Return to play in paediatric & adolescent patients following anterior cruciate ligament reconstruction

BACKGROUND

There is an increased risk of anterior cruciate ligament (ACL) rupture and subsequent ACL reconstruction in patients <18 years old due to their high levels of sporting participation.

PURPOSE

The purpose of this study was to assess the rate and timing of return to play (RTP) in paediatric and adolescent patients following ACL reconstruction, and to compare the outcomes between those undergoing ACL reconstruction with bone patella tendon bone autograft (BTB) and hamstring tendon (HT) autograft.

STUDY DESIGN

Level of Evidence: Level III; Retrospective Comparative Cohort Study.

METHODS

The institutional ACL registry was screened for patients <18 that had undergone a primary ACL reconstruction. Outcomes were analysed for patients undergoing either a BTB or HT autograft for rate and timing of return to play, functional outcomes and subsequent knee injuries. Statistical analysis was performed using SPSS.

RESULTS

358 (BTB; 253, HT; 105) patients were followed up for 24-months (95% follow up). 86 athletes (27 BTB; 59 HT) were aged 13-15 years old with no significant difference in RTP rate or timing between graft types, however, there was a difference in ipsilateral re-ruptures (10.2% HT vs 0% BTB p = 0.03). 272 athletes (226 BTB; 46 HT) were aged 16-18 years old with no significant difference in RTP rate or timing between graft types, or ipsilateral re-ruptures (8.7% HT vs 2.7% BTB p = 0.07). Concurrent ligament, meniscal or chondral injuries found at the time was treated as necessary.

CONCLUSION

Paediatric and adolescent patients undergoing ACL reconstruction with either BTB or HT had high rates of return to play. This was seen in both subgroups with 13-15-year-olds mostly receiving a HT graft repair and 16-18-year-olds mainly receiving a BTB repair. A moderate re-rupture rate was seen at 24-months. However longer follow up is needed to truly see the long-term impact of such an injury at such a young age.

Type V superior labral anterior-posterior tears results in lower rates of return to play

PURPOSE

The purpose of this study was to evaluate the rate of return to play (RTP) in patients who underwent Type V superior labrum anterior-posterior (SLAP) repair compared to patients who underwent isolated Bankart repair in the setting of traumatic anterior shoulder instability.

METHODS

A retrospective review of patients who underwent arthroscopic Bankart repair and SLAP repair by a single surgeon between 2012 and 2017 was performed. Additionally, these were pair-matched in a 1:2 ratio for age, sex, sport and level of pre-operative play, with those undergoing isolated arthroscopic Bankart repair alone as a control group. RTP, level of RTP and the timing of RTP were assessed.

RESULTS

The study included a total of 96 patients, with 32 in the study group and 64 in the control group, and a mean follow-up of 59 months. Overall, there was no significant difference in the overall rate of return to play (26/32 (81.3%) vs 56/64 (87.5%), n.s), but there was a significantly higher rate of RTP at the same/higher level in the control group (14/32 (43.6%) vs 43/64 (67.2%), p = 0.0463). There was no significant difference in timing of RTP between the groups (n.s). There was no significant difference in recurrent instability (6/32 (18.8%) vs 5/64 (7.8%), n.s) but there was a significant difference in revision rates (5/32 (15.6%) vs. 2/64 (3.1%), p = 0.0392) between the Type V SLAP repair group and the control group.

CONCLUSION

Following arthroscopic repair, patients with Type V SLAP tears had a similar overall rate of RTP when compared directly to a control group of patients who underwent arthroscopic Bankart repair alone. However, those who underwent Type V SLAP repair reported significantly lower rates of RTP at the same or higher level compared to the control group.

LEVEL OF EVIDENCE

III.

Hippocampal deformation mapping in MRI negative PET positive temporal lobe epilepsy

OBJECTIVES

To compare hippocampal surface structure, using large deformation high dimensional mapping (HDM-LD), in subjects with temporal lobe epilepsy (TLE) with (HS+ve) and without (HS-ve) hippocampal sclerosis.

METHODS

The study included 30 HS-ve subjects matched with 30 HS+ve subjects from the previously reported epilepsy patient cohort. To control for normal right-left asymmetries of hippocampal surface structure, subjects were regrouped based on laterality of onset of epileptic seizures and presence of HS. Gender ratio, age, duration of epilepsy and seizure frequency were calculated for each of the four groups. Final HDM-LD surface maps of the right and left TLE groups were compared to define differences in subregional hippocampal involvement within the groups.

RESULTS

There were no significant differences in comparisons of the left TLE (left HS-ve compared with HS+ve) or right TLE (right HS-ve compared with HS+ve) groups with respect to age, duration of epilepsy or seizure severity scores. HDM-LD maps showed accentuated surface changes over the lateral hippocampal surface, in the region of the Sommer sector, in the hippocampi affected by HS. However, HS-ve hippocampi showed maximal surface changes in a different pattern, and did not involve the region of Sommer sector.

CONCLUSION

We conclude that differences in segmental volume loss between the HS-ve and HS+ve groups are suggestive that the underlying pathophysiology of hippocampal changes in the two groups is different, and not related to chronic seizure duration or severity.

Predictive value of hippocampal MR imaging-based high-dimensional mapping in mesial temporal epilepsy: preliminary findings

BACKGROUND AND PURPOSE

We objectively assessed surface structural changes of the hippocampus in mesial temporal sclerosis (MTS) and assessed the ability of large-deformation high-dimensional mapping (HDM-LD) to demonstrate hippocampal surface symmetry and predict group classification of MTS in right and left MTS groups compared with control subjects.

METHODS

Using eigenvector field analysis of HDM-LD segmentations of the hippocampus, we compared the symmetry of changes in the right and left MTS groups with a group of 15 matched controls. To assess the ability of HDM-LD to predict group classification, eigenvectors were selected by a logistic regression procedure when comparing the MTS group with control subjects.

RESULTS

Multivariate analysis of variance on the coefficients from the first 9 eigenvectors accounted for 75% of the total variance between groups. The first 3 eigenvectors showed the largest differences between the control group and each of the MTS groups, but with eigenvector 2 showing the greatest difference in the MTS groups. Reconstruction of the hippocampal deformation vector fields due solely to eigenvector 2 shows symmetrical patterns in the right and left MTS groups. A "leave-one-out" (jackknife) procedure correctly predicted group classification in 14 of 15 (93.3%) left MTS subjects and all 15 right MTS subjects.

CONCLUSION

Analysis of principal dimensions of hippocampal shape change suggests that MTS, after accounting for normal right-left asymmetries, affects the right and left hippocampal surface structure very symmetrically. Preliminary analysis using HDM-LD shows it can predict group classification of MTS and control hippocampi in this well-defined population of patients with MTS and mesial temporal lobe epilepsy (MTLE).

Hemifacial motor and crying seizures of temporal lobe onset: case report and review of electro-clinical localisation

OBJECTIVE

To report a case of temporal lobe epilepsy with clinical presentation of paroxysmal episodes of "tightness" over the right hemiface, and ictal crying, and review electroclinical localisation of this phenomenon.

METHODS

Clinical semiology, neurophysiological localising tests, and epilepsy surgery outcome are reported in a subject presenting with paroxysmal right hemifacial movements and ictal crying. Pertinent past reports of somato-motor signs and ictal crying in temporal lobe epilepsy are reviewed and the findings correlated with proposed human facial cortical representation.

RESULTS

Simple partial seizures caused by temporal lobe epilepsy presented with right sided tonic facial movements and ictal crying. Intracranial EEG monitoring documented a left medial temporal onset of seizures that remained asymptomatic until they propagated to the left cingulate region. Anterior temporal lobectomy with resection of the amygdala and anterior hippocampus resulted in cessation of seizures.

CONCLUSIONS

This is a rare example of epileptic seizures of medial temporal onset presenting with isolated somato-motor manifestations and ictal crying. Anatomical-electrical-clinical correlations with cortical regions controlling facial movements were highly suggestive that this case represents secondary activation of "emotional" motor cortex M3 and M4 (rostral and caudal cingulate motor cortex), giving rise to focal hemifacial movements and ictal crying.

Total percentage body weight changes during add-on therapy with tiagabine, carbamazepine and phenytoin

Changes in body weight were evaluated in 349 patients from a study comparing efficacy of add-on therapy with tiagabine (TGB), carbamazepine (CBZ) or phenytoin (PHT). TGB add-on therapy showed no significant weight changes when added to either PHT or CBZ. CBZ add-on therapy showed a significant percentage weight gain of a mean body increase of 1.5% (P = 0.002). Adjunctive TGB therapy had no significant effect on total body weight, while adjunctive CBZ therapy was associated with weight gain.

Mesial temporal sclerosis and temporal lobe epilepsy: MR imaging deformation-based segmentation of the hippocampus in five patients

In five patients with mesial temporal sclerosis, the authors verified the precision and reproducibility of hippocampal segmentations with deformation-based magnetic resonance (MR) imaging. The overall percentage overlap between automated segmentations was 92.8% (SD, 3.5%), between manual segmentations was 73.1% (SD, 9.5%), and between automated and manual segmentations was 74.8% (SD, 10.3%). Deformation-based hippocampal segmentations provided a precise method of hippocampal volume measurement in this patient population.

Shape analysis of hippocampal surface structure in patients with unilateral mesial temporal sclerosis

Structural hippocampal magnetic resonance (MR) imaging-based analysis is helpful in the diagnosis and treatment of mesial temporal epileptic seizures. Computational anatomic techniques provide a framework for objective assessment of three-dimensional hippocampal structure. We applied a previously validated technique of deformation-based hippocampal segmentations in 20 subjects with documented unilateral mesial temporal sclerosis (MTS) and temporal lobe epilepsy. Using composite images, we then measured shape differences between the epileptogenic, smaller hippocampus, and contralateral hippocampus. Final shape differences were projected on the contralateral "normal" side. We calculated results for the left MTS group (10 patients) and right MTS group (10 patients) separately. Both groups showed similar regions of maximal inward deformation in the affected hippocampus, which were the medial and lateral aspect of the head, and posterior aspect of the tail. These results suggest that there are specific three-dimensional patterns of volume loss in patients with mesial temporal epilepsy.

Magnetic resonance imaging deformation-based segmentation of the hippocampus in patients with mesial temporal sclerosis and temporal lobe epilepsy

We compared manual and automated segmentations of the hippocampus in patients with mesial temporal sclerosis. This comparison showed good precision of the deformation-based automated segmentations.

Magnetic resonance and positron emission tomography changes during the clinical progression of Rasmussen encephalitis

The authors describe serial positron emission tomography (PET) and magnetic resonance imaging (MRI) studies in a patient with pathologically confirmed Rasmussen Encephalitis (RE). Results of initial PET and MRI studies were normal. Subsequent studies showed involvement of the percentral and postcentral gyri and the putamen on PET, and the precentral and postcentral gyri on MRI. Coregistration of PET and MR images showed good correlation between the precentral and postcentral gyri involvement. However, subcortical involvement occurred earlier on PET than on MRI. The authors demonstrate the evolution of changes on PET and MR images in a patient with RE. Despite early pathologic confirmation of RE, there were no definite structural or functional imaging changes on PET or MRI until 3 years after symptom onset. These findings demonstrate the variability of imaging changes in RE, and the need to carefully correlate electro-physiologic and clinical findings to confirm the diagnosis of RE.

Triple-technique (MR imaging, single-photon emission CT, and CT) coregistration for image-guided surgical evaluation of patients with intractable epilepsy

Ictal and interictal single-photon emission CT (SPECT) play an increasingly important role in the surgical evaluation of patients with epilepsy. We present a method of coregistration of MR, SPECT, and CT images to correlate structural data (MR imaging), blood flow changes (SPECT), and location of subdural electrodes (CT) for patients undergoing image-guided surgical treatment of epilepsy. MR-SPECT root mean square (rms) mismatch distances were 2.1 to 2.5 mm, and MR-CT rms mismatch distances were 1.0 to 4.5 mm. Coregistration assisted in image-guided placement of subdural electrodes and in surgical resection of the suspected epileptogenic focus.

Perfusion patterns in postictal 99mTc-HMPAO SPECT after coregistration with MRI in patients with mesial temporal lobe epilepsy

OBJECTIVES

To assess patterns of postictal cerebral blood flow in the mesial temporal lobe by coregistration of postictal 99mTc-HMPAO SPECT with MRI in patients with confirmed mesial temporal lobe epilepsy.

METHODS

Ten postictal and interictal 99mTc-HMPAO SPECT scans were coregistered with MRI in 10 patients with confirmed mesial temporal lobe epilepsy. Volumetric tracings of the hippocampus and amygdala from the MRI were superimposed on the postictal and interictal SPECT. Asymmetries in hippocampal and amygdala SPECT signal were then calculated using the equation: % Asymmetry =100 x (right - left) / (right + left)/2.

RESULTS

In the postictal studies, quantitative measurements of amygdala SPECT intensities were greatest on the side of seizure onset in all cases, with an average % asymmetry of 11.1, range 5.2-21.9. Hippocampal intensities were greatest on the side of seizure onset in six studies, with an average % asymmetry of 9.6, range 4.7-12.0. In four scans the hippocampal intensities were less on the side of seizure onset, with an average % asymmetry of 10.2, range 5.7-15.5. There was no localising quantitative pattern in interictal studies.

CONCLUSIONS

Postictal SPECT shows distinctive perfusion patterns when coregistered with MRI, which assist in lateralisation of temporal lobe seizures. Hyperperfusion in the region of the amygdala is more consistently lateralising than hyperperfusion in the region of the hippocampus in postictal studies.

Tooth-brushing epilepsy: a report of a case with structural and functional imaging and electrophysiology demonstrating a right frontal focus

Patients with reflex epilepsies may provide insights into cerebral pathophysiology. We report a patient with an unusual form of reflex epilepsy in whom seizures are induced by tooth brushing. Magnetic resonance imaging (MRI) demonstrated a right posterior frontal low-grade tumor predominantly involving the precentral gyrus. Video-telemetry demonstrated right-sided epileptiform activity during a typical induced complex partial seizure. An ictal single photon emission computed tomography (SPECT) scan showed an area of hyperfusion that corresponded to the MRI lesion on coregistration with a surface-matching technique. A subsequent coregistered interictal SPECT scan demonstrated hypoperfusion in the same region. Ours is the first report to demonstrate a structural focus in this unusual form of reflex epilepsy. Possible mechanisms to explain the induction of the seizures are discussed.

Accuracy of coregistration of single-photon emission CT with MR via a brain surface matching technique

We describe a technique of brain surface matching of single-photon emission CT and MR images in human subjects and document the accuracy of this technique with the use of fiduciary markers. This mismatch averaged 4.3 mm as measured by the fiduciary markers and 2.1 mm as measured by the root mean square distance.

Epilepsy in the nevoid basal-cell carcinoma syndrome (Gorlin syndrome): report of a case due to a focal neuronal heterotopia

We present a case of uncontrolled temporal lobe epilepsy due to a focal left temporal neuronal heterotopia associated with the nevoid-basal-cell carcinoma syndrome. This is the first pathologically described lesion associated with temporal lobe epilepsy in this syndrome. Because the patient's seizures resolved after a modified left anterior temporal lobectomy, this case illustrates that epilepsy in patients with the nevoid basal-cell carcinoma syndrome is potentially curable and should be investigated appropriately.

The magnitude of longitudinal chromatic aberration of the human eye between 458 and 633 nm

The longitudinal chromatic aberration (LCA) of the human eye was determined between wavelengths 458 and 633 nm for ten observers by incorporating Argon and Helium-Neon Lasers into a Badal optometer system such that tonic (or "dark focus") resting positions of accommodation could be measured under darkroom conditions. A mean chromatic range of 1.87 D was found between 488 and 633 nm. The range increased slightly to 1.91 D when the experiment was repeated under cycloplegia on a subset of three subjects. Additional wavelengths (458 and 476 nm) for a further subset (four subjects) increased the range to 2.65 D. This magnitude of LCA would support recent predictions based on Abbe and Pulfrich refractometry analyses of the dispersion of the human crystalline lens and ocular media.

The effect of Timolol Maleate on tonic accommodation, tonic vergence, and pupil diameter

The beta-adrenoceptor antagonist Timolol Maleate (0.5%) was employed topically to determine whether the resting (or "tonic") position of accommodation is a consequence of steady-state equilibrium between parasympathetic and sympathetic innervation of the ciliary muscle. Ten subjects were used, eight men and two women, with an age range of 19-37 (mean = 23.2). All subjects wore an optimum refractive correction giving visual acuities of 20/20 or better. Darkroom measurements of tonic accommodation (TA), tonic vergence (TV), and pupil diameter were determined with a Badal laser optometer , a nonius alignment device and infra-red photography, respectively. Far and near points of accommodation and oculo-motor balance tests were determined by standard optometric techniques and intraocular pressure (IOP) was measured by applanation tonometry. Both TA (mean = 1.66 D) and TV (mean = 2.10 deg) assumed intermediate resting positions in the absence of visual stimulation. A double-blind protocol between Timolol and Saline demonstrated a mean myopic shift in TA of +0.85 D over 40 min with Timolol. All other experimental parameters, apart from IOP, were unaffected by Timolol. It is concluded that sympathetic innervation to the ciliary muscle plays a significant role in determining the TA position and that this innervation is mediated by inhibitory beta adrenoceptors.