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Perkins CA, Nepple JJ, Pang JH, Busch MT, Edmonds EW, Ellis HB, Kocher MS, Li Y, Pandya NK, Pennock AT, Sabatini CS, Spence DD, Willimon SC, Wilson PL, Heyworth BE. Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures. J Pediatr Orthop 2024:01241398-990000000-00560. [PMID: 38712672 DOI: 10.1097/bpo.0000000000002724] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. METHODS This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. RESULTS A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating >20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up. CONCLUSIONS Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
| | | | | | | | | | | | | | - Ying Li
- Texas Scottish Rite Hospital for Children, Dallas, TX
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Ayala SG, Thomas N, Rohde M, Gupta A, Sanchez M, Tompkins M, Parikh SN, Ellis HB, Green DW, Yen YM, Fabricant PD, Wilson P, Shea KG. Osseous and Cartilaginous Trochlear Development in the Pediatric Knee: A Cadaveric Computed Tomography Study. Orthop J Sports Med 2024; 12:23259671241249132. [PMID: 38751851 PMCID: PMC11095196 DOI: 10.1177/23259671241249132] [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: 10/28/2023] [Accepted: 11/13/2023] [Indexed: 05/18/2024] Open
Abstract
Background The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design Descriptive laboratory study. Methods A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint.
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Affiliation(s)
- Salvador G. Ayala
- University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Nicholas Thomas
- Florida State University College of Medicine, Pensacola, Florida, USA
| | - Matthew Rohde
- Stanford School of Medicine, Stanford, California, USA
| | - Anshal Gupta
- Stanford School of Medicine, Stanford, California, USA
| | - Mark Sanchez
- Stanford School of Medicine, Stanford, California, USA
| | - Marc Tompkins
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Shital N. Parikh
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Henry B. Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | - Yi-Meng Yen
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | | | - Phil Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - Kevin G. Shea
- Stanford School of Medicine, Stanford, California, USA
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Orellana KJ, Houlihan NV, Carter MV, Baghdadi S, Baldwin K, Stevens AC, Cruz AI, Ellis HB, Green DW, Kushare I, Johnson B, Kerrigan A, Kirby JC, MacDonald JP, McKay SD, Milbrandt TA, Justin Mistovich R, Parikh S, Patel N, Schmale G, Traver JL, Yen YM, Ganley TJ. Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1357-1366. [PMID: 37326248 DOI: 10.1177/03635465231175674] [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: 06/17/2023]
Abstract
BACKGROUND Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.
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Affiliation(s)
- Kevin J Orellana
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan V Houlihan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael V Carter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soroush Baghdadi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Aristides I Cruz
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | | | | | | | | | | | | | | | - R Justin Mistovich
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Shital Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Neeraj Patel
- Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - Jessica L Traver
- Jessica L. Traver, MD (University of Texas Health Houston, Houston, Texas, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Polinsky SG, Edmonds EW, Bastrom TP, Manhard CE, Heyworth BE, Bae DS, Busch MT, Ellis HB, Hergott K, Kocher MS, Li Y, Nepple JJ, Pandya NK, Perkins C, Sabatini CS, Spence DD, Willimon SC, Wilson PL, Pennock AT. 5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers. Am J Sports Med 2024; 52:1032-1039. [PMID: 38439558 DOI: 10.1177/03635465241228818] [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: 03/06/2024]
Abstract
BACKGROUND Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN Case series; Level of evidence, 4. METHODS Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.
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Affiliation(s)
- Samuel G Polinsky
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Eric W Edmonds
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Tracey P Bastrom
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Claire E Manhard
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Benton E Heyworth
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Donald S Bae
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Michael T Busch
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Katelyn Hergott
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Mininder S Kocher
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Ying Li
- C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University in Saint Louis, Saint Louis, Missouri, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Nirav K Pandya
- UCSF Benioff Children's Hospital, Oakland, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Crystal Perkins
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Coleen S Sabatini
- UCSF Benioff Children's Hospital, Oakland, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - David D Spence
- Department of Orthopaedic Surgery, Campbell Clinic, Memphis, Tennessee, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Samuel C Willimon
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
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Loewen AM, Morris WZ, Ulman S, Tulchin-Francis K, Sucato DJ, Podeszwa DA, Ellis HB. Pre-operative gait kinematics and kinetics do not change following surgery in adolescent patients with femoroacetabular impingement. Gait Posture 2024; 109:213-219. [PMID: 38359697 DOI: 10.1016/j.gaitpost.2024.02.006] [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] [Received: 03/01/2023] [Revised: 12/21/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a condition where the femoral head-neck junction collides with the acetabulum. Open or arthroscopic treatment of FAI aims to increase hip motion while reducing impingement during passive or dynamic movements. RESEARCH QUESTION What are the biomechanical characteristics of the hip and pelvis in adolescents and young adults diagnosed with FAI syndrome 1) pre-operatively compared to controls and 2) pre- to post-operatively? METHODS 43 patients with FAI and 43 controls were included in the study. All patients with FAI had cam deformities and underwent unilateral hip preservation surgery (either open or arthroscopic). Pre- and post-operative imaging, patient-reported outcomes, and gait analysis were performed. Joint angles and internal joint moments were evaluated with an emphasis on the pelvis and hip. A comparative analysis was conducted to evaluate the gait patterns before and after surgical treatment, as well as to compare pre-operative gait patterns to a control group. RESULTS 43 patients with FAI (28 female, 16.5 ± 1.5 yrs) and 43 controls (28 female, 16.0 ± 1.5 yrs) were included. Pre-operative patients with FAI had decreased stride length and walking speed compared to controls, with no significant change following surgery. There were no differences in sagittal and coronal plane hip and pelvis kinematics comparing pre- to post-operative and pre-operative to controls. Pre-operatively, differences in internal hip rotation angle (pre: 3.3˚, post: 3.9˚, controls: 7.7˚) and hip extensor moment (pre: 0.121, post: 0.090, controls: 0.334 Nm/kg) were observed compared to controls with no significant changes observed following surgery. SIGNIFICANCE Compensatory movement strategies in pelvic and hip motion are evident during gait in patients with FAI, particularly in the sagittal and transverse planes. These strategies remained consistent two years post-surgery. While surgery improved radiographic measures and patient-reported outcomes, gait did not elicit biomechanical changes following surgical treatment.
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Affiliation(s)
| | - William Z Morris
- Scottish Rite for Children, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sophia Ulman
- Scottish Rite for Children, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Dan J Sucato
- Scottish Rite for Children, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David A Podeszwa
- Scottish Rite for Children, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
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Yen YM, Kim YJ, Ellis HB, Sink EL, Millis MB, Zaltz I, Sankar WN, Clohisy JC, Nepple JJ. Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient. J Pediatr Orthop 2024; 44:141-146. [PMID: 37982488 DOI: 10.1097/bpo.0000000000002581] [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: 11/21/2023]
Abstract
BACKGROUND Surgical treatment for adolescent patients with femoroacetabular impingement (FAI) is increasing. The purpose of this study was to determine the clinical outcomes of FAI surgery in a multicenter cohort of adolescent patients and to identify predictors of suboptimal outcomes. METHODS One hundred twenty-six adolescent hips (114 patients < 18 years of age) undergoing surgery for symptomatic FAI were studied from a larger multicenter cohort. The group included 74 (58.7%) female and 52 male hips (41.3%) with a mean age of 16.1 (range 11.3 to 17.8). Clinical outcomes included the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (5 domains), and University of California Los Angeles activity score. Failure was defined as revision surgery or clinical failure (inability to reach minimally clinical important differences or patient acceptable symptoms state for the mHHS). Statistical analysis was used to identify factors significantly associated with failure. RESULTS There was clinically important improvement in all patient-reported outcomes for the overall group, but an 18.3% failure rate. This included a revision rate of 8.7%. Females were significantly more likely than males to be classified as a failure (25.7 vs. 7.7%, P =0.01), in part because of lower preoperative mHHS (59.1 vs. 67.0, P < 0.001). Mild cam deformity (alpha angle <55 degrees) was present in 42.5% of female hips compared with 17.3% male hips. Higher alpha angles were inversely correlated with failure. Alpha angles >63 have a failure rate of 8.3%, between 55 and 63 degrees, 12.0% failure rate, and <55 degrees (mild cam) failure rate of 37.5%. Patients who participated in athletics had a 10.3% failure rate compared with nonathletes at 25.0% ( P =0.03, RR (relative risk) 2.4). CONCLUSIONS Adolescent patients undergoing surgical treatment for FAI generally demonstrate significant improvement. However, female sex, mild cam deformities, and lack of sports participation are independently associated with higher failure rates. These factors should be considered in surgical decision-making and during patient counseling. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
| | | | | | | | | | - Ira Zaltz
- Michigan Orthopaedic Surgeons, Royal Oak, MI
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Kirby JC, Jones H, Johnson BL, Brenner ME, Wilson PL, Ellis HB. Genu Valgum in Pediatric Patients Presenting With Patellofemoral Instability. J Pediatr Orthop 2024; 44:168-173. [PMID: 38014718 PMCID: PMC10836788 DOI: 10.1097/bpo.0000000000002576] [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: 11/29/2023]
Abstract
BACKGROUND Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown. PURPOSE The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI). STUDY DESIGN A retrospective cohort study. METHODS A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated. RESULTS Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P <0.001). A higher BMI (24.87±6.95, P =0.03) was associated with valgus alignment. CONCLUSIONS There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Julia C. Kirby
- Texas Scottish Rite Hospital for Children
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Hunter Jones
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Philip L. Wilson
- Texas Scottish Rite Hospital for Children
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Henry B. Ellis
- Texas Scottish Rite Hospital for Children
- University of Texas Southwestern Medical Center, Dallas, TX
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8
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Spence DD, Wilson PL, Pennock AT, Nepple JJ, Pandya NK, Perkins CA, Li Y, Ellis HB, Sabatini CS, Edmonds EW, Willimon SC, Bae DS, Busch MT, Kocher M, Heyworth BE. Treatment of Severely Shortened or Comminuted Clavicular Fractures in Older Adolescent Athletes. Am J Sports Med 2024; 52:423-430. [PMID: 38238901 DOI: 10.1177/03635465231219248] [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: 02/03/2024]
Abstract
BACKGROUND Recent evidence suggests that for completely displaced midshaft clavicular fractures, surgery offers no clear benefit over nonoperative treatment in a general adolescent population from 10 to 18 years of age. However, the comparative outcomes of comminuted and/or severely shortened clavicular fractures specifically in older adolescent athletes have not been explored in a focused, methodologically rigorous fashion. HYPOTHESIS The study hypothesis was that outcomes would be superior in older adolescent athletes who underwent operative treatment compared with nonoperative treatment for comminuted and/or severely shortened clavicular fractures. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A level 2, multicenter, prospective cohort study investigating the outcomes of midshaft fractures in adolescents between 2013 and 2017 was filtered to analyze the subcohorts of athletes 14 to 18 years of age with either fracture comminution or fracture shortening of ≥25 mm or both. Patient characteristics, injury mechanisms, fracture characteristics, and treatments were compared. Complications, rates, timing of return to sports (RTS), and patient-reported outcomes (PROs) were analyzed. RESULTS The 2 treatment groups, which included 136 older adolescent athletes (69 nonoperative, 67 operative), showed similar distributions of primary sport type, competition level, comminution, shortening, and 2-year PRO response rate (n = 99; 73%). The operative group demonstrated 3 mm-greater mean superior displacement, which was therefore statistically controlled for as a confounder in the comparative PRO analysis. No 2-year differences in nonunion, delayed union, symptomatic malunion, refracture, clinically significant complications, or rates of RTS were detected between treatment groups. The difference in timing of RTS (operative, 10.3 weeks; nonoperative, 13.5 weeks) was statistically significant. After controlling for the minor difference in superior displacement, regression analysis and matched comparison cohorts demonstrated no differences between the nonoperative and operative groups in mean or dichotomized PRO scores. CONCLUSION In this prospective, multicenter cohort study investigating older adolescent athletes with comminuted and/or severely shortened clavicular fractures, contrary to the study hypothesis, there were no differences in complications, RTS, or PROs between nonoperatively and operatively treated patients at 2 years. Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment.
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Affiliation(s)
- David D Spence
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, Tennessee, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Philip L Wilson
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jeffrey J Nepple
- Department of Orthopedic Surgery, School of Medicine, Washington University, St. Louis, Missouri, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Crystal A Perkins
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry B Ellis
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - S Clifton Willimon
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael T Busch
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA)
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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McGinley J, Stapleton E, Gale E, Worrall H, Podvin C, Ellis HB, Wilson PL, Ulman S. Differences in athletic identity, sport participation, and psychosocial factors following anterior cruciate ligament rehabilitation in youth athletes. Front Psychol 2024; 14:1303887. [PMID: 38259536 PMCID: PMC10800524 DOI: 10.3389/fpsyg.2023.1303887] [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] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/06/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction While youth sports benefits the developing athlete, athletes may also be subject to injury and subsequent return-to-sport protocols. The current return-to-sport criteria emphasize physical measures; however, psychological measures may also be valuable to inform providers of an athlete's readiness. One such measure is athletic identity defined as the degree to which an individual identifies with the athlete role. To better understand athletic identity in return-to-sport, this study aimed to identify relationships and trends between the Athletic Identity Measurement Scale (AIMS), demographic variables, sport participation measures, and the Athletic Coping Skills Inventory-28 (ACSI-28) in youth athletes during rehabilitation following anterior cruciate ligament reconstruction (ACLR). Methods A retrospective review was completed of patients who underwent ACLR at a sports medicine clinic between October 2019 and May 2021. Patients responded to a series of patient reported outcomes (PROs) regarding physical and psychological function at a pre-surgical baseline and after 1 year of rehabilitation. Patients were then divided into groups of high/low AIMS and an increased/decreased AIMS between 1 year and baseline for comparison. Independent samples t-tests and ANOVAs were performed as appropriate with a 95% confidence interval. Results In the final sample, 87 patients (15.3 ± 1.8 years) were included, with 51.7% being females. Total AIMS scores decreased from 50.3 to 47.5 over rehabilitation (p = 0.019). Furthermore, results indicated that nearly all AIMS scores decreased during rehabilitation, with none showing an increase; however, not all domains were significant. Conversely, all sport participation and coping ability PROs increased over time points except for ACSI-Confidence and Achievement Motivation. Generally, those in the groups with high AIMS and an increase in AIMS also had higher scores in physical function and coping ability PROs, with the groups separated by high/low AIMS exhibiting more frequent statistical significance. Discussion Given these results, it appears that athletes may lose identification with the athlete role after ACLR and struggle even 1 year for rehabilitation, but those who recover athletic identity the best may also be those able to cope most effectively with the stressors induced by injury.
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Affiliation(s)
- James McGinley
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
| | - Emily Stapleton
- Department of Psychology, Scottish Rite for Children, Frisco, TX, United States
| | - Emily Gale
- Department of Psychology, Scottish Rite for Children, Frisco, TX, United States
| | - Hannah Worrall
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
| | - Caroline Podvin
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
| | - Henry B. Ellis
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Philip L. Wilson
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sophia Ulman
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Kemper WC, Carpenter CM, Wagner KJ, Chen CC, Saleem L, Wilson PL, Ellis HB. Differences in Short-Term Sport-Specific Functional Recovery After Primary ACL Reconstruction in the Adolescent Athlete. Sports Health 2024; 16:139-148. [PMID: 36872596 PMCID: PMC10732105 DOI: 10.1177/19417381231156395] [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] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Although anterior cruciate ligament (ACL) injury rates have been studied extensively, it is unclear whether levels of functional and psychological readiness for return-to-sport after primary ACL reconstruction (ACLR) differ based on an athlete's primary sport. HYPOTHESIS Youth athletes in different primary sports will demonstrate differences in short-term functional recovery, as well as patient-reported psychological and functional recovery after primary ACLR. STUDY DESIGN Retrospective cohort study of consecutive patients treated for ACL injury in pediatric sports medicine clinics. LEVEL OF EVIDENCE Level 3. METHODS Patients included underwent primary ACLR between December 1, 2015 and December 31, 2019 and reported sports participation at the time of injury. Demographic data, sports participation, surgical data, functional testing scores (Y-Balance Test [YBT]), functional and psychological patient-reported outcome measures (PROMs), and timing of return-to-play clearance were reviewed. YBT scores were the primary metric for clearance. Four groups were studied: soccer, football, basketball, and other. RESULTS A total of 220 male and 223 female athletes were included; 65.28% of soccer players were female and 100% of football players were male (P < 0.01). At initial postoperative YBT testing (6-9 months), soccer players had higher operative (P < 0.01) and nonoperative (P < 0.01) leg composite scores when compared with basketball players. No significant differences were found between sports in functional or psychological PROMs at presurgical baseline or 6 months postoperatively. When compared with football, soccer players completed functional clearance in a shorter time from surgery (P = 0.02). Multivariate analysis showed level of competition as a significant independent variable for clearance in female athletes. CONCLUSION After primary ACLR, athletes, especially female athletes, demonstrated short-term sport-specific differences in YBT scores. Soccer players attained clearance sooner than football players. Level of competition influenced YBT composite scores in all athletes and time to clearance in female athletes. CLINICAL RELEVANCE Sport-specific differences in reinjury should be investigated to determine whether changes in return-to-play evaluation should be implemented.
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Affiliation(s)
| | | | - K. John Wagner
- Texas Scottish Rite Hospital for Children, Frisco, Texas
| | | | - Laura Saleem
- Texas Scottish Rite Hospital for Children, Frisco, Texas
| | - Philip L. Wilson
- Texas Scottish Rite Hospital for Children, Frisco, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Henry B. Ellis
- Texas Scottish Rite Hospital for Children, Frisco, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
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Morris WZ, Loewen A, Ulman S, Johnson B, Sucato DJ, Podeszwa DA, Ellis HB. Comparison of Gait and Functional Outcomes Between Open and Arthroscopic Treatment of Adolescent and Young Adult Femoroacetabular Impingement. J Pediatr Orthop 2024; 44:22-27. [PMID: 37791636 DOI: 10.1097/bpo.0000000000002532] [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: 10/05/2023]
Abstract
BACKGROUND Management of femoroacetabular impingement (FAI) through an arthroscopic or surgical hip dislocation (SHD) approach has been shown to have similar clinical success and patient-reported outcomes. However, there are limited data comparing functional outcomes. The purpose of this study was to compare gait and functional outcomes of adolescent/young adult patients with FAI treated by either an arthroscopic or open SHD approach. METHODS We identified prospectively enrolled adolescent/young adult patients (≤20 years old) who underwent surgical treatment for FAI through an SHD or arthroscopic approach. Participants were evaluated in a movement science lab preoperatively and postoperatively (minimum 8 months postoperatively) with barefoot walking and a 30-second single-limb balance trial on the affected side. Participants also completed the Harris Hip Score at the same timepoints. Differences from preoperative to postoperative were determined using a paired-samples t test for each surgical technique, and differences between the SHD and arthroscopic groups were determined using an independent samples t test (α=0.05). RESULTS Fifty-five participants (42F, 16.2±1.4 y) were tested and grouped by surgical intervention. The SHD and arthroscopy groups consisted of 28 and 27 participants, respectively, with no significant difference between the SHD and arthroscopic cohorts in age (16.4±1.2 vs. 15.9±1.5 y, respectively, P =0.218) or sex distribution (78.6% vs. 74.1% females, respectively, P =0.75). Each group demonstrated significant postoperative improvement in Harris Hip Score (SHD: 64.8±16.4 to 81.8±17.8; arthroscopy: 57.0±16.7 to 84.7±19.7; preoperatively to postoperatively, respectively, both P <0.001). During gait, increased maximum hip flexion was observed following surgical intervention for the SHD group (32.3±5.7 vs. 36.1±5.2, P =0.003). No other clinically significant changes were detected in the SHD or arthroscopic groups preoperatively to postoperatively in trunk, pelvis, or hip kinematics in the coronal plane. During the balance task, neither cohort demonstrated markers of clinically significant abductor dysfunction. However, post operatively, the arthroscopy group was able to balance longer than the SHD group (18.8±7.8 vs. 14.2±2.7 s, respectively, P =0.008), although no differences were detected in trunk or pelvis position in the coronal plane during balance. CONCLUSIONS Both open SHD and arthroscopic treatment of FAI resulted in improved clinical outcomes with no clinically significant abductor dysfunction 1 year post operatively. However, further study is needed to determine whether more dynamic tasks can potentially elicit subtle differences between the groups. LEVELS OF EVIDENCE Level II-prospective study.
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Affiliation(s)
- William Z Morris
- Department of Orthopedics, Scottish Rite for Children, Dallas, TX
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12
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Kapadia AB, Wilson PL, Gill CS, Wyatt CW, Montgomery GK, Huang SG, Ellis HB. Characteristics of forearm refracture in adolescents. J Pediatr Orthop B 2024; 33:58-64. [PMID: 36723612 PMCID: PMC10686275 DOI: 10.1097/bpb.0000000000001057] [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] [Received: 02/25/2022] [Accepted: 12/26/2022] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to evaluate characteristics of reinjury following forearm fractures in adolescents. An Institutional Review Board-approved retrospective cohort study of forearm fractures (ages 10-18 years) treated by a single academic pediatric orthopaedic group from June 2009 to May 2020 was conducted. All both bone forearm (BBFA) and radius or ulna primary and secondary injuries were included. We excluded open, surgically treated, physeal, epiphyseal, and radial head/neck fractures. Demographics, injury characteristics, and radiographic data were recorded. We evaluated associations of ipsilateral same-site refracture (RE-FRACTURE) versus ipsilateral or contralateral different-site forearm fractures occurring as secondary later injuries (OTHER). Thirty-three of 719 patients sustained a secondary forearm fracture (4.6%; mean age, 11.5 years; M:F, 5.6:1). RE-FRACTURES, compared with OTHER forearm locations, were associated with a sports mechanism at time of original injury ( P = 0.024) and mid-shaft position of fracture on the radius (77.6 vs. 29.8 mm from distal physis; P < 0.001) and ulna (72.0 vs. 27.2 mm from distal physis; P = 0.003). RE-FRACTURES also demonstrated increased radius to ulna distance between BBFA primary injury sites on anteroposterior (19.6 vs. 10.6 mm; P = 0.009) and lateral radiographs (19.6 vs. 10.5 mm; P = 0.020) compared with OTHER forearm locations. Residual angulation and fracture-line visibility were not significantly associated with secondary fracture. Ipsilateral same-site refractures tend to occur in adolescents within 1 year following treatment for widely spaced (>15 mm) and mid-shaft forearm fractures incurred during athletic activity. Further research may be warranted to evaluate biologic, bone health, or personality traits that may lead to secondary fractures of the pediatric forearm.
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Affiliation(s)
- Ami B. Kapadia
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
| | - Philip L. Wilson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
- Department of Orthopaedics and Sports Medicine, Scottish Rite for Children
- Division of Sports Medicine, Children’s Medical Center Dallas, Dallas, Texas, USA
| | - Corey S. Gill
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
- Department of Orthopaedics and Sports Medicine, Scottish Rite for Children
- Division of Sports Medicine, Children’s Medical Center Dallas, Dallas, Texas, USA
| | - Charles W. Wyatt
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
- Department of Orthopaedics and Sports Medicine, Scottish Rite for Children
| | | | - Sharon G. Huang
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
| | - Henry B. Ellis
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center
- Department of Orthopaedics and Sports Medicine, Scottish Rite for Children
- Division of Sports Medicine, Children’s Medical Center Dallas, Dallas, Texas, USA
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Youngman TR, Johnson BL, Morris WZ, Montanez B, Serbin PA, Wagner KJ, Wilson PL, Alizai H, Ellis HB. Soft Tissue Cam Impingement in Adolescents: MRI Reveals Impingement Lesions Underappreciated on Radiographs. Am J Sports Med 2023; 51:3749-3755. [PMID: 37942655 DOI: 10.1177/03635465231206815] [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: 11/10/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) has been described as repetitive and abnormal contact between a structurally abnormal proximal femur (cam) and/or acetabulum (pincer), occurring during the terminal range of motion of the hip. While cam and pincer lesions have traditionally been defined as osseous abnormalities, there may be a subset of adolescent patients whose impingement is primarily soft tissue (nonosseous). The existence of a nonosseous cam lesion in adolescents with FAI has not been well described. PURPOSE To identify and characterize a series of adolescent patients with nonosseous (soft cam) FAI identified on magnetic resonance imaging (MRI) and compare these patients' clinical presentation and outcome with those of a cohort with primary osseous cam FAI in the same age group. STUDY DESIGN Case series; Level of evidence, 4. METHODS A prospective institutional registry of patients with symptomatic FAI was reviewed. Patients were included if they had an MRI scan and a lateral radiograph of the hip (45° Dunn or frog) at a baseline visit. On MRI, the anterolateral femoral head was evaluated using radial, coronal, sagittal, or axial oblique sequences. A soft cam lesion was identified by the presence of soft tissue thickening of ≥2 mm at the anterolateral femoral head-neck junction. An alpha angle was measured on MRI scans and radiographs when a lesion was identified. The cohort with soft cam lesions was reviewed and findings and outcomes were compared with those of a cohort with osseous cam lesions. Continuous variables were first examined for normality, and then nonparametric tests-such as the Kruskal-Wallis test-were considered. The change between pre- and postoperative patient-reported outcomes (PROs) was described by mean and standard deviation and evaluated with an independent-samples t test. RESULTS A total of 31 (9.3%) of 332 hips (mean age, 16.4 years [range 13.1-19.6 years]; women, 83.9%) were identified with a soft tissue impingment lesion on MRI at the femoral head-neck junction between the 12 and 3 o'clock positions. These lesions demonstrated a thickened perichondral ring (71%), periosteal thickening (26%), or a cartilaginous epiphyseal extension (3%). The mean alpha angle on MRI was greater than on radiographs (63.5°± 7.9° vs 51.3°± 7.9°; P < .0001). A total of 22 patients (71%) with soft impingement underwent hip preservation surgery. When compared with patients in the osseous cohort who also underwent surgical management, both groups showed similar significant improvements from pre- to postoperatively (soft: modified Harris Hip Score [mHHS], 26.9 ± 18.2; Hip disability and Osteoarthritis Outcome Score [HOOS], 31.4 ± 22.9; osseous: mHHS, 22.8 ± 20.8; HOOS, 27.4 ± 20.1; P < .0001), with a mean follow-up of 3.4 years (range, 1-7 years) in the soft cam cohort and 3 years (1-10.1 years) in the osseous cam cohort. CONCLUSION Clinicians should be aware of nonosseous or soft cam lesions that cause impingement in adolescent patients without an obvious osseous cam on radiographs. MRI is required to detect these soft cam lesions. When nonoperative treatment fails, the PROs in these patients after operative management are comparable with those in patients with osseous cam lesions. Further research is needed to determine whether the soft cam precedes an osseous cam or whether it is a separate entity.
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Affiliation(s)
- Tyler R Youngman
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - William Z Morris
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Dallas, Texas, USA
| | | | - P Austin Serbin
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Philip L Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Dallas, Texas, USA
| | - Hamza Alizai
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Dallas, Texas, USA
| | - Henry B Ellis
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Dallas, Texas, USA
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Adsit E, Albright J, Algan S, Beck J, Bowen RE, Brey J, Marc Cardelia J, Clark C, Coello P, Crepeau A, Edmonds E, Ellington M, Ellis HB, Fabricant PD, Frank JS, Ganley TJ, Green DW, Gupta A, Heyworth B, Kemper WC, Latz K, Mansour A, Mayer S, McKay SD, Milewski MD, Niu E, Pacicca DM, Parikh SN, Pupa L, Rhodes J, Saper M, Schmale GA, Schmitz M, Shea K, Silverstein RS, Storer S, Wilson PL. Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database. Am J Sports Med 2023; 51:3493-3501. [PMID: 37899536 PMCID: PMC10623608 DOI: 10.1177/03635465231206173] [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] [Received: 08/18/2022] [Accepted: 07/20/2023] [Indexed: 10/31/2023]
Abstract
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.
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Affiliation(s)
| | | | - Jay Albright
- Department of Orthopedics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sheila Algan
- Department of Orthopedic Surgery, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
| | | | - Richard E. Bowen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Jennifer Brey
- Department of Orthopedics, Norton Children's Orthopedics of Louisville, Louisville, Kentucky, USA
| | - J. Marc Cardelia
- Department of Orthopedics and Sports Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Christian Clark
- OrthoCarolina Pediatric Orthopaedic Center, Charlotte, North Carolina, USA)
| | | | - Allison Crepeau
- Elite Sports Medicine at Connecticut Children's, Hartford, Connecticut, USA; Division of Sports Medicine, Department of Orthopedics, UConn Health, Farmington, Connecticut, USA
| | - Eric Edmonds
- Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Matthew Ellington
- Department of Orthopedics, Central Texas Pediatric Orthopedics, Austin, Texas, USA; Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Henry B. Ellis
- Investigation performed at Scottish Rite for Children, University of Texas Southwestern Medical Center, Dallas, USA
| | - Peter D. Fabricant
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA; Weill Cornell Medical College, New York, New York
| | - Jeremy S. Frank
- Division of Pediatric Orthopaedics and Spinal Deformities, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - Theodore J. Ganley
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W. Green
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andrew Gupta
- Division of Pediatric Orthopaedics and Spinal Deformities, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - Benton Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - W. Craig Kemper
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kevin Latz
- Department of Orthopedics-Sports Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Alfred Mansour
- Department of Orthopedic Surgery, UTHealth Houston, McGovern Medical School, Houston, Texas, USA
| | - Stephanie Mayer
- Department of Orthopedics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Scott D. McKay
- Baylor College of Medicine, Houston, Texas, USA; Texas Children's Hospital, Houston, Texas, USA
| | - Matthew D. Milewski
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emily Niu
- Department of Orthopedic Surgery and Sports Medicine, Children's National Medical Center, Washington, DC, USA
| | - Donna M. Pacicca
- Department of Orthopedics-Sports Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Shital N. Parikh
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lauren Pupa
- Baylor College of Medicine, Houston, Texas, USA
| | - Jason Rhodes
- Department of Orthopedics, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Gregory A. Schmale
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew Schmitz
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Kevin Shea
- Department of Orthopaedics, Stanford University School of Medicine, Stanford, California, USA
| | - Rachel S. Silverstein
- Baylor College of Medicine, Houston, Texas, USA; Texas Children's Hospital, Houston, Texas, USA
| | - Stephen Storer
- Division of Pediatric Orthopaedics and Spinal Deformities, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - Philip L. Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA; Scottish Rite for Children, Dallas, Texas, USA)
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Huang SG, Wilson PL, Worrall HM, Ramo BA, Kapadia A, Ellis HB. Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients. J Child Orthop 2023; 17:489-496. [PMID: 37799309 PMCID: PMC10549699 DOI: 10.1177/18632521231198250] [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: 01/20/2023] [Accepted: 08/15/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Methods Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. Results A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Conclusions Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Level of evidence Retrospective level III.
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Affiliation(s)
- Sharon G Huang
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Philip L Wilson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
| | | | - Brandon A Ramo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
| | - Ami Kapadia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Henry B Ellis
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
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Rohde MS, Trivedi S, Randhawa S, Wright CE, Vuong BB, Pham N, Stavinoha T, Ellis HB, Ganley TJ, Green DW, Fabricant PD, Tompkins M, Shea KG. Pediatric meniscus morphology varies with age: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 2023; 31:4179-4186. [PMID: 37178242 DOI: 10.1007/s00167-023-07447-3] [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] [Received: 01/12/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE In adolescent patients, meniscal tear injury can occur either in isolation (e.g., discoid lateral meniscus tears) or in association with other traumatic injuries including tibial eminence fracture or ACL tear. Damage to meniscal integrity has been shown to increase contact pressure in articular cartilage, increasing risk of early onset osteoarthritis. In symptomatic patients failing conservative management, surgical intervention via meniscus repair or meniscus transplant is indicated. The purpose of this study was to evaluate the radial dimensions of pediatric menisci throughout development. The hypothesis was that the average radial meniscus dimensions will increase as specimen age increases, and mean medial and lateral region measurements will increase at a linear rate. METHODS Seventy-eight skeletally immature knee cadaver specimens under age 12 years were included in this study. The meniscal specimens were photographed in the axial view with ruler in the plane of the tibial plateau and analyzed using computer-aided design (CAD) software (Autodesk Fusion 360). Measurements were taken from inner to outer meniscus rims at five 45 degree intervals using the clockface as a reference (12:00, 1:30, 3:00, 4:30, 6:00), and total area of meniscus and tibial plateau was recorded. Generalized linear models were used to evaluate the associations of radial width measurements with age, tibial coverage, and lateral vs. medial meniscus widths. RESULTS All radial width measurements increased significantly with specimen age (p ≤ 0.002), and all lateral-medial meniscal widths increased (p < 0.001). The anterior zones of the meniscus were found to increase at the slowest rate compared to other regions. Tibial plateau coverage was found to not significantly vary with age. CONCLUSIONS Meniscus radial width and lateral-medial meniscus width are related to age. The anterior width of the meniscus varied least with age. Improved anatomic understanding may help surgeons more effectively plan for meniscus repair, discoid resection/saucerization/repair, and also support appropriate selection of meniscus allograft for transplantation.
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Affiliation(s)
- Matthew S Rohde
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA.
| | - Sunny Trivedi
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
| | - Sahej Randhawa
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
| | - Christian E Wright
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
| | - Brian B Vuong
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
| | - Nicole Pham
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
| | | | | | | | | | | | - Marc Tompkins
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kevin G Shea
- Department of Orthopedic Surgery, Stanford University School of Medicine, 453 Quarry Road, Stanford, Palo Alto, CA, 94304, USA
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Wilson PL, Wyatt CW, Johnson BL, Carpenter CM, Ellis HB. Suture-Bridge Fixation of Osteochondral Fractures and Osteochondritis Dissecans in the Knee: Excellent Rates of Early Lesion Stability and Osseous Union. Am J Sports Med 2023; 51:2936-2944. [PMID: 37565525 DOI: 10.1177/03635465231189244] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Preservation of articular cartilage in the setting of acute or chronic injury in the adolescent and young adult knee is paramount for long-term joint health. Achieving osseous union, minimizing implant-related injury, and eliminating the need for reoperation for traumatic chondral and osteochondral lesions (OCLs) and osteochondritis dissecans (OCD) remain a challenge for the orthopaedic surgeon. PURPOSE To evaluate radiographic healing, patient-reported outcomes, and short-term complications after suture-bridge fixation of chondral fragments, osteochondral fractures, and OCD lesions in the knee. STUDY DESIGN Case series; Level of evidence, 4. METHODS The study included consecutive patients (38 patients, 40 knees) treated within a single academic sports medicine institution who underwent suture-bridge fixation of an OCL or an OCD lesion of the knee from initiation of the technique in October 2019 through March 2021. The suture-bridge technique entailed bioabsorbable knotless anchors placed on the outside margins of the lesion with multiple strands of hand-tensioned absorbable (No. 0 or No. 1 Vicryl) or nonabsorbable (1.3-mm braided polyester tape) bridging suture. Healing was assessed by radiography and magnetic resonance imaging (MRI), with MRI scans obtained on all OCD lesions and any chondral-only lesions. MRI scans were available for 33 of 40 (82.5%) knees within 1 year of surgery and were evaluated for lesion healing. Complications and rates and timing of return to sport were evaluated. Patient-reported outcomes in the OCD cohort were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) to determine early pain and functional improvement. RESULTS In total, 33 (82.5%) lesions demonstrated full union, and no lesions failed treatment. MRI assessment of healing (mean, 5.8 months; range, 3-12 months) demonstrated 9 (64.3%) OCD lesions with full union, 5 (35.7%) OCD lesions with stable union, and no OCD lesions with nonunion. Of the OCLs, 17 (89.5%) had full union, 2 (10.5%) had stable union, and none had nonunion. The 7 bony OCLs without an MRI scan demonstrated complete radiographic union. In 30 (75.0%) lesions, patients returned to sports at a mean of 6.5 months (range, 3.8-10.2 months). KOOS Activities of Daily Living, Pain, Quality of Life, and Symptoms scores demonstrated significant improvement from baseline at 6 months and at 1 year. There were 2 (5%) complications, consisting of reoperation for marginal chondroplasty on an otherwise stable lesion, and re-operation for intial un-treated patellar instability, with no reoperations for failure or revision of the suture-bridge construct. CONCLUSION In this series of OCLs and OCD lesions of the knee, suture-bridge fixation demonstrated excellent rates of MRI and radiographic union and good early outcomes with minimal short-term complications. This technique may be used for lesion salvage as an alternative to metallic and nonmetallic screw/tack constructs in the treatment of these challenging lesions. Longer term follow-up and investigation are warranted.
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McGinley J, Worrall H, Althoff C, Clark C, Jo CH, Birch JG, Wilson PL, Ellis HB. Faster Rate of Correction with Distal Femoral Transphyseal Screws Versus Plates in Hemiepiphysiodesis for Coronal-Plane Knee Deformity: Age- and Sex-Matched Cohorts of Skeletally Immature Patients. J Bone Joint Surg Am 2023; 105:1252-1260. [PMID: 37418510 DOI: 10.2106/jbjs.22.01122] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
BACKGROUND Hemiepiphysiodesis (guided-growth) procedures have become the primary method of treatment for coronal-plane knee deformities in skeletally immature patients. Two leading techniques involve the use of a transphyseal screw or a growth modulation plate. However, clinical references for the estimation of correction are lacking, and no consensus has been reached regarding the superiority of one technique over the other. Therefore, the purpose of this study was to compare the rates of correction for distal femoral transphyseal screws and growth modulation plates in age- and sex-matched cohorts with coronal deformities. METHODS Thirty-one knees were included in each cohort on the basis of propensity scoring by chronological age and sex, and radiographic images were retrospectively reviewed preoperatively and postoperatively. Each case was measured for limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (LDFA), and bone age. RESULTS Both the MAD and LDFA rate of correction significantly differed between the screw and plate cohorts. The MAD rate of correction was observed to be 0.42 ± 0.37 mm/week (1.69 mm/month) in the plate cohort and 0.66 ± 0.51 mm/week (2.64 mm/month) in the screw cohort. The LDFA rate of correction was observed to be 0.12° ± 0.13°/week (0.50°/month) in the plate cohort and 0.19° ± 0.19°/week (0.77°/month) in the screw cohort. CONCLUSIONS The current study provides simple clinical references for the rate of correction of MAD and the LDFA for 2 methods of hemiepiphysiodesis. The results suggest that transphyseal screws may correct coronal knee deformities during the initial treatment stage more quickly than growth modulation plates in distal femoral guided growth. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | | | - John G Birch
- Scottish Rite for Children, Frisco, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Philip L Wilson
- Scottish Rite for Children, Frisco, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Henry B Ellis
- Scottish Rite for Children, Frisco, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
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McGurty SA, Ganley TJ, Kushare I, Leska TM, Aoyama JT, Ellis HB, Johnson B, Baghdadi S, Cruz AI, Fabricant PD, Green DW, Lee RJ, McKay SD, Milbrandt TA, Patel NM, Rhodes JT, Sachleben B, Traver JL, Mistovich RJ, Schmale GA, Cook DL, Yen YM. Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter? Orthop J Sports Med 2023; 11:23259671231192978. [PMID: 37655244 PMCID: PMC10467414 DOI: 10.1177/23259671231192978] [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: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 09/02/2023] Open
Abstract
Background Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament. Purpose To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients. Study Design Cohort study; Level of evidence, 3. Methods Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed. Results Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories. Conclusion Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yi-Meng Yen
- Investigation performed at Boston Children’s Hospital, Boston, Massachusetts, USA
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20
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O’Donnell R, Lemme NJ, Piana L, Aoyama JT, Ganley TJ, Fabricant PD, Green DW, McKay SD, Schmale GA, Mistovich RJ, Baghdadi S, Yen YM, Ellis HB, Cruz AI. Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture. Arthrosc Sports Med Rehabil 2023; 5:100739. [PMID: 37645394 PMCID: PMC10461139 DOI: 10.1016/j.asmr.2023.04.022] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/20/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities. Methods A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression. Results Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P = .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance. Conclusions In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Ryan O’Donnell
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Nicholas J. Lemme
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Lauren Piana
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Julien T. Aoyama
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Theodore J. Ganley
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Peter D. Fabricant
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Daniel W. Green
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Scott D. McKay
- Department of Orthopedics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, U.S.A
| | - Gregory A. Schmale
- Division of Pediatric Orthopaedics and Sports Medicine, Seattle Children’s Hospital, Seattle, Washington, U.S.A
| | - R. Justin Mistovich
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Soroush Baghdadi
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Yi-Meng Yen
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, U.S.A
| | - Henry B. Ellis
- Department of Orthopedics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, U.S.A
| | - Aristides I. Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
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21
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Ellis HB, Zak TK, Jamnik A, Lind DRG, Dabis J, Losito M, Wilson P, Moatshe G. Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis. JBJS Rev 2023; 11:01874474-202308000-00001. [PMID: 37535763 DOI: 10.2106/jbjs.rvw.22.00223] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
» Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.» An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.» Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.
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Affiliation(s)
- Henry B Ellis
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | | | | | - Dane R G Lind
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Philip Wilson
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | - Gilbert Moatshe
- Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
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22
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Cannamela P, Cutler H, Sohn G, Wyatt C, Wilson PL, Ellis HB. Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation. Am J Sports Med 2023; 51:2018-2022. [PMID: 37222725 DOI: 10.1177/03635465231171129] [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: 05/25/2023]
Abstract
BACKGROUND Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions-such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions-may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success. PURPOSE To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population. STUDY DESIGN Cross-sectional study, Level of evidence, 3. METHODS Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions-anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion-were assessed for correlations with age, open physeal status, and the presence of any bone loss. RESULTS An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]. CONCLUSION In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.
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Affiliation(s)
- Peter Cannamela
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Holt Cutler
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Garrett Sohn
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Philip L Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Frisco, Texas, USA
| | - Henry B Ellis
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children, Frisco, Texas, USA
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23
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Morris WZ, Mayfield LM, Ellis HB, Gill CS, Sucato DJ, Podeszwa DA, Jo CH, Kim HKW. The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines. J Pediatr Orthop 2023; 43:e411-e415. [PMID: 36998168 DOI: 10.1097/bpo.0000000000002404] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 04/01/2023]
Abstract
BACKGROUND The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click. METHODS We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation. RESULTS Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity. CONCLUSIONS Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click. LEVEL OF EVIDENCE Level II-prospective prognostic study.
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Affiliation(s)
- William Z Morris
- Scottish Rite for Children
- Southwestern Medical Center, University of Texas, Dallas, TX
| | | | - Henry B Ellis
- Scottish Rite for Children
- Southwestern Medical Center, University of Texas, Dallas, TX
| | - Corey S Gill
- Scottish Rite for Children
- Southwestern Medical Center, University of Texas, Dallas, TX
| | - Daniel J Sucato
- Scottish Rite for Children
- Southwestern Medical Center, University of Texas, Dallas, TX
| | - David A Podeszwa
- Scottish Rite for Children
- Southwestern Medical Center, University of Texas, Dallas, TX
| | | | - Harry K W Kim
- Southwestern Medical Center, University of Texas, Dallas, TX
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Johnstone TM, Baird DW, Cuellar-Montes A, van Deursen WH, Tompkins M, Ganley TJ, Yen YM, Ellis HB, Chan CK, Green DW, Sherman SL, Shea KG. Screws or Sutures? A Pediatric Cadaveric Study of Tibial Spine Fracture Repairs. Am J Sports Med 2023:3635465231181059. [PMID: 37382335 DOI: 10.1177/03635465231181059] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Tibial spine fractures are common in the pediatric population because of the biomechanical properties of children's subchondral epiphyseal bone. Most studies in porcine or adult human bone suggest that suture fixation performs better than screw fixation, but these tissues may be poor surrogates for pediatric bone. No previous study has evaluated fixation methods in human pediatric knees. PURPOSE To quantify the biomechanical properties of 2-screw and 2-suture repair of tibial spine fracture in human pediatric knees. STUDY DESIGN Controlled laboratory study. METHODS Cadaveric specimens were randomly assigned to either 2-screw or 2-suture fixation. A standardized Meyers-Mckeever type 3 tibial spine fracture was induced. Screw-fixation fractures were reduced with two 4.0-mm cannulated screws and washers. Suture-fixation fractures were reduced by passing 2 No. 2 FiberWire sutures through the fracture fragment and the base of the anterior cruciate ligament. Sutures were secured through bony tunnels over a 1-cm tibial cortical bridge. Each specimen was mounted at 30° of flexion. A cyclic loading protocol was applied to each specimen, followed by a load-to-failure test. Outcome measures were ultimate failure load, stiffness, and fixation elongation. RESULTS Twelve matched pediatric cadaveric knees were tested. Repair groups had identical mean (8.3 years) and median (8.5 years) ages and an identical number of samples of each laterality. Ultimate failure load did not significantly differ between screw (mean ± SD, 143.52 ± 41.9 7 N) and suture (135.35 ± 47.94 N) fixations (P = .760). Screws demonstrated increased stiffness and decreased elongation, although neither result was statistically significant at the .05 level (21.79 vs 13.83 N/mm and 5.02 vs 8.46 mm; P = .076 and P = .069, respectively). CONCLUSION Screw fixation and suture fixation of tibial spine fractures in human pediatric tissue were biomechanically comparable. CLINICAL RELEVANCE Suture fixations are not biomechanically superior to screw fixations in pediatric bone. Pediatric bone fails at lower loads, and in different modes, compared with adult cadaveric bone and porcine bone. Further investigation into optimal repair is warranted, including techniques that may reduce suture pullout and "cheese-wiring" through softer pediatric bone. This study provides new biomechanical data regarding the properties of different fixation types in pediatric tibial spine fractures to inform clinical management of these injuries.
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Affiliation(s)
- Thomas M Johnstone
- Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | - David W Baird
- Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | | | | | - Marc Tompkins
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Theodore J Ganley
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Department of Orthopedic Surgery, Harvard University, Boston, Massachusetts, USA
| | - Henry B Ellis
- Department of Orthopedic Surgery, Scottish Rite Hospital for Children, Frisco, Texas, USA
| | - Calvin K Chan
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Daniel W Green
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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25
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Wagner KJ, Beck JJ, Carsen S, Crepeau AE, Cruz AI, Ellis HB, Mayer SW, Niu E, Pennock AT, Stinson ZS, VandenBerg C, Ellington MD. Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction. J Pediatr Orthop 2023; 43:e278-e283. [PMID: 36728478 DOI: 10.1097/bpo.0000000000002344] [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: 02/03/2023]
Abstract
BACKGROUND The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. METHODS A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. RESULTS Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. CONCLUSIONS Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - Sasha Carsen
- Children's Hospital of Eastern Ontario, ON, Canada
| | | | | | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical School, Dallas, TX
| | | | - Emily Niu
- Children's National Medical Center, Washington DC
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26
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Serbin PA, Youngman TR, Johnson BL, Wilson PL, Sucato D, Podeszwa D, Ellis HB. Radiographic Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement. Am J Sports Med 2023; 51:687-693. [PMID: 36856281 DOI: 10.1177/03635465221147062] [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: 03/02/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a condition caused by repetitive abutment of a morphologically abnormal proximal femur and/or acetabulum that may result in chondral and labral pathology. An understanding of radiographic parameters associated with successful primary surgery has not been well established. PURPOSE To determine preoperative radiographic parameters that predict reoperation for FAI and correlate radiographic measurements with outcomes in these patients. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A prospectively collected institutional registry of adolescent patients (age, <19 years) who underwent surgery for FAI (arthroscopic/open) was reviewed. Preoperative standing anteroposterior pelvic radiographs were analyzed for femoroepiphyseal acetabular roof (FEAR) index, as well as lateral center-edge angle (LCEA) and alpha, Tönnis, and Sharp angles. Patient-reported outcomes (PROs) (modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score) were analyzed preoperatively and at 1- and 2-year followup. Radiographic indication of risk for reoperation was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlation was calculated between radiographic measurements and PROs at 2 years postoperatively. RESULTS A total of 81 patients (91 hips) underwent primary surgery (57 surgical dislocations vs 34 arthroscopies) for FAI. The mean age at time of primary operation was 16.23 years (range, 10.4-19.6 years) (73.6% female). Eleven hips (12.1%) underwent reoperation at a mean of 20.6 months from primary surgery. The LCEA, FEAR index, Tönnis angle, and Sharp angle before index surgery were significantly different (P < .05) between patients who underwent reoperation and those who did not. ROC analysis indicated that LCEA <22°, FEAR index >-8.7°, Tönnis angle >6.0°, and Sharp angle >44° were predictors for increased risk of reoperation. Using the cutoff values from the ROC analysis in this series, 43% of patients with an LCEA ≤22° had a repeat procedure, while only 8% of those with an LCEA >22° had a repeat procedure. Similar trends were seen with the other aforementioned acetabular radiographic measurements (FEAR index, Tönnis angle, Sharp angle). Patients who did not require a reoperation demonstrated significant improvement in all PRO categories from their preoperative to 2-year postoperative visits (P < .0001). CONCLUSION In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation.
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Affiliation(s)
- Philip A Serbin
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - Tyler R Youngman
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - Benjamin L Johnson
- Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - Philip L Wilson
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - Dan Sucato
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - David Podeszwa
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
| | - Henry B Ellis
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.,Department of Orthopaedic Surgery, Texas Scottish Rite for Children, Dallas, Texas, USA
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Pennock AT, Bastrom TP, Boutelle KE, Carroll AN, Edmonds EW, Nepple JJ, Polinsky SG, Spence DD, Heyworth BE, Perkins C, Willimon SC, Bae DS, Busch MT, Ellis HB, Hergott K, Kocher MS, Li Y, Pandya NK, Sabatini CS, Wilson PL. Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study. Am J Sports Med 2023; 51:871-876. [PMID: 36802767 DOI: 10.1177/03635465231152884] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/23/2023]
Abstract
BACKGROUND Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood. PURPOSE To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction. RESULTS Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling. CONCLUSION Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.
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Affiliation(s)
- Andrew T Pennock
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California San Diego, San Diego, California, USA
| | - Tracey P Bastrom
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Kelly E Boutelle
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Alyssa N Carroll
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Eric W Edmonds
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California San Diego, San Diego, California, USA
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Samuel G Polinsky
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - David D Spence
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, Tennessee, USA
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Donald S Bae
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - Katelyn Hergott
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ying Li
- C. S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Nirav K Pandya
- UCSF Benioff Children's Hospital, Oakland, California, USA
| | | | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
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28
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Kirby JC, Brenner ME, Jones H, Wilson PL, Ellis HB. Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort. Am J Sports Med 2023; 51:656-662. [PMID: 36722715 DOI: 10.1177/03635465221147516] [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: 02/02/2023]
Abstract
BACKGROUND Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population. PURPOSE The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements. RESULTS The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161). CONCLUSION MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.
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Affiliation(s)
- Julia C Kirby
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | - Hunter Jones
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
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29
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Rohde MS, Shea KG, Dawson T, Heyworth BE, Milewski MD, Edmonds EW, Adsit E, Wilson PL, Albright J, Algan S, Beck J, Bowen R, Brey J, Cardelia M, Clark C, Crepeau A, Edmonds EW, Ellington M, Ellis HB, Fabricant P, Frank J, Ganley T, Green D, Gupta A, Heyworth BE, Latz K, Mansour A, Mayer S, McKay S, Milewski M, Niu E, Pacicca D, Parikh S, Rhodes J, Saper M, Schmale G, Schmitz M, Shea K, Storer S, Wilson PL, Ellis HB. Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients. Am J Sports Med 2023; 51:389-397. [PMID: 36629442 DOI: 10.1177/03635465221145939] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/12/2023]
Abstract
BACKGROUND The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options. PURPOSE To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears. STUDY DESIGN Case series; Level of evidence, 4. METHODS Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort. RESULTS There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs. CONCLUSION In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.
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Affiliation(s)
- Matthew S Rohde
- Stanford University School of Medicine, Department of Orthopaedics, Stanford, California, USA
| | - Kevin G Shea
- Stanford University School of Medicine, Department of Orthopaedics, Stanford, California, USA
| | - Timothy Dawson
- Stanford University School of Medicine, Department of Orthopaedics, Stanford, California, USA
| | - Benton E Heyworth
- Boston Children's Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, USA
| | - Matthew D Milewski
- Boston Children's Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Rady Children's Hospital, Division of Orthopaedic Surgery, San Diego, California, USA
| | | | - Philip L Wilson
- Scottish Rite for Children, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Department of Orthopaedics, Dallas, Texas, USA
| | | | - Jay Albright
- Children's Hospital Colorado, Department of Orthopedics, Aurora, Colorado, USA
| | - Sheila Algan
- Oklahoma Children's Hospital, Department of Orthopedic Surgery, Oklahoma City, Oklahoma, USA
| | - Jennifer Beck
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA; Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Richard Bowen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA; Orthopedic Institute for Children's Center for Sports Medicine, Los Angeles, California, USA
| | - Jennifer Brey
- Norton Children's Orthopedics of Louisville, Department of Orthopedics, Louisville, Kentucky, USA
| | - Marc Cardelia
- Children's Hospital of the King's Daughters, Department of Orthopedics and Sports Medicine, Norfolk, Virginia, USA
| | - Christian Clark
- OrthoCarolina Pediatric Orthopaedic Center, Charlotte, North Carolina, USA
| | - Allison Crepeau
- Elite Sports Medicine at Connecticut Children's, Hartford, Connecticut, USA; UConn Health, Division of Sports Medicine, Department of Orthopedics, Farmington, Connecticut, USA
| | - Eric W Edmonds
- Rady Children's Hospital, Division of Orthopaedic Surgery, San Diego, California, USA
| | - Matt Ellington
- Central Texas Pediatric Orthopedics, Department of Orthopedics, Austin, Texas, USA; Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Department of Orthopaedics, Dallas, Texas, USA
| | - Peter Fabricant
- Hospital for Special Surgery, Division of Pediatric Orthopaedic Surgery, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Jeremy Frank
- Joe DiMaggio Children's Hospital, Division of Pediatric Orthopaedics and Spinal Deformities, Hollywood, Florida, USA
| | - Ted Ganley
- Children's Hospital of Philadelphia, Sports Medicine and Performance Center, Philadelphia, Pennsylvania, USA
| | - Dan Green
- Hospital for Special Surgery, Division of Pediatric Orthopaedic Surgery, New York, New York, USA
| | - Andrew Gupta
- Joe DiMaggio Children's Hospital, Division of Pediatric Orthopaedics and Spinal Deformities, Hollywood, Florida, USA
| | - Benton E Heyworth
- Boston Children's Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, USA
| | - Kevin Latz
- Children's Mercy, Department of Orthopedics-Sports Medicine, Kansas City, Missouri, USA
| | - Alfred Mansour
- UTHealth Houston, McGovern Medical School, Department of Orthopedic Surgery, Houston, Texas, USA
| | - Stephanie Mayer
- Children's Hospital of Colorado, Department of Orthopaedic Surgery, Denver, Colorado, USA
| | - Scott McKay
- Texas Children's Hospital, Department of Orthopedic Surgery, Houston, Texas, USA
| | - Matt Milewski
- Boston Children's Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, USA
| | - Emily Niu
- Children's National Medical Center, Department of Orthopedic Surgery and Sports Medicine, Washington, DC, USA
| | - Donna Pacicca
- Children's Mercy, Department of Orthopedics-Sports Medicine, Kansas City, Missouri, USA
| | - Shital Parikh
- Cincinnati Children's Hospital Medical Center, Division of Orthopaedic Surgery, Cincinnati, Ohio, USA
| | - Jason Rhodes
- Children's Hospital Colorado, Department of Orthopedics, Aurora, Colorado, USA
| | - Michael Saper
- Seattle Children's Hospital, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Greg Schmale
- Seattle Children's Hospital, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Matthew Schmitz
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Kevin Shea
- Stanford University School of Medicine, Department of Orthopaedics, Stanford, California, USA
| | - Stephen Storer
- Joe DiMaggio Children's Hospital, Division of Pediatric Orthopaedics and Spinal Deformities, Hollywood, Florida, USA
| | - Philip L Wilson
- Scottish Rite for Children, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Department of Orthopaedics, Dallas, Texas, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Department of Orthopaedics, Dallas, Texas, USA.,Investigation performed at Scottish Rite for Children, University of Texas Southwestern, Dallas, Texas, USA
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Carpenter CM, Cooper SB, Wilson PL, Miller SM, Wyatt CW, Johnson BL, Shea KG, Ellis HB. An Activity Scale for All Youth Athletes? Clinical Considerations for the HSS Pedi-FABS. Orthop J Sports Med 2022; 10:23259671221143534. [PMID: 36582933 PMCID: PMC9793053 DOI: 10.1177/23259671221143534] [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: 08/02/2022] [Accepted: 09/16/2022] [Indexed: 12/24/2022] Open
Abstract
Background The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) has demonstrated normally distributed scores in children aged 10 to 18 years. It has been used to evaluate knee injuries; however, there is limited information regarding its use in evaluating other injury types. Purpose To (1) assess the validity and utility of HSS Pedi-FABS in youth athletes with injuries to different parts of the body and (2) evaluate the association between the HSS Pedi-FABS and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health 7 (PGH), as well as PROMIS-Pain Interference (PGH-PI) and PROMIS-Fatigue (PGH-F) components. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods The authors performed a retrospective review of youth athletes aged 10 to 18 years who completed the HSS Pedi-FABS as part of their previsit intake questionnaire between April 2016 and July 2020. HSS Pedi-FABS score distributions were compared and evaluated for ceiling effects in cohorts determined by demographic, injury characteristic, and sports participation variables; a ceiling effect was determined to be present if >15% of respondents received the highest possible score. HSS Pedi-FABS scores were analyzed for a correlation with PGH, PGH-PI, and PGH-F components. Results Included were 2274 patients (mean age, 14.6 ± 2.1 years; 53.0% female) participating in 21 distinct primary sports for 9.6 ± 7.9 hours per week. The mean HSS Pedi-FABS scores by injury group were as follows: elbow (22.7 ± 6.7), shoulder (21.0 ± 8.7), ankle (20.2 ± 8.8), knee (19.5 ± 9.1), and hip (15.4 ± 10.4) (P < .001). Broad distribution was seen in each cohort, with no floor or ceiling effects. The HSS Pedi-FABS score correlated with patient-reported hours per week (r = 0.33), days per week (r = 0.33), and years of participation (r = 0.21) (P < .001 for all). All 3 PROMIS components correlated with HSS Pedi-FABS: PGH (r = 0.28), PGH-PI (r = -0.11), and PGH-F (r = -0.15) (P < .001). Conclusion Study findings indicated that the HSS Pedi-FABS is a valid tool for measuring physical activity level in most injured youth athletes, not just those with knee injuries. The correlation of HSS Pedi-FABS with the PGH suggests a positive relationship of childhood physical activity with general health.
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Affiliation(s)
- Connor M. Carpenter
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA.,Texas A&M University School of Medicine, Bryan, Texas,
USA.,Connor M. Carpenter, BBA, Center for Excellence in Sports
Medicine, Scottish Rite for Children, 5700 Dallas Pkwy, Frisco, TX 75034, USA
() (Twitter: @CMCarpenter25)
| | - Savannah B. Cooper
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA
| | - Philip L. Wilson
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA.,Department of Orthopaedic Surgery, University of Texas Southwestern
Medical Center, Dallas, Texas, USA
| | - Shane M. Miller
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA.,Department of Orthopaedic Surgery, University of Texas Southwestern
Medical Center, Dallas, Texas, USA
| | - Charles W. Wyatt
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA
| | - Benjamin L. Johnson
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA
| | - Kevin G. Shea
- Department of Orthopaedic Surgery, Stanford University School of
Medicine, Stanford, California, USA
| | - Henry B. Ellis
- Center for Excellence in Sports Medicine, Scottish Rite for
Children, Frisco, Texas, USA.,Department of Orthopaedic Surgery, University of Texas Southwestern
Medical Center, Dallas, Texas, USA
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Miller SM, Zynda AJ, Sabatino MJ, Jo C, Ellis HB, Dimeff RJ. A Pilot Randomized Controlled Trial of Docosahexaenoic Acid for the Treatment of Sport-Related Concussion in Adolescents. Clin Pediatr (Phila) 2022; 61:785-794. [PMID: 35722886 DOI: 10.1177/00099228221101726] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 11/16/2022]
Abstract
The objective was to examine the use of docosahexaenoic acid (DHA) for the treatment of sport-related concussion (SRC) in adolescent athletes. We hypothesize that participants who intake 2 g of DHA daily will not experience differences in recovery compared with participants who take a placebo. This double-blind, randomized controlled pilot trial was performed in a tertiary pediatric sports medicine clinic from 2013 to 2017 in adolescents (14-18 years) presenting with diagnosed SRC within 4 days of injury. Forty participants were randomized into DHA or PLACEBO group and were instructed to take 2 capsules twice daily for 12 weeks. Participants in the DHA group were symptom-free earlier than the PLACEBO group (11.0 vs 16.0 days, P = .08) and were cleared to begin the Return to Sport progression (14.0 vs 19.5 days, P = .12) sooner. The use of 2 g/day of DHA was well-tolerated and did not significantly affect recovery times in adolescent athletes following SRC.Clinical Trial Registration: ClincalTrials.gov, NCT01903525.
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Affiliation(s)
- Shane M Miller
- Scottish Rite for Children, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Chanhee Jo
- Scottish Rite for Children, Dallas, TX, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ha AS, Chang EY, Bartolotta RJ, Bucknor MD, Chen KC, Ellis HB, Flug J, Leschied JR, Ross AB, Sharma A, Thomas JM, Beaman FD. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022; 19:S409-S416. [PMID: 36436966 DOI: 10.1016/j.jacr.2022.09.009] [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] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Roger J Bartolotta
- Division Chief, Musculoskeletal Imaging, Weill Cornell Medical College, New York, New York
| | - Matthew D Bucknor
- Associate Chair, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Karen C Chen
- Musculoskeletal Radiology Section Chief, VA San Diego Healthcare System, San Diego, California
| | - Henry B Ellis
- Medical Director, Clinical Research, Texas Scottish Rite Hospital for Children, Dallas, Texas; American Academy of Orthopaedic Surgeons; Board of Directors, Pediatric Research in Sports Medicine; Board of Directors, Texas Orthopaedic Association; Council of Delegates, Texas Representative, AAOS
| | - Jonathan Flug
- Committee Chair, Radiology Quality Oversight, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jessica R Leschied
- Committee on Emergency Radiology-GSER, Henry Ford Health System, Detroit, Michigan
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Akash Sharma
- Chair, Research Committee, Radiology and Chair, PET-MRI Workgroup, Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | - Jonelle M Thomas
- Vice-Chair, Clinical Affairs and Director, Radiology Informatics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Cruz AI, Lee RJ, Kushare I, Baghdadi S, Green DW, Ganley TJ, Ellis HB, Mistovich RJ. Tibial Spine Fractures in Young Athletes. Clin Sports Med 2022; 41:653-670. [DOI: 10.1016/j.csm.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Heyworth BE, Pennock AT, Li Y, Liotta ES, Dragonetti B, Williams D, Ellis HB, Nepple JJ, Spence D, Willimon SC, Perkins CA, Pandya NK, Kocher MS, Edmonds EW, Wilson PL, Busch MT, Sabatini CS, Farley F, Bae DS. Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. Am J Sports Med 2022; 50:3045-3055. [PMID: 35984091 DOI: 10.1177/03635465221114420] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. PURPOSE/HYPOTHESIS The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity-based confounders for creation of comparable subgroups for analysis. RESULTS Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of "suboptimal" scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ-5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. CONCLUSION Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. REGISTRATION NCT04250415 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Brittany Dragonetti
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry B Ellis
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Jeffrey J Nepple
- Department of Orthopedic Surgery, School of Medicine, Washington University, St Louis, Missouri, USA
| | - David Spence
- Department of Orthopaedic Surgery, Campbell Clinic Orthopaedics, Memphis, Tennessee, USA
| | | | - Crystal A Perkins
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Philip L Wilson
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Michael T Busch
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Frances Farley
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Fabricant PD, Heath MR, Mintz DN, Emery K, Veerkamp M, Gruber S, Green DW, Strickland SM, Wall EJ, Shubin Stein BE, Parikh SN, Chambers CC, Ellis HB, Farr J, Heyworth BE, Koh JL, Kramer DE, Magnussen RA, Redler LH, Sherman SL, Tompkins MA, Wilson PL. Many Radiographic and Magnetic Resonance Imaging Assessments for Surgical Decision Making in Pediatric Patellofemoral Instability Patients Demonstrate Poor Interrater Reliability. Arthroscopy 2022; 38:2702-2713. [PMID: 35398485 DOI: 10.1016/j.arthro.2022.03.033] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training. METHODS Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]: <0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable. RESULTS Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961). CONCLUSIONS With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability. LEVEL OF EVIDENCE II, prospective diagnostic study.
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Affiliation(s)
| | | | | | | | | | - Simone Gruber
- Hospital for Special Surgery, New York, New York, U.S.A
| | | | | | - Eric J Wall
- Cincinnati Children's Hospital, Cincinnati, Ohio, U.S.A
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Ulman S, Erdman AL, Loewen A, Worrall HM, Tulchin-Francis K, Jones JC, Chung JS, Ellis HB, Cullum CM, Miller SM. Improvement in balance from diagnosis to return-to-play initiation following a sport-related concussion: BESS scores vs center-of-pressure measures. Brain Inj 2022; 36:921-930. [PMID: 35957571 DOI: 10.1080/02699052.2022.2109736] [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] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Accurate assessment of balance recovery throughout treatment of a sport-related concussion is imperative. This study examined differences in balance from diagnosis to return-to-play initiation in adolescent patients post-concussion. Second, this study investigated the extent to which the Balance Error Scoring System (BESS) correlated with center-of-pressure (COP) measures. METHODS Forty participants performed the BESS while standing on a force platform such that COP data were obtained simultaneously. Spatial and velocity COP-based measures were computed for the double-stance conditions. RESULTS BESS scores and COP-based measures indicated improved balance performance between visits. Specifically, 62.5/65.0% of participants exhibited improved firm/foam BESS final scores, respectively, and 56.4-71.8% exhibited improved COP-based measures. However, once normative ranges were referenced to identify maintained performance, the percentage of participants who substantially improved differed from initial findings (BESS: 2.5/7.5%, COP: 48.7-69.2%). Additionally, positive correlations between balance measures were primarily found at diagnosis (r=0.33-0.53), while only three correlations were maintained at return-to-play initiation (r=0.34-0.39). CONCLUSIONS BESS scores successfully identified poor balance performance at diagnosis when symptoms were most pronounced, but failed to accurately depict performance once balance impairment, indicated by COP-based measures, became less apparent. Further work is needed to implement more advanced balance assessments into clinical environments.
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Affiliation(s)
- Sophia Ulman
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashley L Erdman
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA
| | - Alex Loewen
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA
| | - Hannah M Worrall
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA
| | - Kirsten Tulchin-Francis
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jacob C Jones
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jane S Chung
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B Ellis
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - C Munro Cullum
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shane M Miller
- Scottish Rite for Children, Division Director of Movement Science Lab, Frisco, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Baskar D, Stavinoha TJ, Sanchez M, Gupta A, Randhawa SD, Rohde MS, Vuong B, Tompkins MA, Ganley TJ, Ellis HB, Wilson PL, Fabricant PD, VandenBerg C, Green DW, Segovia NA, Shea KG. Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study. Am J Sports Med 2022; 50:2433-2438. [PMID: 35763589 DOI: 10.1177/03635465221103250] [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: 01/31/2023]
Abstract
BACKGROUND The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients. PURPOSE To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens. STUDY DESIGN Descriptive laboratory study. METHODS A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface. RESULTS The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts (P < .047) and the younger and older cohorts (P < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively. CONCLUSION This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens. CLINICAL RELEVANCE As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.
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Affiliation(s)
- Danika Baskar
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Tyler J Stavinoha
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Mark Sanchez
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Anshal Gupta
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Sahej D Randhawa
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Matthew S Rohde
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Brian Vuong
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Marc A Tompkins
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Theodore J Ganley
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Henry B Ellis
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Philip L Wilson
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Peter D Fabricant
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Curtis VandenBerg
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Daniel W Green
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Nicole A Segovia
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
| | - Kevin G Shea
- Investigation performed at Stanford University School of Medicine, Stanford, California, USA
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38
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Shimberg JL, Leska TM, Cruz AI, Ellis HB, Patel NM, Yen YM, Schmale GA, Mistovich RJ, Fabricant PD, Ganley TJ, Green DW, Johnson B, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes J, Sachleben B, Traver JL. Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group. Orthop J Sports Med 2022; 10:23259671221099572. [PMID: 35677019 PMCID: PMC9168882 DOI: 10.1177/23259671221099572] [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: 01/31/2022] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm–displaced fractures
of the tibial eminence and anterior cruciate ligament (ACL) insertion that
are traditionally managed nonoperatively with immobilization. Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and
therefore do not require advanced imaging or additional interventions aside
from immobilization. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 52 patients who were classified by their treating institution
with type 1 tibial spine fractures. Patients aged ≤18 years with
pretreatment plain radiographs and ≤ 1 year of follow-up were included.
Pretreatment imaging was reviewed by 4 authors to assess classification
agreement among the treating institutions. Patients were categorized into 2
groups to ensure that outcomes represented classic type 1 fracture patterns.
Any patient with universal agreement among the 4 authors that the fracture
did not appear consistent with a type 1 classification were assigned to the
type 1+ (T1+) group; all other patients were assigned to the true type 1
(TT1) group. We evaluated the rates of pretreatment imaging, concomitant
injuries, and need for operative interventions as well as treatment outcomes
overall and for each group independently. Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group,
while 8 were in the T1+ group, indicating less than universal agreement in
the classification of these fractures. Overall, 12 (25%) underwent surgical
treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required
additional surgical management including ACL reconstruction (n = 4), lateral
meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an
incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1). Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior
thought, a substantial number of patients with these fractures (>20%)
were found to have concomitant injuries. Overall, surgical management was
performed in 25% of patients in our cohort.
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Affiliation(s)
- Jilan L. Shimberg
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Tomasina M. Leska
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Aristides I. Cruz
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Henry B. Ellis
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Neeraj M. Patel
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Yi-Meng Yen
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Gregory A. Schmale
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Justin Mistovich
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Peter D. Fabricant
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Theodore J. Ganley
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Daniel W. Green
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Benjamin Johnson
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Indranil Kushare
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Jay Lee
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Scott D. McKay
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Todd A. Milbrandt
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jason Rhodes
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Brant Sachleben
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jessica L. Traver
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
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Tisano B, Zynda AJ, Ellis HB, Wilson PL. Epidemiology of Pediatric Gymnastics Injuries Reported in US Emergency Departments: Sex- and Age-Based Injury Patterns. Orthop J Sports Med 2022; 10:23259671221102478. [PMID: 35722179 PMCID: PMC9201328 DOI: 10.1177/23259671221102478] [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: 11/30/2021] [Accepted: 01/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Despite increasing participation rates in youth gymnastics, the majority of
epidemiologic literature focuses on older elite athletes or stratifies
athletes by level of competition. Hypothesis: The authors hypothesized that sex- and age-based patterns in youth
gymnastics–related injuries exist, which are otherwise overlooked in an
unstratified population. Study Design: Descriptive epidemiology study. Methods: Publicly available injury data from the National Electronic Injury
Surveillance System were collected on pediatric gymnastics injuries
presenting to emergency departments in the United States. Participation data
from the National Sporting Goods Association were used to calculate national
injury incidence rates in 7- to 11-year-olds (childhood) and 12- to
17-year-olds (adolescence) from January 1, 2012, to December 31, 2018.
Z tests were conducted for the comparison of injury
rates between girls and boys within each age group and for overall injury
rate across age groups. Results: Girls participated in gymnastics at a frequency 6.5 times that of boys in
childhood and 13.5 times that of boys in adolescence. An estimated 72,542
youth gymnastics–related injuries were reported in US emergency departments
each year. A large proportion (61.3%) occurred in childhood, with female
predominance in both age groups. Overall, there was no difference in
weighted annual injury rate (injuries per 100,000 athlete-days per year) by
age group (6.9 [childhood] vs 8.8 [adolescence]; P = .19)
or sex (7.4 [girls] vs 8.1 [boys]; P = .65). In
adolescence, boys were more likely than girls to experience injury (16.47 vs
8.2; P = .003). Wrist and lower arm fractures were more
common in childhood than adolescence (1.07 vs 0.43; P =
.002) and specifically in girls (childhood vs adolescence, 1.06 vs 0.37;
P = .001). Ankle injuries and concussions were more
common in adolescence vs childhood (P = .01 and .0002). Conclusion: Upper extremity injuries predominated among childhood gymnasts, particularly
girls. In adolescence, girls and boys experienced increases in concussions
and foot and ankle injuries. Although representing a lower overall number of
training gymnasts as compared with girls, adolescent boys experience a
higher rate of injuries overall.
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Affiliation(s)
- Breann Tisano
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aaron J Zynda
- Michigan State University, East Lansing, Michigan, USA
| | - Henry B Ellis
- University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Scottish Rite for Children, Dallas, Texas, USA
| | - Philip L Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Scottish Rite for Children, Dallas, Texas, USA
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40
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Beck JJ, Carpenter CM, West N, Sabatino MJ, Ellis HB. Treatment Variability and Complications Associated With Pediatric Lateral Ankle Injuries: A POSNA Quality, Safety, and Value Initiative Survey. Orthop J Sports Med 2022; 10:23259671221100223. [PMID: 35668871 PMCID: PMC9163735 DOI: 10.1177/23259671221100223] [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: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/26/2022] Open
Abstract
Background Isolated pediatric lateral ankle injuries, including ankle sprain (AS) and nondisplaced Salter-Harris type 1 (SH-1) distal fibular fracture, are common orthopaedic sports-related injuries. Variability in treatment is suspected among pediatric orthopaedic surgeons. Complications from medical treatment or lack thereof have not been reported in this population. Purpose The purpose of this study was to investigate treatment variability and associated complications after pediatric AS and SH-1 via a survey of members of the Pediatric Orthopaedic Society of North American (POSNA). Study Design Cross-sectional study. Level of evidence, 5. Methods A voluntary, anonymous survey was distributed to POSNA membership (approximately 1400 members) via email. Survey questions, specific to both grade 1 or 2 AS and nondisplaced or minimally displaced SH-1 injuries in skeletally immature patients, focused on initial evaluation, immobilization, return to sports, and complications. We analyzed variability both in treatment between AS and SH-1 injury and in respondent characteristics. For statistical analysis, chi-square or Fisher exact test was used for categorical variables, and analysis of variance was used for continuous variables. Results The survey response rate was 16.4% (229/1400). Of the respondents, 27.7% used examination only to distinguish between AS and SH-1, whereas 18.7% performed serial radiography to aid with diagnosis. A controlled ankle motion boot or walking boot was the most common immobilization technique for both AS (46.3%) and SH-1 (55.6%); the second most common technique was bracing in AS (33.5%) and casting in SH-1 (34.7%). Approximately one-third of all respondents recommended either outpatient or home physical therapy for AS, whereas only 11.4% recommended physical therapy for SH-1 (P < .01). Results showed that 81.2% of respondents reported no complications for SH-1 treatment and 87.8% reported no complications for AS treatment. Cast complications were reported by 9.6% for SH-1 and 5.2% for AS. Rare SH-1 complications included distal fibular growth arrest, infection, nonunion, late fracture displacement, and recurrent fracture. Conclusion Significant variability was found in primary treatment of pediatric AS and SH-1 injuries. Rare complications from injury, treatment, and neglected treatment after SH-1 and AS were reported.
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Affiliation(s)
- Jennifer J. Beck
- Orthopaedic Institute for Children, Los Angeles, California, USA
| | | | - Nicole West
- Orthopaedic Institute for Children, Los Angeles, California, USA
| | | | - Henry B. Ellis
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern, Dallas, Texas, USA
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McGinley J, Stapleton E, Worrall H, Ellis HB, Wilson PL, Ulman S. Sport Participation and Psychosocial Factors Which Influence Athletic Identity in Youth Athletes With Anterior Cruciate Ligament Injury. Front Psychol 2022; 13:906300. [PMID: 35712149 PMCID: PMC9197472 DOI: 10.3389/fpsyg.2022.906300] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Athletic identity, or the degree with which individuals identify with the athlete role, is an important rehabilitation factor for sports care providers to consider; however, it lacks extensive study in youth. The purpose of this study was to identify demographic, sport participation, and psychosocial measures which correlate with youth athletic identity after anterior cruciate ligament injury. Participants completed standardized sports medicine intake and patient-reported outcome measures, including the Athletic Identity Measurement Scale (AIMS). A total of 226 participants were included, and two groups were created based on high or low total AIMS score. Results indicated that sex (p = 0.002), years active in sport (p = 0.049), activity level (p = 0.038), and ACSI-Coachability (p = 0.027) differed by AIMS score. While youth athletes appear resilient, these results emphasize that they identify strongly with the athlete role and may suffer psychosocial consequences after injury. Future work should evaluate similar factors over course of recovery in a larger, diversified population.
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Affiliation(s)
- James McGinley
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, United States
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- *Correspondence: James McGinley,
| | - Emily Stapleton
- Department of Psychology, Scottish Rite for Children, Frisco, TX, United States
| | - Hannah Worrall
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
| | - Henry B. Ellis
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Philip L. Wilson
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sophia Ulman
- Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Shimberg JL, Leska TM, Cruz AI, Patel NM, Ellis HB, Ganley TJ, Johnson B, Milbrandt TA, Yen YM, Mistovich RJ. A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures. J Pediatr Orthop 2022; 42:195-200. [PMID: 35067605 DOI: 10.1097/bpo.0000000000002049] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Aristides I Cruz
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | - Ben Johnson
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | - R Justin Mistovich
- Case Western Reserve University
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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Ellis HB, Ulman SM, John Wagner K, Carpenter CM, Gale EB, Shea KG, Wilson PL. Youth athletes sleep more, practice less, and may lose interest in playing sports due to social distancing mandates. Prev Med Rep 2022; 26:101722. [PMID: 35132371 PMCID: PMC8811421 DOI: 10.1016/j.pmedr.2022.101722] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/09/2022] [Accepted: 01/29/2022] [Indexed: 02/07/2023] Open
Abstract
62% were single sports athletes with >50% elementary and middle school aged. Specialization may contribute to psychological symptoms following routine alteration. Training hours per week decreased 3.3 h per week during the pandemic. Older participants, age 15–19 reported the least compliance with social distancing.
In-person sport participation was suspended across the United States in the spring of 2020 to slow the spread of the novel coronavirus (COVID-19). The purpose of this study was to survey the impact of COVID-19 on young athletes during a period of social and organized sports restrictions. An anonymous cross-sectional survey study was conducted of youth athletes in the midst of social distancing mandates and consisted of six components: demographics, sport participation, changes in sport-related goals/aspirations, sleep habits, and measures of anxiety and depression. 711 individuals who accessed the survey link yielded 575 (81%) participants with responses available for analysis. All respondents (aged 13.0 years) played organized sports, 62% were single-sport athletes, and 74% considered high-level. Participants were training ∼3.3 h less per week, spending more time outside, and 86% of participants continued to train while social distancing. Sleep duration increased (∼1.2 h/night) and sleep quality improved in 29% of young athletes. Additionally, 22% and 28% reported PROMIS® anxiety and depression scores characterized as ‘mild’, ‘moderate’, or ‘severe’. Older single-sport participants reported higher depression scores, while higher anxiety scores were seen in female participants with fewer years played. 10% of young athletes and 20% of teenagers changed their sports-related goals. Training style modifications, decreased training, and increased sleep quantity and quality were positive effects of COVID-19 restrictions, while athletic aspirational changes were undesirable effects. Single-sport athletes may be at greater risk for psychological symptoms when their routine is altered.
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Affiliation(s)
- Henry B. Ellis
- Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA
- University of Texas Southwestern Medical Center, Department of Orthopaedic Surgery, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
- Corresponding author.
| | - Sophia M. Ulman
- Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA
- University of Texas Southwestern Medical Center, Department of Orthopaedic Surgery, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - K. John Wagner
- Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA
| | - Connor M. Carpenter
- Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA
| | - Emily B. Gale
- Scottish Rite for Children, Department of Psychology, 2222 Welborn St, Dallas, TX 75219, USA
| | - Kevin G. Shea
- Stanford University School of Medicine, Department of Orthopaedic Surgery, 291 Compus Dr, Stanford, CA 94305, USA
| | - Philip L. Wilson
- Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA
- University of Texas Southwestern Medical Center, Department of Orthopaedic Surgery, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [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: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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Tisano B, Ellis HB, Wyatt C, Wilson PL. Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee. Orthop J Sports Med 2022; 10:23259671211072515. [PMID: 35178463 PMCID: PMC8844736 DOI: 10.1177/23259671211072515] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 09/21/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied. Purpose: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed). Results: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm2 and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; P = .002) and more commonly male (80% vs 35%; P = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; P = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; P = .04) and KOOS Quality of Life (87.0 vs 56.8; P = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion. Conclusion: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.
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Affiliation(s)
- Breann Tisano
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B. Ellis
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children Sports Medicine Campus, Frisco, Texas, USA
| | - Chuck Wyatt
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L. Wilson
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Scottish Rite for Children Sports Medicine Campus, Frisco, Texas, USA
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Abstract
PURPOSE OF REVIEW The incidence of patellar instability in pediatric patients ranges is 50-100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population. RECENT FINDINGS In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment. SUMMARY Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.
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Affiliation(s)
- Nicolas Pascual-Leone
- Divison of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Henry B Ellis
- Department of Orthopaedics Surgery, University of Texas Southwestern, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
| | - Daniel W Green
- Divison of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Zynda AJ, Wagner KJ, Liu J, Chung JS, Miller SM, Wilson PL, Ellis HB. Epidemiology of Pediatric Basketball Injuries Presenting to Emergency Departments: Sex- and Age-Based Patterns. Orthop J Sports Med 2022; 10:23259671211066503. [PMID: 35071658 PMCID: PMC8777358 DOI: 10.1177/23259671211066503] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022] Open
Abstract
Background: There is limited epidemiologic data on pediatric basketball injuries and the
comparison of these injuries before and after adolescence and between male
and female athletes. Purpose: To assess common sex- and age-based injury patterns in pediatric basketball
players. Study Design: Descriptive epidemiology study. Methods: Injury data from the National Electronic Injury Surveillance System (NEISS)
and participation data from the National Sporting Goods Association were
used to complete this study. Data on pediatric basketball injuries between
January 2012 and December 2018 in patients aged 7 to 11 years (childhood)
and 12 to 17 years (adolescence) were extracted and used to calculate
national injury incidence rates with 95% CIs. Sex and age group patterns
were examined utilizing Pearson chi-square tests. Z tests
were conducted for the comparison of injury rates between female and male
athletes in each age group and overall injury rate across age groups. Results: An average of 9582 basketball injuries were reported annually in the NEISS,
which calculated to an annual national estimate of 294,920 injuries. The
most common diagnoses were ankle strain/sprain (17.7%), finger
strain/sprain/fracture (12.1%), concussion/head injury (9.4%), knee
strain/sprain (4.5%), and facial laceration (3.3%). There was a significant
increase in injury prevalence in adolescents (12- to 17-year-old category:
238,678 injuries per year) when compared with childhood (7- to 11-year-old
category: 56,242 injuries per year) (P < .0001).
Concussions/head injuries occurred at a high rate in childhood, second only
to finger strain/sprain/fracture, and at a similar rate in females and males
(injuries per 100,000 athlete-days: 4.9 [95% CI, 3.1-6.7] vs. 5.9 [4.3-7.5],
respectively; P = .41). From childhood to adolescence,
injury prevalence increased for all areas and across both sexes, except for
female finger strain/sprain/fracture; however, the rate of increase for
concussion/head injuries and knee injuries was significantly higher in
female compared with male athletes (P < .0001 for both).
In adolescents, ankle injuries were the most common injury overall. Conclusion: Ankle injuries continue to be the most predominant pediatric basketball
injury. However, disproportionate rates of both knee and concussion/head
injuries in female athletes during adolescent basketball are of concern and
have implications for injury prevention.
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Affiliation(s)
| | | | - Jie Liu
- Scottish Rite for Children, Dallas, Texas, USA
| | - Jane S. Chung
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shane M. Miller
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L. Wilson
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B. Ellis
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Nissen CW, Albright JC, Anderson CN, Busch MT, Carlson C, Carsen S, Chambers HG, Edmonds EW, Ellermann JM, Ellis HB, Erickson JB, Fabricant PD, Ganley TJ, Green DW, Grimm NL, Heyworth BE, Po JHH, Kocher MS, Kostyun RO, Krych AJ, Latz KH, Loveland DM, Lyon RM, Mayer SW, Meenen NM, Milewski MD, Myer GD, Nelson BJ, Nepple JJ, Nguyen JC, Pace JL, Paterno MV, Pennock AT, Perkins CA, Polousky JD, Saluan P, Shea KG, Shearier E, Tompkins MA, Wall EJ, Weiss JM, Willimon SC, Wilson PL, Wright RW, Zbojniewicz AM, Carey JL. Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort. Am J Sports Med 2022; 50:118-127. [PMID: 34818065 DOI: 10.1177/03635465211057103] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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 Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. PURPOSE To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. RESULTS As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. CONCLUSION The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.
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Affiliation(s)
- Carl W Nissen
- PRISM Sports Medicine, Hartford, Connecticut; Hartford Healthcare's Bone and Joint Institute, Hartford, Connecticut, USA
| | | | | | | | - Cathy Carlson
- College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota, USA
| | - Sasha Carsen
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Henry G Chambers
- Rady Children's Hospital and UC San Diego, San Diego, California, USA
| | - Eric W Edmonds
- Rady Children's Hospital and UC San Diego, San Diego, California, USA
| | | | - Henry B Ellis
- Scottish Rite for Children Sports Medicine, Frisco, Texas, USA
| | - John B Erickson
- Children's Hospital of Wisconsin, Greenfield, Wisconsin, USA
| | | | - Theodore J Ganley
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | - Regina O Kostyun
- Hartford Healthcare's Bone and Joint Institute, Hartford, Connecticut, USA
| | | | | | | | - Roger M Lyon
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Norbert M Meenen
- Asklepios Hospital St. George, Children's Sports Medicine, Hamburg, Germany
| | | | - Gregory D Myer
- Emory Sport Performance and Research Center, Flowery Branch, Georgia; Emory Sports Medicine Center, Atlanta, Georgia; Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Jeffrey J Nepple
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jie C Nguyen
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - J Lee Pace
- Andrew's Institute, Children's Health, Plano, Texas, USA
| | - Mark V Paterno
- Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andrew T Pennock
- Rady Children's Hospital and UC San Diego, San Diego, California, USA
| | | | - John D Polousky
- Akron Children's Hospital Department of Orthopedics, Akron, Ohio, USA
| | | | - Kevin G Shea
- Stanford Children's Hospital, Sunnyvale, California, USA
| | - Emily Shearier
- Hartford Healthcare's Bone and Joint Institute, Hartford, Connecticut, USA
| | - Marc A Tompkins
- Gillette Children's Specialty Healthcare; University of Minnesota; TRIA Orthopaedic Center, Minneapolis, Minnesota, USA
| | - Eric J Wall
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer M Weiss
- Southern California Permanente Medical Group, Los Angeles, California, USA
| | | | - Philip L Wilson
- Scottish Rite for Children Sports Medicine, Frisco, Texas, USA
| | - Rick W Wright
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew M Zbojniewicz
- Michigan State University; Advanced Radiology Services, Grand Rapids, Michigan, USA
| | - James L Carey
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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- Investigation performed at multiple sites
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49
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Pennock AT, Heyworth BE, Bastrom T, Bae DS, Boutelle KE, Busch MT, Edmonds EW, Ellis HB, Hergott K, Kocher MS, Li Y, Liotta ES, Pandya NK, Perkins C, Sabatini CS, Spence DD, Willimon SC, Wilson PL, Nepple JJ. Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study. J Shoulder Elbow Surg 2021; 30:2729-2737. [PMID: 34089880 DOI: 10.1016/j.jse.2021.05.006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/03/2021] [Accepted: 05/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. METHODS This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. RESULTS One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. CONCLUSION Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.
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Affiliation(s)
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Donald S Bae
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | | | | | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Katelyn Hergott
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ying Li
- C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Elizabeth S Liotta
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Nirav K Pandya
- UCSF Benioff Children's Hospital-Oakland, Oakland, CA, USA
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50
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Smith HE, Mistovich RJ, Cruz AI, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Fabricant PD, Green DW, Jagodzinski J, Johnson B, Kushare I, Lee RJ, McKay SD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Yen YM, Patel NM. Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures? Am J Sports Med 2021; 49:3842-3849. [PMID: 34652247 DOI: 10.1177/03635465211046928] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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Affiliation(s)
- Haley E Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - R Justin Mistovich
- Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I Cruz
- School of Medicine, Brown University, Providence, Rhode Island, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M Leska
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J Ganley
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T Aoyama
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Peter D Fabricant
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason Jagodzinski
- UCSF Benioff Children's Hospital, San Francisco, California, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Benjamin Johnson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J Lee
- Johns Hopkins Children's Center, Baltimore, Maryland, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T Rhodes
- Children's Hospital Colorado, Aurora, Colorado, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C Sachleben
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - M Catherine Sargent
- Central Texas Pediatric Orthopaedics, Austin, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA].,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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