Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database

BACKGROUND

Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy.

PURPOSE

To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete).

RESULTS

In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair.

CONCLUSION

To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

Reliability of Radiographic Imaging Characteristics for Osteochondritis Dissecans of the Capitellum

BACKGROUND

A primary challenge in the treatment of capitellar osteochondritis dissecans (OCD) is accurate imaging assessment. Radiographic classification consensus is not available in the current literature, and correlation of radiographs with lesion stability and resultant best treatment is lacking.

PURPOSE

To determine the inter- and intrarater reliability of the presence or absence and common radiographic characteristics of capitellar OCD lesions.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Anteroposterior, lateral, and oblique radiographs for 29 cases were reviewed by 7 orthopaedic surgeons. Images were assessed for elbow anthropometry and morphology, OCD presence, lesion characteristics, the presence of progeny bone and progeny features, and radial head abnormalities. Intra- and interrater reliability was assessed using Fleiss and Cohen kappa for nominal variables and intraclass correlation coefficients (ICCs) for continuous variables.

RESULTS

Surgeons demonstrated substantial to excellent inter- and intrarater reliability when assessing elbow characteristics: anthropometric (interrater ICC, 0.94-0.99; intrarater ICC, 0.82-0.96) and morphologic (Fleiss, 0.61-0.76; Cohen, 0.68). When the OCD lesion was assessed, fair to moderate interrater agreement was found for classifying the absence or presence of a lesion (Fleiss, 0.28-0.46) and the location of the OCD (Fleiss, 0.24-0.52), poor agreement for assessing the contour of the lesion (Fleiss, 0.00-0.09), and excellent agreement for measuring the size of the lesion (ICC, 0.82-0.94). Poor to fair interrater agreement was found for radial head abnormalities (Fleiss, 0.00-0.27). Progeny bone visualization and fragmentation demonstrated moderate interrater agreement (Fleiss, 0.43-0.47) where displacement of the bone demonstrated poor interrater agreement (Fleiss, 0.11-0.16). Intrarater agreement for OCD lesion characteristics, progeny bone visualization, and progeny bone features was moderate to excellent.

CONCLUSION

Given only the fair to moderate agreement among raters for identifying OCD on radiographs, this imaging modality may not serve as a dependable screening tool in isolation. Additional imaging should be obtained if the clinical presentation suggests capitellar OCD and a definitive diagnosis is not possible with radiographs. However, clinicians can reliability measure the size of radiographically apparent OCD, suggesting that radiographs may serve as an appropriate imaging modality for follow-up care.

The Challenges of Treating Female Soccer Players With ACL Injuries: Hamstring Versus Bone-Patellar Tendon-Bone Autograft

Background:

Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear.

Purpose/Hypothesis:

To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort.

Study Design:

Case series; Level of evidence, 4.

Methods:

We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport.

Results:

Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection.

Conclusion:

Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

Subtle Cognitive Decline predicts progression to Mild Cognitive Impairment Above and Beyond Alzheimer’s Disease Risk Factors

Objective

Early identification of those at risk for mild cognitive impairment (MCI) and Alzheimer’s disease (AD) is critical for early intervention. Recent work shows that subtle cognitive decline (SCD), operationally-defined using sensitive neuropsychological scores, predicts progression to MCI/AD and is associated with AD biomarkers. We aimed to determine whether SCD adds unique value in predicting progression to MCI/AD above and beyond other AD risk factors.

Method

547 cognitively unimpaired participants from the Alzheimer’s Disease Neuroimaging Initiative (359 without SCD; 188 with SCD) underwent neuropsychological testing and lumbar puncture. Participants were classified as SCD if they performed >1 SD below the demographically-adjusted mean on 1) two neuropsychological total scores in different cognitive domains, or 2) two memory test process scores (e.g., intrusion errors), or 3) one total score and one process score. Cox regressions examined whether SCD status predicted progression to MCI and AD within 5 years after adjusting for age, education, sex, MMSE, depressive symptoms, ischemia risk, apolipoprotein E genotype, and AD biomarker “positivity” based on the cerebrospinal fluid phosphorylated tau-to-β-amyloid ratio.

Results

SCD status predicted progression to MCI (HR = 2.74, 95% CI = 2.07-3.63, p < .001) and AD (HR = 2.20, 95% CI = 1.04-4.65, p = .04) within 5 years, even after including known AD risk factors in the model.

Conclusion

SCD conveys a 2-3 fold increased risk of progression to MCI/AD and is a unique predictor above and beyond risk factors that are commonly used in preclinical AD research. These findings support our novel SCD criteria as a cost-effective and non-invasive method for identifying those at risk for future cognitive decline.

Outcomes of Revision Anterior Cruciate Ligament Surgery in Adolescents

BACKGROUND

Although primary anterior cruciate ligament (ACL) reconstructions have been well studied in children and adolescents, the literature lacks information about revision ACL reconstructions in this population.

PURPOSE

This study aims to analyze the outcomes of revision ACL surgeries in the pediatric population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective study was performed on all revision ACL reconstructions performed at a single institution between 2009 and 2017. Patient demographic, injury, and operative data from both the initial surgery and the revision were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity score, visual analog scale for pain, Hospital for Special Surgery Pediatric Functional Activity Brief Scale score, patient satisfaction, ability to return to the same level of sport, and any additional injury and/or surgery. Outcomes of the revision surgeries were compared with our institution's outcome database of primary ACL reconstructions.

RESULTS

During the study period, 60 revision ACL reconstructions were performed in 57 patients. Of these patients, 84% (n = 48) were available for a minimum 2-year follow-up and a mean follow-up of 4.4 years. A greater number of meniscal tears and cartilage injuries were documented in the revision cohort. Compared with the primary cohort, the revision cohort had lower SANE scores, Lysholm scores, and satisfaction. Furthermore, the revision cohort had a higher rate of graft failure than the primary cohort (21% vs 9%, respectively; P = .015), and only 27% of revision patients returned to the same level of sport. In a comparison of revision procedures performed with autograft versus allograft tissue, the autograft patients had higher Lysholm scores than the allograft patients (91 vs 83, respectively; P = .045) and trended toward a lower failure rate (11% vs 27%, respectively; P = .199).

CONCLUSION

Adolescent patients undergoing revision ACL reconstruction had more meniscal and cartilage abnormalities, poorer functional outcomes, and higher graft failure rates than patients undergoing primary ACL reconstructions. Additionally, revision procedures performed with allograft tissue resulted in lower Lysholm scores and a trend toward higher failure rates. When an ACL graft fails in a young patient, strong consideration should be given to using autograft tissue for the revision.

A highly immunogenic trivalent T cell receptor peptide vaccine for multiple sclerosis

Background: T cell receptor (TCR) peptide vaccination is a novel approach to treating multiple sclerosis (MS). The low immunogenicity of previous vaccines has hindered the development of TCR peptide vaccination for MS. Objective: To compare the immunogenicity of intramuscular injections of TCR BV5S2, BV6S5 and BV13S1 CDR2 peptides in incomplete Freund’s adjuvant (IFA) with intradermal injections of the same peptides without IFA. Methods: MS subjects were randomized to receive TCR peptides/IFA, TCR peptides/saline or IFA alone. Subjects were on study for 24 weeks. Results: The TCR peptides/IFA vaccine induced vigorous T cell responses in 100% of subjects completing the 24-week study (9/9) compared with only 20% (2/10) of those receiving the TCR peptides/saline vaccine (P =0.001). IFA alone induced a weak response in only one of five subjects. Aside from injection site reactions, there were no significant adverse events attributable to the treatment. Conclusions: The trivalent TCR peptide in IFA vaccine represents a significant improvement in immunogenicity over previous TCR peptide vaccines and warrants investigation of its ability to treat MS.

Age- and sex-related variation in song-control regions in Cassin's finches, Carpodacus cassinii

Male Cassin's finches (Carpodacus cassinii) sing long, complex songs that incorporate many elements mimicked from other species. Although one-year-old males (males in their first breeding season) are sexually competent and do breed, they sing a simpler song (fewer syllable types) than do males two or more years old (called after-second-year males). Females do occasionally sing, but with much less stereotypy and complexity than breeding males of any age. We collected brains from free-living breeding after-second-year males (identified by their red plumage), one-year-old males (identified by their female-like brown plumage), and adult females to examine sex- and age-related differences in three song-control nuclei: HVC, Area X and RA. Nuclei volumes were reconstructed by measuring the Nissl-defined area in every second section. There was a large sex difference in all three nuclei, with female volumes 40-50% that of males. There was no difference in HVC volume between age classes of males. However, one-year-old (brown) males had significantly larger Area X volume than did the older (red) males, with red males' Area X about 75% the volume of brown males'. These data raise questions regarding the functional significance of Area X and related nuclei in relation to song development in vocal mimics.

Managing unstable angina and coronary care beds effectively

This article is an evaluation of a new chest pain admission policy at Western Hospital. Our aim was to determine the clinical outcomes of patients with unstable angina treated according to this new policy. It involved attempting to identify a group at low risk of serious complications and to manage them in a general ward area without cardiac monitoring, to reduce the pressure on coronary care unit beds. We conducted a retrospective case note review and concluded that that selected patients with an admission diagnosis of unstable angina can be safely managed in unmonitored medical beds provided mechanisms are in place for their transfer to the coronary care unit if recurrent pain or a complication occurs.

Telephone triage: 5 years' experience

Triaging by telephone has long been a 'bone of contention' among emergency nurses in Victoria, Australia, with some nurses adamant that telephone advice is appropriate and other nurses equally adamant that telephone advice should not be given at all. Almost unanimously agreed upon by both groups is that documentation of the call, and/or the advice given, is time consuming and may pose a legal risk to the nurse if something untoward should happen to the patient. This paper relates our experience including our policy on telephone triage with an analysis of 5 years of documented telephone calls from January 1991 to January 1996.

Managing potentially ischaemic chest pain and coronary care beds effectively

One of the most common reasons why patients attend emergency departments in Australia is chest pain that is potentially due to coronary artery disease (myocardial infarction, unstable or stable angina pectoris). A number of models for the investigation and treatment of these patients have been employed over the last five to ten years. This paper describes the evolution of a model for managing ischaemic chest pain that aims to avoid potentially preventable deaths from undiagnosed myocardial infarction, to admit to hospital patients who could benefit from inpatient treatment, to admit to a coronary care unit patients at significant risk of complications, and to avoid inter-hospital transfer of patients. Introduction of the model has led to an increase in the appropriate hospital admission of patients with ischaemic chest pain, a marked reduction in inter-hospital transfers, and better utilisation of coronary care beds. Unmonitored, general ward management of low risk patients with clinical unstable angina has not resulted in compromised outcomes.

Human-computer interface evaluation: not user-friendliness but design for operation

This paper considers human-computer interface evaluation in the context of design and development. It is argued that it is not helpful to view evaluation as a method for achieving user-friendliness, rather it should be seen as a participating activity within design and development. The centre of concern is the operation of the system when employed in practice. Such evaluation is not necessarily to be conducted by independent observation and experiment, but may be closely integrated with other design activities. In fact the very theory underlying the evaluation finds its embodiment in the artifact of the user interface. Taking this view has technical, as well as human factors, implications.