Early- and Late-Stage Benefits of Blood Flow Restriction Training on Knee Strength in Adolescents After Anterior Cruciate Ligament Reconstruction.

Background: Blood flow restriction training (BFRT) after anterior cruciate ligament reconstruction (ACLR) is rising in popularity because of its benefits in reducing muscle atrophy and mitigating knee strength deficits. Purpose: To investigate the impact BFRT has on adolescent knee strength after ACLR at 2 postoperative time points: at 3 months and the time of return to sport (RTS). Study Design: Cohort study; Level of evidence, 3. Methods: A prospective intervention (BFRT) group was compared to an age-, sex-, and body mass index-matched retrospective control group. Patients aged 12 to 18 years who underwent primary ACLR with a quadriceps tendon autograft were included. Along with a traditional rehabilitation protocol, the BFRT group completed a standardized BFRT protocol (3 BFRT exercises performed twice weekly for the initial 12 weeks postoperatively). Peak torque values for isometric knee extension and flexion strength (at 3 months and RTS) and isokinetic strength at 180 deg/s (at RTS) as well as Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected. Differences between the BFRT and control groups were compared with 2-way mixed analysis of variance and 1-way analysis of variance. Results: The BFRT group consisted of 16 patients (10 female; mean age, 14.84 ± 1.6 years) who were matched to 16 patients in the control group (10 female; mean age, 15.35 ± 1.3 years). Regardless of the time point, the BFRT group demonstrated significantly higher isometric knee extension torque compared to the control group (2.15 ± 0.12 N·m/kg [95% CI, 1.90-2.39] vs 1.74 ± 0.12 N·m/kg [95% CI, 1.49-1.98], respectively; mean difference, 0.403 N·m/kg; P = .024). The BFRT group also reported significantly better Pedi-IKDC scores compared to the control group at both 3 months (68.91 ± 9.68 vs 66.39 ± 12.18, respectively) and RTS (89.42 ± 7.94 vs 72.79 ± 22.81, respectively) (P = .047). Conclusion: In adolescents, the addition of a standardized BFRT protocol to a traditional rehabilitation protocol after ACLR significantly improved knee strength and patient-reported function compared to a traditional rehabilitation program alone.

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

BACKGROUND: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. PURPOSE: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). RESULTS: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. CONCLUSION: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction.

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.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients.

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.

Reliability of Radiographic Imaging Characteristics for Osteochondritis Dissecans of the Capitellum.

BACKGROUND: A primary challenge in the treatment of capitellar osteochondritis dissecans (OCD) is accurate imaging assessment. Radiographic classification consensus is not available in the current literature, and correlation of radiographs with lesion stability and resultant best treatment is lacking. PURPOSE: To determine the inter- and intrarater reliability of the presence or absence and common radiographic characteristics of capitellar OCD lesions. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Anteroposterior, lateral, and oblique radiographs for 29 cases were reviewed by 7 orthopaedic surgeons. Images were assessed for elbow anthropometry and morphology, OCD presence, lesion characteristics, the presence of progeny bone and progeny features, and radial head abnormalities. Intra- and interrater reliability was assessed using Fleiss and Cohen kappa for nominal variables and intraclass correlation coefficients (ICCs) for continuous variables. RESULTS: Surgeons demonstrated substantial to excellent inter- and intrarater reliability when assessing elbow characteristics: anthropometric (interrater ICC, 0.94-0.99; intrarater ICC, 0.82-0.96) and morphologic (Fleiss, 0.61-0.76; Cohen, 0.68). When the OCD lesion was assessed, fair to moderate interrater agreement was found for classifying the absence or presence of a lesion (Fleiss, 0.28-0.46) and the location of the OCD (Fleiss, 0.24-0.52), poor agreement for assessing the contour of the lesion (Fleiss, 0.00-0.09), and excellent agreement for measuring the size of the lesion (ICC, 0.82-0.94). Poor to fair interrater agreement was found for radial head abnormalities (Fleiss, 0.00-0.27). Progeny bone visualization and fragmentation demonstrated moderate interrater agreement (Fleiss, 0.43-0.47) where displacement of the bone demonstrated poor interrater agreement (Fleiss, 0.11-0.16). Intrarater agreement for OCD lesion characteristics, progeny bone visualization, and progeny bone features was moderate to excellent. CONCLUSION: Given only the fair to moderate agreement among raters for identifying OCD on radiographs, this imaging modality may not serve as a dependable screening tool in isolation. Additional imaging should be obtained if the clinical presentation suggests capitellar OCD and a definitive diagnosis is not possible with radiographs. However, clinicians can reliability measure the size of radiographically apparent OCD, suggesting that radiographs may serve as an appropriate imaging modality for follow-up care.

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

BACKGROUND: Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine. METHODS: An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in. RESULTS: Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%). CONCLUSIONS: Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old. LEVEL OF EVIDENCE: Level of evidence IV.

Side Effects and Patient Tolerance with the Use of Blood Flow Restriction Training after ACL Reconstruction in Adolescents: A Pilot Study.

Background: Blood flow restriction training (BFRT) has gained popularity in rehabilitation due to its benefits in reducing muscle atrophy and mitigating strength deficits following anterior cruciate ligament reconstruction (ACLR). While the effectiveness and safety of BFRT has been well studied in healthy adult subjects, there is limited information about the use of BFRT in the adolescent population, specifically related to patient tolerance and reported side effects post ACLR. Purpose: To investigate and record reported side effects and patient tolerance to BFRT during ACLR rehabilitation in adolescents. Study Design: Prospective Cohort Study. Methods: Patients between 12 and 18 years of age who underwent ACLR at Connecticut Children's were included. Patients utilized an automatic personalized tourniquet system and followed a standardized BFRT exercise protocol over 12 weeks starting 8.72 ± 3.32 days post-op. Upon completion of exercise while using BFRT, patients reported side effects and any adverse events were logged. Descriptive statistics were used to describe the reported side effects and adverse events associated with BFRT and calculate the frequencies of those events over a 12-week period. Results: Five hundred and thirty-five total BFRT sessions were completed between 29 patients (15.39 ± 1.61 years of age). There were zero reports of subcutaneous hemorrhage (SubQ hemorrhage) and deep vein thrombosis (DVT). Reported minor side effects to BFRT included itchiness of the occluded limb (7.85%), lower extremity paresthesia (2.81%), and dizziness (0.75%). A total of 10.47% of BFR treatment sessions were unable to be completed due to tolerance, and 3.5% of sessions required a reduction in limb occlusion pressure (LOP). Conclusion: These preliminary data suggest that BFRT is safe with only minor side effects noted in the adolescent population after ACLR. Further investigations are warranted to continue to evaluate patient tolerance and safety with BFRT, because while these preliminary results suggest a positive safety profile and good tolerance in the adolescent population after ACLR, they represent the experiences of only a small sample. Level of Evidence: Level 3.

Favorable Patient-Reported Outcomes and High Return to Sport Rates Following Hip Arthroscopy in Adolescent Athletes: A Systematic Review.

PURPOSE: The purpose of this systematic review is to synthesize the existing literature surrounding hip arthroscopy in the adolescent athlete population to determine patient-reported outcomes, return to sport rates, complications, and reoperations associated with this intervention. METHODS: A systematic literature review was performed using PubMed (MEDLINE), Cochrane Library, and Embase according to PRISMA guidelines. Studies were included if they were published in English with greater than 2 participants, contained patients aged 10-19 years old or classified as "high school athletes" or "middle school athletes," and reported postoperative patient-reported outcomes and return to sport. Patient-reported outcomes (PROs) and their associated P values were recorded. Finally, return-to-sport outcomes and sports played were also extracted from the included studies. Weighted kappa was used to assess inter-reviewer agreement. RESULTS: Eleven studies included in the final analysis, resulting in 344 patients and 408 hips were analyzed by this review. Patient-reported outcomes (PROs) were reported in all studies. The modified Harris Hip Score (mHHS) was used in all but 1 study. Six of the 11 studies reported a 100% return-to-sport rate, for a total of 98/98 athletes returning to sport. Fabricant et al. did note that a majority of athletes who returned to sport were able to do so at a subjective "nearly normal" level. Only 4 of the studies reported complications, with the majority being transient neuropraxias. CONCLUSIONS: Adolescent athletes who undergo hip arthroscopy demonstrate favorable postoperative patient-reported outcome scores, high rates of return to sport, and an overall low complication rate. The heterogeneity in both surgical methodology and outcome measures used for evaluation and treatment leads to continued ambiguity with regard to the optimal method for managing adolescent athletes with hip pathology. LEVEL OF EVIDENCE: V, systematic review of Level II-V studies.

Short-term isokinetic and isometric strength outcomes after anterior cruciate ligament reconstruction in adolescents.

OBJECTIVES: To examine differences in knee strength outcomes after ACL reconstruction according to quadriceps tendon (QT) or hamstring tendon (HT) autograft in adolescents. DESIGN: Retrospective cohort. METHODS: Surgical and clinical outcome data were collected. Analyses were conducted separately for female and male cohorts and grouped by graft type (HT or QT). A Mann-Whitney U test of independent samples was used to examine group differences according to graft type. RESULTS: 107 females (age = 15.6 ± 1.5 years) and 94 males (age = 15.7 ± 1.5 years) were included. Mean time since surgery ranged from 7.2 to 7.9 months. Those with a QT autograft had decreased normalized isokinetic quadriceps peak torque on the involved limb compared to the HT group (p < 0.01, ES = 0.71-0.89). Normalized isometric hamstring peak torque was decreased for those with HT autograft in the female cohort (p = 0.02, ES = 0.57). CONCLUSION: Normalized isokinetic quadriceps peak torque was reduced by 18-20% on the involved limb in those with a QT autograft. Normalized isometric hamstring peak torque was decreased by 13% for those with HT autograft in the female cohort. Method of strength testing may be an important consideration to fully appreciate strength deficits after ACL reconstruction according to graft type.

Traumatic Patellar Dislocations in Childhood and Adolescents.

Patellar instability and associated patellar dislocation can result in significant pain, disability, and associated injuries in young athletes. The patellofemoral joint is a complex articulation with stabilizing restraints, both medially and laterally, that help guide the patella into the corresponding trochlear groove as the knee cycles through an extension-to-flexion arc. In addition to soft tissue injuries, many osseous aberrancies can contribute to patellar instability in young athletes, including trochlear dysplasia, patella alta, and axial and coronal plane abnormalities. There is a role for nonoperative treatment in these young athletes; however, if recurrent or associated injuries are identified surgical intervention is warranted. Correct diagnosis of the underlying cause of the patellar instability is paramount to developing a surgical plan that will yield the most favorable outcome for these young athletes.

Sport Participation and Specialization Characteristics Among Pediatric Soccer Athletes.

BACKGROUND: Soccer is an increasingly popular sport for children and adolescents in the United States. Little is known about participation patterns related to sport specialization. PURPOSE: To investigate soccer participation levels and sport specialization characteristics among youth soccer athletes. STUDY DESIGN: Cross-sectional study. METHODS: Adolescent athletes aged between 12 and 18 years completed an online survey addressing participant demographics, sports and soccer participation history, and level of specialization. Descriptive analyses characterized participation, while chi-square and Kruskal-Wallis tests assessed the influence of specialization, sex, and grade on survey variables. RESULTS: Overall, 83.7% of 746 respondents participated in an organized soccer league outside of school, and 37% played in multiple leagues concurrently. Nearly three-quarters of respondents trained in soccer more than 8 months of the year, with those who participated in club soccer being more likely to train more than 8 months of the year. More respondents were classified as high specialization (37.5%), followed by moderate (35.6%) and low (28.6%) specialization. No differences between sexes were noted for level of specialization or quitting other sports to specialize in soccer, but male athletes were more likely to train more than 8 months per year compared with female athletes. Respondents in older grades (9th-10th and 11th-12th grades) were more likely to be highly specialized and quit other sports to focus on soccer. No differences between grade levels were found among respondents training more than 8 months per year. CONCLUSION: The study findings suggest that many youth soccer athletes participated in multiple teams or leagues at the same time and trained more than 8 months of the year. Characteristics including participation on a club team, level of specialization, and male sex were associated with a greater likelihood of exceeding the 8-month training recommendation.

Intracapsular Pressures After Stable Slipped Capital Femoral Epiphysis.

PURPOSE: Stable slipped capital femoral epiphysis (SCFE) has been shown to have a lower rate of avascular necrosis than unstable SCFE. A recent study found increased intracapsular hip pressures in the setting of unstable SCFE, thus increasing the risk of osteonecrosis. The purpose of this study was to measure the intracapsular pressure in stable SCFE and compare it to the intracapsular pressure in normal hips and in unstable SCFE. METHODS: Thirteen hips with stable SCFE and 15 hips with unstable SCFE were identified. Using a side-bored needle, intracapsular hip pressures were measured at the time of surgery. Within these 2 study groups, 11 unaffected (normal) hips were also measured. Diastolic blood pressure and mean arterial pressure at the time of measurement were also recorded. RESULTS: The average intracapsular hip pressure in the stable SCFE group was 27.0 mm Hg, whereas the average pressure in the unstable SCFE group was 48.2 mm Hg and the average pressure in the normal group was 21.8 mm Hg. There was no significant difference between the normal and stable SCFE groups. There was a statistically significant difference between the stable SCFE and unstable SCFE groups (P<0.001). We found similar trends when comparing the intracapsular hip pressure as a percentage of the mean arterial pressure as well as the difference between diastolic blood pressure and hip pressure. CONCLUSIONS: As expected, the intracapsular pressure in the setting of stable SCFE approaches that of normal hips. This may explain why the risk of AVN in stable SCFE is significantly lower than that of unstable SCFE. It also supports the idea that capsulotomy is indicated for unstable slips to decrease the elevated hip pressure but not in stable SCFE.

Radius crossover sign: an indication of malreduced radius shaft greenstick fractures.

BACKGROUND: Radius shaft greenstick fractures in children can be a challenging injury to treat because angulation and rotational alignment are difficult to assess. METHODS: In this report, we describe a simple method for analyzing the deformity and identifying rotational and angular malalignment. This technique involves analyzing the forearm radiographs as 2 segments, proximal and distal, and assuring that the rotational position of each matches the other. RESULTS: We present 3 cases of proximal radius greenstick fractures in malalignment to demonstrate the radius crossover sign. CONCLUSIONS: Identifying the radius crossover sign, and proceeding with further closed reduction may prevent deformity that could otherwise result in a significant loss of forearm motion. LEVEL OF EVIDENCE: Level V.

Prospective evaluation of patient comprehension of informed consent.

BACKGROUND: Physicians and society may overestimate the level of patient comprehension during the process of obtaining informed consent for medical and surgical treatment. The purpose of this study was to prospectively measure the immediate level of patient comprehension at the time that surgical consent is obtained and the effect of time on this level of understanding. In addition, we studied the effect of sex, education level, and age on comprehension. METHODS: One hundred patients scheduled for elective orthopaedic surgery were enrolled voluntarily into this study. Following discussion of risks and benefits with the surgeon and a reading and explanation of the entire consent form, each patient immediately completed a questionnaire to test recall of the information that had just been reviewed. The same questionnaire was administered to each patient at the first postoperative visit and, if applicable, again at the second postoperative visit. Age, sex, education level, and questionnaire scores were recorded. RESULTS: Ninety-eight patients completed the questionnaire preoperatively and scored an average of 70.7% correct answers. Seventy-five patients completed the first postoperative questionnaire, scoring an average of 59.5%. Thirty-nine patients completed the second postoperative questionnaire, scoring an average of 60.8%. The decline between the preoperative and the first postoperative score was significant. The mean score did not differ significantly according to sex at any time point. College-educated patients scored higher than patients without a college education did on both the preoperative and postoperative questionnaires, with the difference in the preoperative score being significant. Patients who were less than fifty years old scored higher than older patients did, with the difference in the postoperative score being significant. CONCLUSIONS: Patient comprehension and recall immediately following a thorough discussion of the consent form was unexpectedly low. This poor recall deteriorated further between the preoperative visit and the first postoperative visit (a period of no more than two weeks). Greater age and lower education level were associated with poorer comprehension. Sex did not affect any of the scores.