuries: A 15-Year Retrospective Review. Clin J Sport Med 2021; 31:295-303. [PMID: 30985309 DOI: 10.1097/jsm.0000000000000743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To analyze the characteristics of injuries sustained by young figure skaters who were evaluated at regional pediatric sports medicine clinics. DESIGN Retrospective chart review (2003-2017). SETTING Sports medicine clinics at a tertiary-level pediatric medical center. PATIENTS Two hundred ninety-four figure skaters (271 female and 23 male). Age rage: 9 to 19 years. Mean age: 14.2 ± 2.3 years. INTERVENTIONS None. MAIN OUTCOME MEASURES Mechanism of injury (acute vs overuse), injured body areas, diagnoses for most commonly injured body areas, and distribution of bone stress injuries. RESULTS Eight hundred sixty-four figure skating-related injuries were identified. Approximately 68.9% were overuse and 31.1% were acute. In female figure skaters, the most frequently injured body areas were foot/ankle (29.6%), knee (19.3%), and back (15.8%). In male figure skaters, they were foot/ankle (25.4%), hip (16.4%), and knee (14.9%). Most common diagnoses at these body areas were tendinopathy (foot/ankle), extensor mechanism (knee), and posterior column bone stress injuries (back). All injuries to anterior knee structures, excluding bone contusions, were categorized as extensor mechanism injuries. About 11.8% of all injuries were bone stress reactions/fractures with the majority occurring at the back (42.2%), foot/ankle (32.4%), and lower leg (15.7%). CONCLUSION Most injuries sustained by figure skaters were overuse and occurred most commonly at the foot/ankle (29.6%), knee (19.3%), and back (15.8%). Approximately 1 in 10 injuries were bone stress reactions/fractures, and nearly 1 in every 3 skaters who presented with back pain was diagnosed with a posterior column bone stress injury. Health care providers who take care of young figure skaters need to maintain a high index of suspicion for overuse injuries, especially bone stress reactions/fractures.
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Affiliation(s)
- Agnieszka D Kowalczyk
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ellen T Geminiani
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Bridget W Dahlberg
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
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L Biernacki J, Stracciolini A, Fraser J, J Micheli L, Sugimoto D. Risk Factors for Lower-Extremity Injuries in Female Ballet Dancers: A Systematic Review. Clin J Sport Med 2021; 31:e64-e79. [PMID: 30589745 DOI: 10.1097/jsm.0000000000000707] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ballet dancers have a high prevalence of injuries to the lower extremity. Many studies have investigated the relationship between dance injury and risk factors. However, risk factors for lower-extremity injury comparing recreational- and elite-level ballet dancers are scarce. OBJECTIVE To systematically review available original studies to assess risk factors for lower-extremity injury in female ballet dancers between recreational and elite ballet dancers. DATA SOURCES Five online databases [Web of Science, PubMed, OVID (Medline), EBSCO, and ProQuest] were searched systematically. STUDY SELECTION Included studies had an analytic study design published in the past 11 years and investigated an association between potential risk factors and lower-extremity injury in female ballet dancers. STUDY APPRAISAL Assessed independently by 2 reviewers using the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine. RESULTS Seventeen studies were included. Alignment was a risk factor for lower-extremity injury in both recreational and elite ballet dancers. In elite ballet dancers, poor lumbopelvic movement control, inappropriate transversus abdominis contraction, decreased lower-extremity strength, and poor aerobic fitness were risk factors for lower-extremity injury. In recreational ballet dancers, hypermobility of the hip and ankle and longer training hours were risk factors for lower-extremity injury. Mean DB score was 15.94 (SD 1.57). The majority of studies were retrospective cohort studies or had poor follow-up, with 7 level 2b studies, 6 level 3b studies (cross-sectional), and 4 level 1b studies (prospective cohort with good follow-up). CONCLUSIONS Alignment was identified as a common risk factor for recreational and elite ballet dancers. Other risk factors differed between recreational ballet dancers and elite ballet dancers. Future studies are warranted to use a prospective study design, identify dance level-specific risk factors, and implement evidence-based prevention strategies.
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Affiliation(s)
- Jessica L Biernacki
- Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Andrea Stracciolini
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Joana Fraser
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts; and
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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Heyworth BE, Zheng ET, Vavken P, Liotta ES, Kramer DE, Yen YM, Micheli LJ, Kocher MS. Early Outcomes of Adolescent ACL Reconstruction With Hybrid Hamstring Tendon Autograft-Allograft Versus Hamstring Tendon Autograft Alone. Orthop J Sports Med 2021; 9:2325967120979985. [PMID: 33553459 PMCID: PMC7841686 DOI: 10.1177/2325967120979985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Small-diameter semitendinosus-gracilis tendon autografts may be encountered intraoperatively during anterior cruciate ligament reconstruction (ACLR); these have been shown to be at increased risk of graft rupture. One option that surgeons have pursued to reduce the theoretical failure rate of these smaller-diameter grafts is augmenting them with allograft material, thereby forming a larger-diameter hybrid autograft-allograft construct. Purpose/Hypothesis: The purpose of this study was to compare outcomes in adolescent athletes of primary ACLR using a hybrid autologous hamstring tendon and soft tissue allograft construct versus ACLR using small-diameter hamstring tendon autograft. The hypothesis was that the hybrid hamstring autograft-allograft construct would provide superior short-term results. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective analysis of 47 patients aged between 12 and 20 years who underwent hybrid graft ACLR (mean diameter, 9.1 mm) at a single institution. Electronic medical records including clinic notes, radiographic images, operative notes, and pathology reports were reviewed for study analysis. A control group of 64 patients who underwent small-diameter hamstring reconstruction (mean diameter, 7.1 mm) without allograft supplementation was compiled. Corresponding clinical, radiographic, and surgical characteristics were collected for the control group to allow for comparative analysis. Results: Mean follow-up was 2.7 years for the hybrid cohort and 2.3 years for the control group. Despite a significantly larger mean graft diameter in the hybrid group as compared with the control group (P < .001), no significant difference in retear rate was seen between cohorts (hybrid, 9%; control, 13%; P = .554). Patients with hybrid anterior cruciate ligament constructs also underwent a comparable number of reoperations overall (P = .838). Functionally, all patients with adequate follow-up returned to sports, with no significant difference in time to return to sports between the groups (P = .213). Radiographically, hybrid graft constructs did not undergo a significantly larger degree of tunnel lysis (P = .126). Conclusion: A cohort of adolescents with hybrid anterior cruciate ligament grafts was shown to have retear rates and overall clinical results comparable with those of a control group that received small-diameter hamstring tendon autografts alone.
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Affiliation(s)
- Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Evan T Zheng
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Elizabeth S Liotta
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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26
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Kallini J, Micheli LJ, Miller PE, Kramer DE, Kocher MS, Heyworth BE. Operative Treatment of Bipartite Patella in Pediatric and Adolescent Athletes: A Retrospective Comparison With a Nonoperatively Treated Cohort. Orthop J Sports Med 2021; 9:2325967120967125. [PMID: 33457432 PMCID: PMC7797588 DOI: 10.1177/2325967120967125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Bipartite patella (BPP) is a developmental anomaly that forms when incomplete patellar ossification leaves a residual fibrocartilaginous synchondrosis between ossification centers. Repetitive traction forces across the synchondrosis can cause knee pain, most commonly presenting in adolescence. Symptoms frequently resolve with nonoperative management. Few surgical case series exist to guide treatment approaches for refractory pain. Purpose: To investigate the clinical features, surgical techniques, and outcomes associated with operative treatment of symptomatic BPP in pediatric and adolescent athletes and to compare features of the series with a large control group managed nonoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective medical record review was conducted of all patients aged ≤20 years who were diagnosed with symptomatic, radiologically confirmed BPP between 2003 and 2018 at a single tertiary-care pediatric hospital (N = 266). Demographic and clinical variables were analyzed, and additional radiologic and perioperative variables were collected for the surgical subcohort. Results: Of the 266 patients included, 27 were treated operatively (10.2%). When compared with those treated nonoperatively (with rest, physical therapy, cryotherapy, and anti-inflammatory medications), the operatively managed group experienced a longer duration of symptoms before first presentation (21.5 vs 7.6 months; P < .001) and were more likely to be older (mean age, 15.4 vs 12.4 years; P < .001), female (59.3% vs 35.6%; P = .03), and competitive athletes (100% vs 84.5%; P = .02). In the 27 patients treated operatively, procedures were categorized as isolated fragment excision (n = 9), fragment excision with lateral release (n = 8), isolated lateral release (n = 5), fragment screw fixation (n = 4), and synchondrosis drilling (n = 1). The mean time between surgery and return to sports was 2.2 months. Four patients (14.8%) reported residual symptoms requiring secondary surgery, including lateral release (n = 1), excision of residual fragment (n = 1), and fixation screw removal (n = 2). Conclusion: BPP can cause knee pain in adolescent athletes and is generally responsive to nonoperative treatment. Patients undergoing surgical treatment—most commonly female competitive athletes with prolonged symptoms—represented 10% of cases. A variety of surgical techniques may be effective, with a 15% risk of persistent or recurrent symptoms warranting reoperation. Prospective multicenter investigations are needed to identify optimal candidates for earlier interventions and the optimal operative treatment technique.
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Affiliation(s)
- Jennifer Kallini
- University of California Los Angeles/UCLA-Health, Los Angeles, California, USA
| | - Lyle J Micheli
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Patricia E Miller
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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27
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Croman M, Kramer DE, Heyworth BE, Kocher MS, Micheli LJ, Yen YM. Osteochondritis Dissecans of the Tibial Plateau in Children and Adolescents: A Case Series. Orthop J Sports Med 2020; 8:2325967120941380. [PMID: 32923496 PMCID: PMC7453468 DOI: 10.1177/2325967120941380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/13/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Osteochondritis dissecans (OCD) of the knee is a relatively well-known condition, most commonly arising in the femoral condyle. Lesions arising in the tibial plateau are rarely described. Purpose: To present a case series of OCD lesions of the tibial plateau. Study Design: Case series; Level of evidence, 4. Methods: Medical records and diagnostic imaging of patients <20 years of age with confirmed diagnosis of OCD of the tibial plateau from a single institution were retrospectively reviewed. Characteristic and radiographic features as well as details of both nonoperative and surgical management were investigated. Lesion characteristics and treatment outcomes were also analyzed. Results: A total of 9 lesions were identified in 9 patients (5 females, 4 males) who fit the inclusion criteria. The mean age at diagnosis was 14.2 years (range, 9-17 years). Knee pain (8/9) of longer than 1 year in duration was the most common presenting symptom. All 9 lesions were located on the lateral tibial plateau, and concomitant lateral compartment pathology was present in 5 of 9 patients (4 lateral femoral condyle OCDs, 3 lateral meniscal tears [1 discoid], and 1 discoid meniscus). Only 2 lesions were visible on initial radiographs; all 9 were visible on magnetic resonance imaging. All patients underwent initial nonoperative treatment; 2 patients demonstrated resolution of symptoms. Two patients underwent surgery for concomitant pathology, and the OCD was not addressed surgically. A total of 5 patients continued to be symptomatic after nonoperative treatment, prompting surgical intervention, which consisted of microfracture and chondroplasty in all 5 cases. A total of 2 of the 5 microfracture patients had resolution of symptoms, while another 2 patients had continued symptoms ultimately responsive to steroid injection treatment. One patient had revision microfracture, followed by autologous chondrocyte implantation and an arthroscopic lysis of adhesions. At final follow-up, ranging from 7 months to 10 years, 8 patients were asymptomatic, while 1 patient had developed early osteoarthritis. Conclusion: OCD of the tibial plateau in young patients is rare, usually involves the lateral side, and may have significant long-term implications for knee function. Presenting symptoms are often vague, and lesions may not always be visible on initial radiographs, which may lead to delayed treatment and adversely affect outcomes.
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Affiliation(s)
- Millicent Croman
- Department of General Surgery, Case Western Reserve, Cleveland, Ohio, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Sugimoto D, Whited AJ, Brodeur JJ, Liotta ES, Williams KA, Kocher MS, Micheli LJ, Heyworth BE. Long-Term Follow-up of Skeletally Immature Patients With Physeal-Sparing Combined Extra-/Intra-articular Iliotibial Band Anterior Cruciate Ligament Reconstruction: A 3-Dimensional Motion Analysis. Am J Sports Med 2020; 48:1900-1906. [PMID: 32519583 DOI: 10.1177/0363546520927399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The physeal-sparing iliotibial band (ITB) anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established technique for treating skeletally immature patients with ACL rupture. However, the long-term implications of the procedure on the intricacies of kinetic and kinematic function of the knee have not been comprehensively investigated. PURPOSE To assess the short-, mid-, and long-term effects of ITB ACLR on kinetic and kinematic parameters of knee functions. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 38 patients who had undergone an ITB ACLR as a skeletally immature child were recruited to participate in a 3-dimensional (3D) motion analysis testing protocol at an institutional injury prevention center between 1 and 20 years after reconstruction. Exclusion criteria were congenital ACL deficiency and any other major knee injury (defined as an injury requiring surgery or rehabilitation >3 months) on either knee. 3D and force plate parameters included in the analysis were knee moment, ground-reaction force, and vertical jump height measured during drop vertical jump and vertical single-limb hop. Paired t tests and equivalency analyses were used to compare the parameters between cases (ITB ACLR limb) and controls (contralateral/nonsurgical limbs). RESULTS Paired t tests showed no statistically significant differences between limbs, and equivalency analyses confirmed equivalency between limbs for all tested outcome variables. CONCLUSION The ITB ACLR appears to restore normal, symmetric, physiologic kinetic and kinematic function in the growing knee by 1 year after reconstruction, with maintenance of normal parameters for up to 20 years.
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Affiliation(s)
- Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Amy J Whited
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
| | - Jeff J Brodeur
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
| | - Elizabeth S Liotta
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathryn A Williams
- Biostatistics and Research Design Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
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29
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Sugimoto D, Heyworth BE, Carpenito SC, Davis FW, Kocher MS, Micheli LJ. Low proportion of skeletally immature patients met return-to-sports criteria at 7 Months following ACL reconstruction. Phys Ther Sport 2020; 44:143-150. [DOI: 10.1016/j.ptsp.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 01/09/2023]
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30
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Freiberger C, Kiapour AM, Liu S, Henderson RN, Barnett S, Sant NJ, Proffen BL, Fleming BC, Ecklund K, Kramer DE, Micheli LJ, Murray MM, Yen YM. Higher Physiologic Platelet Counts in Whole Blood Are Not Associated With Improved ACL Cross-sectional Area or Signal Intensity 6 Months After Bridge-Enhanced ACL Repair. Orthop J Sports Med 2020; 8:2325967120927655. [PMID: 32656289 PMCID: PMC7331772 DOI: 10.1177/2325967120927655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: A bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR) procedure places an extracellular matrix implant, combined with autologous whole blood, in the gap between the torn ends of the ligament at the time of suture repair to stimulate healing. Prior studies have suggested that white blood cell (WBC) and platelet concentrations significantly affect the healing of other musculoskeletal tissues. Purpose/Hypothesis: The purpose of this study was to determine whether concentrations of various blood cell types placed into a bridging extracellular matrix implant at the time of ACL repair would have a significant effect on the healing ligament cross-sectional area or tissue organization (as measured by signal intensity). We hypothesized that patients with higher physiologic platelet and lower WBC counts would have improved healing of the ACL on magnetic resonance imaging (MRI) (higher cross-sectional area and/or lower signal intensity) 6 months after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 61 patients underwent MRI at 6 months after bridge-enhanced ACL repair as part of the BEAR II trial. The normalized signal intensity and average cross-sectional area of the healing ligament were measured from a magnetic resonance stack obtained using a gradient echo sequence. The results were stratified by sex, and univariate and multivariate regression analyses determined significant correlations between blood cell concentrations on these 2 magnetic resonance parameters. Results: In unadjusted analyses, older age and male sex were associated with greater healing ligament cross-sectional area (P < .04) but not signal intensity (P > .15). Adjusted multivariable analyses indicated that in female patients, a higher monocyte concentration correlated with a higher ACL cross-sectional area (β = 1.01; P = .049). All other factors measured, including the physiologic concentration of platelets, neutrophils, lymphocytes, basophils, and immunoglobulin against bovine gelatin, were not significantly associated with either magnetic resonance parameter in either sex (P > .05 for all). Conclusion: Although older age, male sex, and monocyte concentration in female patients were associated with greater healing ligament cross-sectional area, signal intensity of the healing ligament was independent of these factors. Physiologic platelet concentration did not have any significant effect on cross-sectional area or signal intensity of the healing ACL at 6 months after bridge-enhanced ACL repair in this cohort. Given these findings, factors other than the physiologic platelet concentration and total WBC concentration may be more important in the rate and amount of ACL healing after bridge-enhanced ACL repair.
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Affiliation(s)
- Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata M Kiapour
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shanshan Liu
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas J Sant
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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31
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Barnett S, Badger GJ, Kiapour A, Yen YM, Henderson R, Freiberger C, Proffen B, Sant N, Trainor B, Fleming BC, Micheli LJ, Murray MM, Kramer DE. Females Have Earlier Muscle Strength and Functional Recovery After Bridge-Enhanced Anterior Cruciate Ligament Repair. Tissue Eng Part A 2020; 26:702-711. [PMID: 32589515 DOI: 10.1089/ten.tea.2020.0057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: While a sex effect on outcomes following anterior cruciate ligament (ACL) reconstruction surgery has been previously documented, less is known following bridge-enhanced ACL repair (BEAR). We hypothesized that female sex would have significantly worse early functional outcomes and higher retear rates following primary repair of the ACL enhanced with a tissue-engineered scaffold. Methods: Sixty-five patients (28 males and 37 females), age 14-35 with a complete ACL tear underwent primary repair of the ACL enhanced with a tissue-engineered scaffold (bridge-enhanced ACL repair) within 45 days of injury. International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome (KOOS) scores, as well as instrumented anteroposterior (AP) laxity through KT-1000 testing and functional outcome measures were obtained at time points up to 2 years postoperatively and compared between males and females using mixed model repeated measures analyses and chi square tests. Results: There was no significant sex difference on the postoperative IKDC Subjective Score at 3, 6, 12, or 24 months or any of the five KOOS scores at 12 and 24 months. Instrumented AP laxity testing demonstrated mean (standard deviation) side-to-side differences that were similar in the two sexes at 2 years; 1.7 (2.7) mm and 1.5 (3.7) mm in females and males, respectively, p = 0.72. At 6 months postoperatively, males had a larger deficit in hamstring strength on the operated leg (14.0% vs. 1.7%; p = 0.03) and a larger deficit in quadriceps strength on the operated leg (11.3% vs. 2.0%; p = 0.004); however, no sex difference was noted at 12 or 24 months. Females demonstrated superior single leg hop testing at 6 and 12 months ([91.3% vs. 78.1%, p = 0.001], [96.9% vs. 87.0%, p = 0.01] respectively). There were no significant sex differences on ipsilateral (males; 14.3% vs. females; 13.9%, p = 1.00) or contralateral (males; 3.6% vs. females; 2.8%, p = 1.00) ACL reinjury rates. Conclusions: Female subjects had better hamstring and quadriceps strength indices at 6 months than males as well as better hop test results at the 6 and 12-month time period. Despite this, there was no significant sex difference on patient-reported outcomes and objective AP laxity testing at time points up to 2 years postoperatively. Impact statement This is the first study comparing sex specific outcomes following the bridge-enhanced ACL repair technique (BEAR). The results of this study suggest that females have earlier recovery of both muscle strength and functional outcomes compared to their male counterparts. This is an important finding when considering future modifications to postoperative care and rehabilitation in females and males following this tissue-engineered BEAR technique.
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Affiliation(s)
- Samuel Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Ata Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Sant
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany Trainor
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopedics, Bioengineering Labs, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Barnett S, Murray MM, Liu S, Micheli LJ. Resolution of Pain and Predictors of Postoperative Opioid use after Bridge-Enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2020; 2:e219-e228. [PMID: 32548587 PMCID: PMC7283945 DOI: 10.1016/j.asmr.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/12/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose To compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription. Methods A nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined. Results The total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not. Conclusions Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients. Level of Evidence Level III, case control study (therapeutic).
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Affiliation(s)
- Samuel Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | - Shanshan Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | | | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
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Murray MM, Fleming BC, Badger GJ, Freiberger C, Henderson R, Barnett S, Kiapour A, Ecklund K, Proffen B, Sant N, Kramer DE, Micheli LJ, Yen YM. Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial. Am J Sports Med 2020; 48:1305-1315. [PMID: 32298131 PMCID: PMC7227128 DOI: 10.1177/0363546520913532] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR). HYPOTHESIS We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, -11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone-patellar tendon-bone]). Outcomes-including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength-were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit. RESULTS In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, -1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, -0.15 mm [95% CI, -1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure (P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure. CONCLUSION BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified. REGISTRATION NCT02664545 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Martha M. Murray
- Martha M. Murray, MD, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Ave, Hunnewell 2, Boston, MA 02115, USA ()
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Salzler M, Maguire K, Heyworth BE, Nasreddine AY, Micheli LJ, Kocher MS. Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners. Sports Health 2020; 12:304-309. [PMID: 32163722 DOI: 10.1177/1941738120907897] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. HYPOTHESIS Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. STUDY DESIGN Case series. LEVEL OF EVIDENCE Level 4. METHODS Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. RESULTS A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. CONCLUSION Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. CLINICAL RELEVANCE Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.
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Affiliation(s)
- Matthew Salzler
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Kathleen Maguire
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Adam Y Nasreddine
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
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Kramer DE, Kalish LA, Kocher MS, Yen YM, Micheli LJ, Heyworth BE. Complications of Bioabsorbable Tibial Interference Screws After Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Athletes. Orthop J Sports Med 2020; 8:2325967120904010. [PMID: 32154321 PMCID: PMC7045297 DOI: 10.1177/2325967120904010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Interference screw fixation using bioabsorbable implants has become the most common form of tibial-sided graft fixation in anterior cruciate ligament reconstruction (ACLR). Complications related to implant use in the pediatric and adolescent population have not been well studied. Purpose/Hypothesis: The purpose of this study was to retrospectively analyze the complications associated with tibial bioabsorbable interference screw use in adolescents after ACLR. We hypothesized that complication rates would be low (<5%) and that different screw types would have similar complication rates and clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were patients aged ≤18 years who underwent ACLR with a bioabsorbable tibial interference screw between 2000 and 2011 at a single institution. The subpopulation with screw-related symptoms or complications were identified through chart review. The following 2 outcomes were considered: screw-related symptoms and secondary surgery related to the screw. Multivariable logistic regression was used for adjusted analysis of any screw-related problem. Results: There were 925 ACLR procedures in 858 patients (mean age, 15.7 years; range, 10-18 years) who met inclusion criteria. The median follow-up period was 32.0 months. Of the 925 knees, 89 (9.6%) developed a screw-related problem. In 44 (4.8%) cases, no surgery was required; in 45 (4.9%) cases, surgery for a screw-related problem occurred at a median of 24 months postoperatively. The most common surgical indication was pain at the tibial screw site (42/45, 93%), followed by intra-articular screw issues (3/45, 7%). In adjusted analysis, ACLR procedure performed by a “low-volume” ACL surgeon was the only significant predictor identified. After screw removal surgery, 25 of 27 (93%) patients with at least 12 months of follow-up had complete resolution of screw site symptoms, 18 of 23 (78%) evaluable patients returned to sports, while 8 of 27 (30%) patients underwent additional surgeries, 7 of which were unrelated to the screw procedure. Conclusion: The rate of clinical sequelae from bioabsorbable tibial interference screws was surprisingly high, with symptoms arising after approximately 1 of 10 ACLRs in adolescents. Reoperation for these symptoms was performed in approximately 5% of the knees in the study, at a median 2 years postoperatively. Most patients were able to return to sports after screw removal surgery.
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Affiliation(s)
- Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Kalish
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Objective: To describe the evaluation, management and recovery time of hallux sesamoid fractures in young athletes.Methods: A retrospective chart review was performed in a large academic teaching institution over a 5-year period (1/1/2010-12/31/2014). All patients with a sesamoid injury were initially included. Excluded were those patients who: 1) did not receive the diagnosis of hallux sesamoid fracture, had a history of prior foot surgery, or had medical records inadequate for analysis, 2) had missing or unclear diagnostic imaging, 3) were age >21 years, or 4) did not report sports participation. Descriptive statistics were employed to analyze the data.Results: Fifty-eight patients (51 females and 7 males) with a mean age of 15.4 years (range: 9-21) were identified with a total of 59 sesamoid fractures. Dancing (37.9%), running (13.8%), and gymnastics (13.8%) were the most common sports reported among these patients. A greater number of fractures were classified as repetitive stress injuries (83.1%), rather than acute traumatic injuries (16.9%). Fractures were treated conservatively in the majority of cases (89.8%), and only six fractures (10.2%) were treated surgically. Most patients (84.7%) were able to return to sports and activities. The average time from diagnosis/start of treatment to pain-free state/cleared to return to sport was 161.4 days.Conclusion: Diagnosis of sesamoid fractures can be challenging, but overall most patients do well with conservative treatment and are able to return to sports and activities. Providers should keep sesamoid fracture in the differential when evaluating patients with pain in the area around the base of the first toe, especially in dancers, gymnasts, and runners. Understanding that the recovery from a sesamoid fracture can be a prolonged process may help patients develop realistic expectations.
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Affiliation(s)
- Cynthia J Stein
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Nathalie R Slick
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Corey J Lanois
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Bridget W Dahlberg
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Rebecca L Zwicker
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Sugimoto D, Borg DR, Brilliant AN, Meehan WP, Micheli LJ, Geminiani ET. Effect of Sports and Growth on Hamstrings and Quadriceps Development in Young Female Athletes: Cross-Sectional Study. Sports (Basel) 2019; 7:sports7070158. [PMID: 31261679 PMCID: PMC6680738 DOI: 10.3390/sports7070158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/23/2019] [Accepted: 06/25/2019] [Indexed: 11/17/2022] Open
Abstract
Context: Lower extremity muscular strength may vary by different sport participation during growth process. Objective: To investigate effect of sport participation and growth by comparing strength of the hamstrings, quadriceps, and hamstrings to quadriceps strength ratio (H:Q ratio) between young female figure skaters and soccer players. Design: Cross-sectional. Settings: Laboratory affiliated with regional sports medicine center. Participants: pediatric and adolescent female athletes. Procedures: Isometric hamstrings and quadriceps strength were measured. Main Outcome Measures: Strength of the hamstrings, quadriceps, and hamstrings to quadriceps strength ratio (H:Q ratio). Statistical Analysis: Effect of sport participation and growth was analyzed through a two-way (two sports: figure skaters and soccer players; three age groups: <12 years, 13–16 years, and >17 years) analysis of covariance. Results: Hamstrings strength was significantly greater in figure skaters than soccer players. Also, hamstring strength of 13–16 years and >17 years was higher compared to <12 years. Additionally, significantly higher H:Q ratio in figure skaters compared to soccer players. Conclusions: There is effect of growth on hamstrings strength among 13–16 years and >17 years compared to <12 years. Figure skaters showed greater hamstrings strength and H:Q ratio than female soccer players.
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Affiliation(s)
- Dai Sugimoto
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA.
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA.
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02453, USA.
| | - Dennis R Borg
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA
| | - Anna N Brilliant
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA
| | - William P Meehan
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02453, USA
| | - Lyle J Micheli
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02453, USA
| | - Ellen T Geminiani
- The Micheli Center-for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, MA 02453, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02453, USA
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West AM, d'Hemecourt PA, Bono OJ, Micheli LJ, Sugimoto D. Diagnostic Accuracy of Magnetic Resonance Imaging and Computed Tomography Scan in Young Athletes With Spondylolysis. Clin Pediatr (Phila) 2019; 58:671-676. [PMID: 30813766 DOI: 10.1177/0009922819832643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to determine diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT) scans in young athletes diagnosed with spondylolysis. A cross-sectional study was used. Twenty-two young athletes (14.7 ± 1.5 years) were diagnosed as spondylolysis based on a single-photon emission CT. Following the diagnosis, participants underwent MRI and CT scan imaging tests on the same day. The sensitivity and false-negative rate of the MRI and CT scans were analyzed. MRI test confirmed 13 (+) and 9 (-) results while CT test showed 17 (+) and 5 (-) results. The sensitivity and false-negative rate of MRI were, respectively, 59.1% (95% confidence interval [CI] = 36.7% to 78.5%) and 40.9% (95% CI = 21.5% to 63.3%). Furthermore, the sensitivity and false-negative rate of CT scan were 77.3% (95% CI = 54.2% to 91.3%) and 22.7% (95% CI = 0.09% to 45.8%). Our results indicated that CT scan is a more accurate imaging modality to diagnose spondylolysis compared with MRI in young athletes.
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Affiliation(s)
- Amy M West
- 1 Spaulding Rehabilitation Hospital, Boston, MA, USA.,2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Pierre A d'Hemecourt
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | | | - Lyle J Micheli
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Dai Sugimoto
- 2 Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA.,3 Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston MA, USA.,4 The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Murray MM, Kalish LA, Fleming BC, Flutie B, Freiberger C, Henderson RN, Perrone GS, Thurber LG, Proffen BL, Ecklund K, Kramer DE, Yen YM, Micheli LJ. Bridge-Enhanced Anterior Cruciate Ligament Repair: Two-Year Results of a First-in-Human Study. Orthop J Sports Med 2019; 7:2325967118824356. [PMID: 30923725 PMCID: PMC6431773 DOI: 10.1177/2325967118824356] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Bridge-enhanced anterior cruciate ligament repair (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with a specific extracellular matrix scaffold (the BEAR scaffold) that is placed in the gap between the torn ends of the ACL to facilitate ligament healing. Purpose/Hypothesis The purpose of this study was to report the 12- and 24-month outcomes of patients who underwent the BEAR procedure compared with a nonrandomized concurrent control group who underwent ACL reconstruction (ACLR) with an autograft. We hypothesized that the BEAR group would have physical examination findings, patient-reported outcomes, and adverse events that were similar to those of the ACLR group. Study Design Cohort study; Level of evidence, 2. Methods Ten patients underwent BEAR, and 10 underwent ACLR with a 4-stranded hamstring autograft. At 24 months, 9 of the 10 BEAR patients and 7 of the 10 ACLR patients completed a study visit. Outcomes reported included International Knee Documentation Committee (IKDC) subjective and objective results, knee anteroposterior (AP) laxity findings via an arthrometer, and functional outcomes. Results There were no graft or repair failures in the first 24 months after surgery. The IKDC subjective scores in both groups improved significantly from baseline (P < .0001) at 12 and 24 months, to 84.6 ± 17.2 in the ACLR group and to 91.7 ± 11.7 in the BEAR group. An IKDC objective grade of A (normal) was found in 44% of patients in the BEAR group and in 29% of patients in the ACLR group at 24 months; no patients in either group had C (abnormal) or D (severely abnormal) grades. Arthrometer testing demonstrated mean side-to-side differences in AP laxity that were similar in the 2 groups at 24 months (BEAR, 1.94 ± 2.08 mm; ACLR, 3.14 ± 2.66 mm). Functional hop testing results were similar in the 2 groups at 12 and 24 months after surgery. Hamstring strength indices were significantly higher in the BEAR group compared with the ACLR group (P = .0001). Conclusion In this small, first-in-human study, BEAR produced similar outcomes to ACLR with a hamstring autograft. BEAR may result in knee stability and patient-reported outcomes at 2 years sufficient to warrant longer term studies of efficacy in larger groups of patients.
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Affiliation(s)
- Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Leslie A Kalish
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Brett Flutie
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gabriel S Perrone
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Laura G Thurber
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Kramer DE, Kalish LA, Martin DJ, Yen YM, Kocher MS, Micheli LJ, Heyworth BE. Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents. Orthop J Sports Med 2019; 7:2325967118820305. [PMID: 30729144 PMCID: PMC6350150 DOI: 10.1177/2325967118820305] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Bucket-handle meniscal tears (BHMTs), which we define as vertical
longitudinal tears of the meniscus with displacement of the torn inner
fragment toward the intercondylar notch region, are a well-recognized tear
pattern. Optimizing the management of BHMTs in younger patients is
important, as preserving meniscal tissue may limit future joint
degeneration. Purpose/Hypothesis: The purpose of this study was to review the patient demographics, clinical
presentation, operative details, outcomes, and risk factors for a
reoperation associated with operatively treated BHMTs in a pediatric
population. We hypothesized that the repair of BHMTs in adolescents would
yield a higher reoperation rate than meniscectomy in our population. Study Design: Case-series; Level of evidence, 4. Methods: A departmental database was queried to identify all patients 19 years or
younger who presented with a BHMT and underwent surgery between October 2002
and February 2013. Clinical, radiological, and surgical data were
retrospectively collected, and risk factors for a reoperation and persistent
pain were assessed in all patients with longer than or equal to 6 months of
follow-up. Results: A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine
fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years
(range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most
injuries occurred during sports (203/248; 82%) and involved the medial
meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery
was performed in 103 cases (37%). Meniscal repair was performed in 181 cases
(65%) and was more common in younger patients (P = .01) and
for the lateral meniscus (P < .001). Among 185 (66%)
cases with longer than or equal to 6 months of adequate follow-up data
(which included 126 meniscal repairs [68%]), a meniscus-related reoperation
occurred in 45 (24%) cases. A reoperation related to the original BHMT
injury or surgery was more common after meniscal repair than after
meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P =
.001) and less common with concurrent ACL surgery (P =
.07), although this was not statistically significant. Among patients
injured during sports and with adequate follow-up, all but 1 patient
(176/177; 99%) returned to sports; a slower rate of return was seen in those
undergoing meniscal repair (P = .002) and concurrent ACL
surgery (P < .001). At final follow-up, 170 of 185
patients (92%) were pain free. For the 15 patients with persistent pain at
final follow-up, no identifiable risk factors for persistent pain were
identified. Conclusion: Most BHMTs in younger patients occurred in males and during sports and
affected the medial meniscus. Concurrent ACL surgery was indicated in
approximately one-third of cases and was associated with a lower reoperation
rate and slower return to sports. Two-thirds of patients underwent meniscal
repair, over two-thirds of whom did not require a reoperation during the
study period, despite the high activity levels in this age group.
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Affiliation(s)
- Dennis E Kramer
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Kalish
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel J Martin
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Tepolt FA, Bido J, Burgess S, Micheli LJ, Kocher MS. Opioid Overprescription After Knee Arthroscopy and Related Surgery in Adolescents and Young Adults. Arthroscopy 2018; 34:3236-3243. [PMID: 30396797 DOI: 10.1016/j.arthro.2018.07.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the number of opioids prescribed with the amount of pain medication required after knee arthroscopy and related surgery in adolescent and young adult patients to determine the effectiveness of current pain-control practices at a single institution. The secondary purpose was to determine what demographic or surgical factors are associated with increased opioid intake. METHODS Adolescent and young adult patients who underwent knee arthroscopy and related surgery, including ligament reconstruction or tibial tubercle osteotomy, between May and August 2016 were provided pain-control logbooks in which they were asked to maintain a record of daily pain medication intake. The outcome of the study was defined as the total number of opioids consumed per patient. RESULTS One hundred patients returned completed logbooks, 56% of whom were female patients. The average age was 17.54 years (standard deviation [SD], 3.51 years). Most patients underwent an open procedure concurrent with knee arthroscopy (60%), underwent nerve block placement (51%), and underwent injection of local anesthesia (91%). Use of both intravenous acetaminophen and ketorolac during the perioperative period was also common (41%). Patients were prescribed an average of 50.98 oxycodone pills (SD, 12.50 pills) and reported consuming an average of 16.52 pills (SD, 13.94 pills), approximately 32.4% of those prescribed. Eleven percent never consumed opioids, and only 1 patient requested a refill during the 21-day postoperative period. Multivariate analysis showed that increased weight, longer surgery time, and increased diazepam use were most closely associated with increased opioid consumption. CONCLUSIONS After knee arthroscopy and related surgery, including ligament reconstruction or tibial tubercle osteotomy, adolescent and young adult patients are commonly overprescribed opioids, consuming on average only approximately one-third of those prescribed. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Frances A Tepolt
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, U.S.A
| | - Jennifer Bido
- Harvard Medical School, Boston, Massachusetts, U.S.A.; Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A
| | - Stephanie Burgess
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, U.S.A
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, U.S.A.; Harvard Medical School, Boston, Massachusetts, U.S.A.; The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, U.S.A
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children's Hospital, Boston, U.S.A.; Harvard Medical School, Boston, Massachusetts, U.S.A.; Harvard T.H. Chan School of Public Health, Boston, MA, U.S.A..
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Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ. Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. J Bone Joint Surg Am 2018; 100:1087-1094. [PMID: 29975275 DOI: 10.2106/jbjs.17.01327] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are occurring in youth athletes with increasing frequency. Many ACL reconstruction procedures designed to allow for continued growth in patients with open physes have been described, but large series with mid- to long-term outcomes data are lacking. The purpose of the current study was to assess the clinical outcomes of a large cohort of prepubescent children who underwent a physeal-sparing, combined intra- and extra-articular ACL reconstruction with iliotibial (IT) band autograft over a 23-year period. METHODS Included in our analysis were 237 patients (240 knees) who underwent ACL reconstruction using IT band autograft at Tanner stage 1 or 2 (mean age of 11.2 ± 1.7 years). Physical examination data were analyzed for 225 of the 240 knees (mean follow-up, 25.8 months), and 137 (57%) of the knees had corresponding patient-reported clinical outcomes (patient-reported graft rupture and Pediatric International Knee Documentation Committee [Pedi-IKDC], Tegner activity scale, and Lysholm scores; mean follow-up, 6.2 years). Rates of growth arrest, IT band graft-harvest morbidity, and return to sports were analyzed. RESULTS Physical examination revealed that 96.8% of the knees were grade A on the Lachman test and 98.8% were grade A on the pivot-shift test. Graft rupture occurred in 9 (6.6%) of 137 knees, at an average of 33.5 months (range, 8.2 months to 8.0 years) postoperatively. For patients who did not sustain a graft rupture, the mean Pedi-IKDC score was 93.3 ± 11.0, the mean Lysholm score was 93.4 ± 9.9, and the mean score on the Tegner activity scale was 7.8 (mode, 7). While lateral thigh asymmetry at the IT band harvest site was noted by 48% of the subjects, only 1.6% reported associated pain. No cases of limb-length discrepancy or angular deformity were observed. CONCLUSIONS This procedure was associated with excellent functional outcomes, minimal risk of growth disturbance, and a low graft-rupture rate in skeletally immature prepubescent children. These results appear durable at mid- to long-term follow-up, at an average of >6 years postoperatively. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Context: As the popularity and technical demands of figure skating increase, so will the number of athletes presenting with sport-related problems. Evidence Acquisition: Searches were performed across PubMed from 1980 to 2017. The keywords searched were skating, skaters, incidence, and injuries. The search was limited to English-language articles and human participants. Relevant articles were cross-referenced. Study Design: Clinical review. Level of Evidence: Level 5. Results: Previous studies suggest an increase in incidence of figure skating injuries from 1982 to 2003. When combining all disciplines of figure skating, there is a similar proportion of acute and overuse injuries. Within disciplines, overuse injuries appear to be more common in singles skating, while acute injuries are more common in pairs skating, ice dancing, and synchronized skating. Lower extremity injuries are more common than upper extremity injuries in all disciplines, and pairs skating accounts for the majority of upper extremity injuries. Ankle sprains are the most common skating injury, and patellar tendinitis is the most common overuse injury across all disciplines. Stress fractures are the most common overuse injury in female singles skaters. Conclusion: The predominance of overuse injuries in singles disciplines reflects their increasing technical difficulty, with more difficult jumps and longer training hours. Partner disciplines are more likely to involve acute injuries and upper extremity injuries due to high-risk throws and lifts. Emphasis should be placed on properly fitting skating boots, intrinsic foot and ankle strengthening, and lower extremity flexibility, which may prevent many of the common lower extremity and back injuries in figure skating.
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Affiliation(s)
- Julie S Han
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ellen T Geminiani
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopaedics, Boston Children's Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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Sugimoto D, Heyworth BE, Collins SE, Fallon RT, Kocher MS, Micheli LJ. Comparison of Lower Extremity Recovery After Anterior Cruciate Ligament Reconstruction With Transphyseal Hamstring Versus Extraphyseal Iliotibial Band Techniques in Skeletally Immature Athletes. Orthop J Sports Med 2018; 6:2325967118768044. [PMID: 29780839 PMCID: PMC5954349 DOI: 10.1177/2325967118768044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The influence of graft type on recovery after anterior cruciate ligament reconstruction (ACLR) has not been adequately studied in pediatric patients. Purpose To describe lower extremity functional recovery parameters at the 6-month mark after ACLR across 3 distinct groups of skeletally immature patients: pediatric male patients with transphyseal hamstring grafts (PM-HS), pediatric female patients with transphyseal hamstring grafts (PF-HS), and pediatric male patients with extraphyseal iliotibial band grafts (PM-ITB). Study Design Cohort study; Level of evidence, 3. Methods Thigh circumference, knee range of motion, lower extremity strength, dynamic balance, and hop test performance were assessed in all patients 6 months postoperatively. All participants were ≤15 years of age with open physes. The limb symmetry index was used to compare deficits between the operated and uninvolved limbs for all 3 groups (PM-HS, PF-HS, and PM-ITB). Analysis of variance with post hoc correction was employed. Results A total of 93 pediatric patients who underwent ACLR (PM-HS: n = 21 [mean age, 13.6 ± 1.0 years]; PF-HS: n = 33 [mean age, 13.4 ± 0.7 years]; PM-ITB: n = 39 [mean age, 12.5 ± 1.3 years]) were examined. There was no statistically significant difference in thigh circumference, range of motion, dynamic balance, or hop test performance between the groups. Of the various additional comparisons analyzed, there were statistical differences in hamstring strength deficits among the 3 groups (P = .004). The PM-HS group showed a greater hamstring strength deficit (-32.2% relative to healthy limb) than the PM-ITB group (-5.4% relative to healthy limb) (P = .012). The hamstring strength deficit of the PF-HS group (-18.7% relative to healthy limb) was less than that of the PM-HS group and greater than that of the PM-ITB group but not statistically significant in either case. Conclusion Significant hamstring strength deficits were detected in the PM-HS group compared with the PM-ITB group at 6 months following ACLR. Such findings may influence decisions regarding graft selection, timing of return to sports, and postoperative rehabilitation regimens.
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Affiliation(s)
- Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton E Heyworth
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara E Collins
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan T Fallon
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Boston Children's Hospital, Waltham, Massachusetts, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Fabricant PD, Yen YM, Kramer DE, Kocher MS, Micheli LJ, Lawrence JTR, Ganley TJ, Heyworth BE. Fixation of Traumatic Chondral-Only Fragments of the Knee in Pediatric and Adolescent Athletes: A Retrospective Multicenter Report. Orthop J Sports Med 2018; 6:2325967117753140. [PMID: 29450207 PMCID: PMC5808975 DOI: 10.1177/2325967117753140] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: While traditional biological principles have suggested that fragments consisting of cartilage alone cannot be reaffixed to bone with expectable long-term healing, case reports of successful healing after fixation in younger patients indicate that this concept remains incompletely explored. Purpose: To evaluate the presenting features, techniques, healing rates, and clinical and radiological results in a cohort of pediatric and adolescent athletes who underwent fixation of traumatic chondral-only fragments in the knee. Study Design: Case series; Level of evidence, 4. Methods: Patient registries at 2 tertiary care children’s hospitals were reviewed to identify patients ≤18 years old who underwent fixation of a “chondral-only” fragment in the knee, defined as the inability to visualize the fragment on injury radiographs or discern bone on the articular portion of a fragment intraoperatively. The mechanism of injury, fragment features, fixation technique, and postoperative clinical course, including timing of sports clearance, healing on postoperative magnetic resonance imaging (MRI), and any complications or reoperations, were assessed. Results: Fifteen patients with a median age at surgery of 12.7 years (interquartile range [IQR], 11.7-14.2 years) and median follow-up of 12.0 months (IQR, 6.0-19.2 months) were analyzed. All patients sustained an acute knee injury before surgery. The injured sites, as assessed on MRI, were the patella (n = 6), trochlea (n = 5), and lateral femoral condyle (n = 4). The median fragment surface area was 492.0 mm2 (IQR, 400.0-787.5 mm2). Fixation with bioabsorbable implants was performed in all patients at a median of 1.6 weeks (IQR, 1.0-2.6 weeks) after the injury. One patient (7%) sustained a fall 8 weeks postoperatively, requiring secondary surgery for excision of a dislodged fragment, and 1 patient (7%) underwent unrelated patellar stabilization surgery 3.4 years postoperatively, at which time the fragment was found to be stable. MRI was performed in 9 of 14 patients with retained fragments (median, 12.0 months postoperatively), with 5 patients (56%) showing restoration of the cartilage contour and the resolution of subchondral edema; 2 patients showed thinning but intact cartilage, 1 had cartilage thickening, and 1 had subchondral edema, fissuring, and cystic changes. The median time to return to sports for all 15 patients was 26.0 weeks (IQR, 22.8-40.9 weeks), including 2 patients who required second surgery and returned to sports at 26.1 and 191.1 weeks. Conclusion: Fixation of traumatic chondral-only fragments using bioabsorbable implants may result in successful short-term healing in the majority of pediatric and adolescent athletes.
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Affiliation(s)
- Peter D Fabricant
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Yi-Meng Yen
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - J Todd R Lawrence
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J Ganley
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benton E Heyworth
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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West AM, d'Hemecourt PA, Bono OJ, Micheli LJ, Sugimoto D. Poster 50: Diagnostic Accuracy of CT and MRI in Young Athletes with Spondylolysis. PM R 2017. [DOI: 10.1016/j.pmrj.2017.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Amy M. West
- Spaulding Rehab Hosp/Harvard Med Schl, Charlestown, Massachusetts, United States
| | | | - Olivia J. Bono
- Spaulding Rehab Hosp/Harvard Med Schl, Charlestown, Massachusetts, United States
| | - Lyle J. Micheli
- Spaulding Rehab Hosp/Harvard Med Schl, Charlestown, Massachusetts, United States
| | - Dai Sugimoto
- Spaulding Rehab Hosp/Harvard Med Schl, Charlestown, Massachusetts, United States
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Abstract
CONTEXT Injury data on hip and groin injuries vary, and these injuries are often misrepresented or overlooked for more commonly seen injuries, such as those to the foot and ankle. OBJECTIVE To provide a systematic review of the injury rates of hip and groin pathology in dancers and look to establish a better understanding of the occurrence of hip and groin injuries in the dancer population. DATA SOURCES A literature search was performed using PubMed and CINAHL databases for articles published between 2000 and 2016. STUDY SELECTION Inclusion criteria consisted of (1) documentation of the number of hip and/or groin injuries, (2) study population consisting of dancers whose training included some level of ballet, and (3) studies of levels 1 through 3 evidence. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 3. DATA EXTRACTION A single reviewer identified studies that met the inclusion criteria. The number of overall injuries, hip/groin injuries, study participants, injured participants, training hours per week, mean age of study group, injury definition, injury reporting method, and study time frame were extracted. RESULTS Thirteen unique studies were included in the descriptive analysis. Of the 2001 dancers included in this study, 3527 musculoskeletal injuries were seen in 1553 dancers. Of these, 345 injuries were localized to the hip and groin region (overall rate, 17.2%). An incidence rate of 0.09 hip and groin injuries per 1000 dance-hours was seen in the selected cohort studies. Of 462 professional dancers, 128 hip/groin injuries were recorded, for an injury rate of 27.7%. Of the 1539 student dancers, 217 hip/groin injuries were recorded, for an injury rate of 14.1% ( P < 0.01). CONCLUSION Data on hip and groin injuries have many limitations. However, these injuries represent an important health issue for dancers of all skill levels, encompassing 17.2% of musculoskeletal injuries seen in dancers. An increasing rate of hip/groin injuries is seen in professional dancers compared with students.
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Affiliation(s)
- Natasha Trentacosta
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lyle J Micheli
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Abstract
As more children and adolescents participate in competitive organized sports, there has been an increase in the reported incidence of anterior cruciate ligament (ACL) injuries in these age groups. ACL injuries in skeletally immature athletes present a challenge, as reconstruction must preserve the physis of the distal femur and of the proximal tibia to avoid growth disturbances. Historically, a skeletally immature athlete with an ACL injury was treated with a brace and activity modification until skeletal maturity, with ACL reconstruction being performed at that time in the “non-copers” who experienced instability. More recently, evidence has shown that delayed reconstruction may lead to increased damage to the meniscus and articular cartilage. As a result, early reconstruction is favored to protect the meniscus and allow continued physical activity. While adolescents at or those near skeletal maturity may be treated with standard reconstruction techniques, they may result in growth disturbances in younger athletes with significant growth remaining. In response to the growing need for ACL reconstruction techniques in skeletally immature individuals, physeal-sparing and physeal-respecting reconstruction techniques have been developed. In addition to the advancements in surgical technique, ACL injury prevention has also gained attention. This growing interest in ACL prevention is in part related to the high risk of ACL re-tear, either of the ACL graft or of the contralateral ACL, in children and adolescents. Recent reports indicate that well-designed neuromuscular training programs may reduce the risk of primary and subsequent ACL injuries.
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Affiliation(s)
- Pamela J Lang
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Sugimoto D, Stracciolini A, Dawkins CI, Meehan WP, Micheli LJ. Implications for Training in Youth: Is Specialization Benefiting Kids? Strength Cond J 2017. [DOI: 10.1519/ssc.0000000000000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lloyd RS, Cronin JB, Faigenbaum AD, Haff GG, Howard R, Kraemer WJ, Micheli LJ, Myer GD, Oliver JL. National Strength and Conditioning Association Position Statement on Long-Term Athletic Development. J Strength Cond Res 2016; 30:1491-509. [PMID: 26933920 DOI: 10.1519/jsc.0000000000001387] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There has recently been a growing interest in long-term athletic development for youth. Because of their unique physical, psychological, and social differences, children and adolescents should engage in appropriately prescribed exercise programs that promote physical development to prevent injury and enhance fitness behaviors that can be retained later in life. Irrespective of whether a child is involved in organized sport or engages in recreational physical activity, there remains a need to adopt a structured, logical, and evidence-based approach to the long-term development of athleticism. This is of particular importance considering the alarmingly high number of youth who fail to meet global physical activity recommendations and consequently present with negative health profiles. However, appropriate exercise prescription is also crucial for those young athletes who are physically underprepared and at risk of overuse injury because of high volumes of competition and an absence of preparatory conditioning. Whether the child accumulates insufficient or excessive amounts of exercise, or falls somewhere between these opposing ends of the spectrum, it is generally accepted that the young bodies of modern day youth are often ill-prepared to tolerate the rigors of sports or physical activity. All youth should engage in regular physical activity and thus should be viewed as "athletes" and afforded the opportunity to enhance athleticism in an individualized, holistic, and child-centered manner. Because of emerging interest in long-term athletic development, an authorship team was tasked on behalf of the National Strength and Conditioning Association (NSCA) to critically synthesize existing literature and current practices within the field and to compose a relevant position statement. This document was subsequently reviewed and formally ratified by the NSCA Board of Directors. A list of 10 pillars of successful long-term athletic development are presented, which summarize the key recommendations detailed within the position statement. With these pillars in place, it is believed that the NSCA can (a) help foster a more unified and holistic approach to long-term athletic development, (b) promote the benefits of a lifetime of healthy physical activity, and
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Affiliation(s)
- Rhodri S Lloyd
- 1Youth Physical Development Unit, School of Sport, Cardiff Metropolitan University, Cardiff, United Kingdom; 2Sports Performance Research Institute New Zealand, AUT University, Auckland, New Zealand; 3Center for Exercise and Sport Science Research, Edith Cowan University, Joondalup, Australia; 4Department of Health and Exercise Science, The College of New Jersey, Ewing, New Jersey; 5Department of Kinesiology, West Chester University, West Chester, Pennsylvania; 6Department of Human Sciences, The Ohio State University, Columbus, Ohio; 7Department of Orthopaedics, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts; 8Harvard Medical School, Boston, Massachusetts; 9The Micheli Center for Sports Injury Prevention, Boston, Massachusetts; 10Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; 11Department of Pediatrics and Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and 12Department of Orthopaedics, University of Pennsylvania, Philadelphia, Pennsylvania
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