Athletic Identity Associations in Young Sports Medicine Patients.

INTRODUCTION: Few studies have assessed athletic identity levels in young patients. This study examined athletic identity in adolescents and explored associations between athletic identity, patterns of sport participation, and coping skills. METHODS: Patients aged 12 to 18 years who received sports medicine care completed a one-time, voluntary, anonymous survey. Surveys included demographics, sport participation information, Athletic Identity Measurement Scale (AIMS), and Athletic Coping Skills Inventory (ACSI). Statistical analysis included Fisher exact test, Student t test, Wilcoxon rank sum test, Kruskal-Wallis test, and Pearson correlation. RESULTS: Three hundred thirty-four patients (mean ± SD age 15.0 ± 1.8 years, 64.7% girls) completed questionnaires. The mean AIMS and ACSI scores were 45.2 ± 11.5 and 50.2 ± 10.9, respectively. No notable differences were observed in AIMS scores between age groups or sexes. An increase in mean AIMS scores (higher athletic identity) was seen with greater weekly hours of sport participation (P < 0.001) and months per year of primary sport participation (P < 0.001). Multisport per season athletes had higher AIMS scores than single-sport athletes (48.2 ± 10.1 vs. 43.0 ± 11.9, P < 0.001). Team sport athletes reported higher athletic identities than individual sport athletes (47.0 ± 10.7, 41.4 ± 11.4, P < 0.001). Athletic Identity Measurement Scale scores positively correlated with ACSI scores (r = 0.31, P < 0.0001). Athletes with the highest athletic identity had markedly higher scores on ACSI subscales of Coachability, Concentration, Confidence and Achievement Motivation, Goal Setting and Mental Preparation, and Peaking Under Pressure than athletes with the least athletic identity. However, those with the highest athletic identities reported significantly lower scores on the ACSI Freedom From Worry subscale (P < 0.001). DISCUSSION: Athletic identity did not differ among adolescents by age or sex. Athletic identity was higher in team sport athletes and those with increased sport participation volumes. While high athletic identity was associated with higher scores on favorable coping skill dimensions, these athletes may also worry more, potentially placing them at greater psychological risk after injury.

Arthroscopic Bankart Repair for Anterior Glenohumeral Instability in 488 Adolescents Between 2000 and 2020: Risk Factors for Subsequent Recurrent Instability Requiring Revision Stabilization.

BACKGROUND: After arthroscopic Bankart repair (ABR) for anterior glenohumeral instability (GHI), adolescent athletes have higher rates of subsequent recurrent GHI than any other subpopulation. Elucidating which adolescents are at highest risk of postoperative recurrent GHI may optimize surgical decision-making. PURPOSE: To identify prognostic factors associated with subsequent recurrent GHI requiring revision stabilization surgery (RSS) after ABR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The study included patients 12 to 21 years old who had undergone ABR for anterior GHI at a pediatric tertiary care hospital by 1 of 5 sports medicine fellowship-trained surgeons between 2000 and 2020. A multivariate Cox proportional hazards model, with percentage of patients with recurrent GHI undergoing subsequent RSS, was used with a time-to-event outcome analysis. The Cox model effects were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha of .05. RESULTS: Records of 488 adolescent patients with ABR (78% male; mean age, 16.9 ± 1.98 years) were analyzed. Of these, 86 patients (17.6%) underwent subsequent RSS for recurrent GHI, yielding a cumulative risk of 8.8% at 2 years, 16.5% at 5 years, and 20% at 15 years. RSS occurred at a mean of 2.6 ± 2.1 years after ABR. Risk factors for RSS included >1 preoperative dislocation (2 dislocations: HR = 7.4, P = .0003; ≥3 dislocations: HR = 10.9, P < .0001), presence of a Hill-Sachs lesion (small: HR = 2.5, P = .0114; medium-large: HR = 4.2, P = .0004), younger age (1-year decrease: HR = 1.2, P = .0015), and participation in contact sports (HR = 1.8, P = .01). Adolescents with only 1 preoperative dislocation had a cumulative incidence of RSS (3.2%), which was significantly lower than those with 2 (24.2%) or ≥3 preoperative dislocations (33.5%). CONCLUSION: The number of dislocations before index ABR was the strongest risk factor for recurrent GHI requiring RSS in adolescents with anterior GHI, with 2 dislocations conferring >7-fold increased risk compared with a single preoperative dislocation. Other significant risk factors included the presence of a Hill-Sachs lesion, younger age, and participation in contact sports.

Effect of Age and Sex on Anterior Cruciate Ligament Functional Tests Approximately 6 Months After Anterior Cruciate Ligament Reconstruction.

Purpose: To examine age- and sex-related differences in postoperative functional outcomes at approximately 6 months after anterior cruciate ligament reconstruction (ACLR). Methods: In this study, patients who underwent primary ACLR performed a series of return-to-sport functional tests at 5 to 8 months after surgery. Functional tests included strength tests (knee extensors, knee flexors, hip abductors, and hip extensors), a balance test (Y-balance composite score), and hop tests (single, triple, crossover, and 6-m timed hop tests). Limb symmetry was calculated to compare the reconstructed limb with the uninvolved limb. A 2-way multivariate analysis of covariance was used, and effect size was calculated for data analysis. Results: A total of 176 subjects were included in this study. There were no significant interaction between age and sex on return-to-sport functional tests after ACLR. Also, no main effects of age and sex on return-to-sport functional tests were found in our data. Conclusions: Age and sex do not significantly affect functional test performance after ACLR 6 months postoperatively. Level of Evidence: Level III, retrospective review of prospective cohort study.

The Role of Transparency in Digital Contact Tracing During COVID-19: Insights from an Expert Survey.

Health technologies such as apps for digital contract tracing [DCT] played a crucial role in containing and combating infections during the COVID-19 pandemic. Their primary function was to prevent the spread of SARS-CoV-2 by consistently generating and disseminating information related to various events such as encounters, vaccinations or infections. While the functionality of DCT has been well researched, the necessity of transparency in the use of DCT and the consent to share sensitive information such as users' health, vaccination and location status remains unclear. On one hand, DCT enabled the continuous monitoring of various risk factors, including data-based calculations of infection probabilities. On the other hand, digital monitoring of health risks was closely associated with various uncertainties, such as the ambiguous storage of personal data and its potential future misuse, e.g., by tech companies or health authorities. Our contribution aims to retrospectively analyze the COVID-19 pandemic from a post-pandemic perspective and utilize it as a case study for the implementation of new technological measures. We argue that under the condition of voluntary use of DCT, transparency plays a key role in convincing individuals to install health technologies on their mobile devices, keep them activated and consent to the sharing of sensitive data. We support our argument with qualitative data from an expert survey conducted between 2020 and 2021 and analyzed according to the principles of Grounded Theory.

Outcomes of treatment of patella fractures in children and adolescents.

Purpose: The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures. Methods: A retrospective review was completed for patients aged 5-19 years treated for a unilateral patella fracture at a single pediatric level-1 trauma center. Patients were excluded for osteochondral fracture associated with patellar dislocation, polytrauma presentation with additional fractures, or <3 months of clinical follow-up. Functional outcomes were assessed via the Pediatric International Knee Documentation Committee form and the Marx Knee Activity Scale. Results: A total of 53 patients met inclusion criteria; 30 patients were treated operatively and 23 patients were treated nonoperatively. Patients with patellar sleeve/pole fractures were significantly younger by 5.2 years (p < 0.01) and presented with greater variability in mechanism of injury (p < 0.01). The nonoperative cohort achieved bony healing and returned to sports at a median (interquartile range) of 1.7 (1.2-2.3) months and 2.8 (2.3-3.3) months, respectively, post-injury. The operative group achieved bony healing and returned to sports at 2.8 (2.1-3.5) months and 5.9 (4.0-7.1) months, respectively, following surgery. Median (interquartile range) Pediatric International Knee Documentation Committee and Marx scores were 98 (89-100) and 14 (10-16), respectively, for the nonoperative group, and 92 (84-99) and 13 (12-16), respectively, for the operative group. No significant differences in patient-reported outcomes were observed between fracture patterns or treatment cohorts. Conclusion: Pediatric and adolescent patients sustaining patella fractures reported long-term functional outcomes comparable to normative values, across multiple fracture patterns and with appropriate operative and nonoperative treatment. Fractures requiring surgery were expectedly associated with slower healing and return to sport timelines. Level of evidence: Therapeutic Level III.

Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital.

Background: The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts. Hypotheses: That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure. Results: Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort (P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy (P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair (P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts (P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort (P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort (P = .03). Conclusion: More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction.

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital.

BACKGROUND: There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients. HYPOTHESIS: There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL). RESULTS: Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014). CONCLUSION: These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Posterior Tibiotalar Impingement After Pediatric Ankle Fracture Surgical Fixation: A Case Report.

CASE: A 13-year-old healthy, nearly skeletally mature, female patient presented to an outpatient clinic after sustaining a bimalleolar ankle fracture-dislocation, which was subsequently treated with open reduction and internal fixation and casting. Postoperatively, the patient had significant limitations to ankle range of motion. Imaging revealed posterior tibiotalar impingement. The patient underwent arthroscopic debridement and osteoplasty, and she was able to return to previous levels of activity. CONCLUSIONS: Complications from pediatric ankle fractures are rare, so further diagnostic workup is warranted for patients with persistent pain and limitations.

Smartphone Apps for Containing the COVID-19 Pandemic in Germany: Qualitative Interview Study With Experts Based on Grounded Theory.

BACKGROUND: Smartphone apps, including those for digital contact tracing (DCT), played a crucial role in containing infections during the COVID-19 pandemic. Their primary function is to generate and disseminate information to disrupt transmissions based on various events, such as encounters, vaccinations, locations, or infections. Although the functionality of these apps has been extensively studied, there is still a lack of qualitative research addressing critical issues. OBJECTIVE: We will demonstrate that the use of DCT presents a challenge due to the tension between continuous health monitoring and uncertainties related to transparency and user sovereignty. On one hand, DCT enables the monitoring of various risk factors, including data-based calculations of infection probabilities. On the other hand, continuous risk management is intertwined with several uncertainties, including the unclear storage of personal data, who has access to it, and how it will be used in the future. METHODS: We focus on the German "Corona-Warn-App" and support our argument with empirical data from 19 expert interviews conducted between 2020 and 2021. The interviews were conducted using a semistructured questionnaire and analyzed according to the principles of grounded theory. RESULTS: Our data underscores 3 dimensions: transparency, data sovereignty, and the east-west divide. While transparency is considered an essential foundation for establishing trust in the use of DCT by providing a sense of security, data sovereignty is seen as a high value during the pandemic, protecting users from an undesired loss of control. The aspect of the east-west divide highlights the idea of incorporating sociocultural values and standards into technology, emphasizing that algorithms and data-driven elements, such as distance indicators, encounters, and isolations, are also influenced by sociocultural factors. CONCLUSIONS: The effective use of DCT for pandemic containment relies on achieving a balance between individual control and technological prevention. Maximizing the technological benefits of these tools is crucial. However, users must also be mindful of the information they share and maintain control over their shared data.

MRI Analysis of Knee Bony Morphology Variations in Children and Adolescents With Lateral Discoid Meniscus Compared With Asymptomatic Healthy Controls.

BACKGROUND: Lateral discoid meniscus accounts for most meniscal tears in children 10 years of age and younger. The role of bony morphology in discoid meniscus has been previously studied in a limited capacity using radiographs. PURPOSE: To use magnetic resonance imaging to measure features of the femoral condyles and tibial plateaus in patients with discoid meniscus to assess potential determinants of symptoms and subsequent surgery and to compare with matched controls to investigate age-related changes in bony features. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: After institutional review board approval, detailed morphology of the femoral condyles and tibial plateau was measured in 177 patients (3-18 years of age; 56% female) with confirmed lateral discoid meniscus. Measurements from 269 participants (3-18 years of age; 55% female) with asymptomatic knees were used as controls. Two-way analysis of variance with Holm-Sídák post hoc was used to compare measurements between discoid menisci and matched controls. Independent t tests were used to compare aspects of bony morphology within the discoid meniscus cohort. RESULTS: Compared with controls, patients with a lateral discoid meniscus had a larger bicondylar width and notch width (7- to 10-year-old and 15- to 18-year-old age groups; P < .05), larger tibial plateau width (11- to 14-year-old and 15- to 18-year-old age groups; P < .001), and smaller lateral (P < .02) and coronal (P < .02) tibial slopes across all age groups. Among patients with a discoid meniscus, larger bicondylar width, larger tibial plateau width, larger notch width, and a flatter lateral femoral condyle were associated with pain (P < .005) and lateral meniscal tears (P < .02). Larger notch width and notch width index were also associated with subsequent surgery (P < .05). CONCLUSION: There are clinically significant abnormalities in bony morphology in patients with a discoid meniscus, including larger femoral condyles and tibial plateaus and a flatter tibial plateau. Additionally, femoral size, femoral curvature, and tibial plateau size may influence the likelihood of knee pain, meniscal tear, and need for surgery. These findings highlight the importance of bony morphology in discoid meniscus pathophysiology in children and adolescents. Such measurements may also aid radiographic detection of discoid meniscus and guide decisions regarding the timing of potential surgical intervention.

Cultural Implications Regarding Privacy in Digital Contact Tracing Algorithms: Method Development and Empirical Ethics Analysis of a German and a Japanese Approach to Contact Tracing.

BACKGROUND: Digital contact tracing algorithms (DCTAs) have emerged as a means of supporting pandemic containment strategies and protecting populations from the adverse effects of COVID-19. However, the impact of DCTAs on users' privacy and autonomy has been heavily debated. Although privacy is often viewed as the ability to control access to information, recent approaches consider it as a norm that structures social life. In this regard, cultural factors are crucial in evaluating the appropriateness of information flows in DCTAs. Hence, an important part of ethical evaluations of DCTAs is to develop an understanding of their information flow and their contextual situatedness to be able to adequately evaluate questions about privacy. However, only limited studies and conceptual approaches are currently available in this regard. OBJECTIVE: This study aimed to develop a case study methodology to include contextual cultural factors in ethical analysis and present exemplary results of a subsequent analysis of 2 different DCTAs following this approach. METHODS: We conducted a comparative qualitative case study of the algorithm of the Google Apple Exposure Notification Framework as exemplified in the German Corona Warn App and the Japanese approach of Computation of Infection Risk via Confidential Locational Entries (CIRCLE) method. The methodology was based on a postphenomenological perspective, combined with empirical investigations of the technological artifacts within their context of use. An ethics of disclosure approach was used to focus on the social ontologies created by the algorithms and highlight their connection to the question about privacy. RESULTS: Both algorithms use the idea of representing a social encounter of 2 subjects. These subjects gain significance in terms of risk against the background of a representation of their temporal and spatial properties. However, the comparative analysis reveals 2 major differences. Google Apple Exposure Notification Framework prioritizes temporality over spatiality. In contrast, the representation of spatiality is reduced to distance without any direction or orientation. However, the CIRCLE framework prioritizes spatiality over temporality. These different concepts and prioritizations can be seen to align with important cultural differences in considering basic concepts such as subject, time, and space in Eastern and Western thought. CONCLUSIONS: The differences noted in this study essentially lead to 2 different ethical questions about privacy that are raised against the respective backgrounds. These findings have important implications for the ethical evaluation of DCTAs, suggesting that a culture-sensitive assessment is required to ensure that technologies fit into their context and create less concern regarding their ethical acceptability. Methodologically, our study provides a basis for an intercultural approach to the ethics of disclosure, allowing for cross-cultural dialogue that can overcome mutual implicit biases and blind spots based on cultural differences.

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction.

Background: Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process. Purpose: To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores. Study Design: Prospective cohort study; Level of evidence, 2. Methods: Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex. Results: A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001). Conclusion: This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

Pediatric and Adolescent Shoulder Instability.

PURPOSE OF REVIEW: Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations. RECENT FINDINGS: Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.

Predicting anterior cruciate ligament failure load with T2* relaxometry and machine learning as a prospective imaging biomarker for revision surgery.

Non-invasive methods to document healing anterior cruciate ligament (ACL) structural properties could potentially identify patients at risk for revision surgery. The objective was to evaluate machine learning models to predict ACL failure load from magnetic resonance images (MRI) and to determine if those predictions were related to revision surgery incidence. It was hypothesized that the optimal model would demonstrate a lower mean absolute error (MAE) than the benchmark linear regression model, and that patients with a lower estimated failure load would have higher revision incidence 2 years post-surgery. Support vector machine, random forest, AdaBoost, XGBoost, and linear regression models were trained using MRI T2* relaxometry and ACL tensile testing data from minipigs (n = 65). The lowest MAE model was used to estimate ACL failure load for surgical patients at 9 months post-surgery (n = 46) and dichotomized into low and high score groups via Youden's J statistic to compare revision incidence. Significance was set at alpha = 0.05. The random forest model decreased the failure load MAE by 55% (Wilcoxon signed-rank test: p = 0.01) versus the benchmark. The low score group had a higher revision incidence (21% vs. 5%; Chi-square test: p = 0.09). ACL structural property estimates via MRI may provide a biomarker for clinical decision making.

Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration.

BACKGROUND: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Automated segmentation of the healed anterior cruciate ligament from T2 * relaxometry MRI scans.

Collagen organization of the anterior cruciate ligament (ACL) can be evaluated using T2 * relaxometry. However, T2 * mapping requires manual image segmentation, which is a time-consuming process and prone to inter- and intra- segmenter variability. Automating segmentation would address these challenges. A model previously trained using Constructive Interference in Steady State (CISS) scans was applied to T2 * segmentation via transfer learning. It was hypothesized that there would be no significant differences in the model's segmentation performance between T2 * and CISS, structural measures versus ground truth manual segmentation, and reliability versus independent and retest manual segmentation. Transfer learning was conducted using 54 T2 * scans of the ACL. Segmentation performance was assessed with Dice coefficient, precision, and sensitivity, and structurally with T2 * value, volume, subvolume proportions, and cross-sectional area. Model performance relative to independent manual segmentation and repeated segmentation by the ground truth segmenter (retest) were evaluated on a random subset. Segmentation performance was analyzed with Mann-Whitney U tests, structural measures with Wilcoxon signed-rank tests, and performance relative to manual segmentation with repeated-measures analysis of variance/Tukey tests (α = 0.05). T2 * segmentation performance was not significantly different from CISS on all measures (p > 0.35). No significant differences were detected in structural measures (p > 0.50). Automatic segmentation performed as well as the retest on all segmentation measures, whereas independent segmentations were lower than retest and/or automatic segmentation (p < 0.023). Structural measures were not significantly different between segmenters. The automatic segmentation model performed as well on the T2 * sequence as on CISS and outperformed independent manual segmentation while performing as well as retest segmentation.

Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure.

BACKGROUND: Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE: To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS: A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION: Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.

Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery.

PURPOSE: Quantitative magnetic resonance imaging (qMRI) has been used to determine the failure properties of ACL grafts and native ACL repairs and/or restorations. How these properties relate to future clinical, functional, and patient-reported outcomes remain unknown. The study objective was to investigate the relationship between non-contemporaneous qMRI measures and traditional outcome measures following Bridge-Enhanced ACL Restoration (BEAR). It was hypothesized that qMRI parameters at 6 months would be associated with clinical, functional, and/or patient-reported outcomes at 6 months, 24 months, and changes from 6 to 24 months post-surgery. METHODS: Data of BEAR patients (n = 65) from a randomized control trial of BEAR versus ACL reconstruction (BEAR II Trial; NCT02664545) were utilized retrospectively for the present analysis. Images were acquired using the Constructive Interference in Steady State (CISS) sequence at 6 months post-surgery. Single-leg hop test ratios, arthrometric knee laxity values, and International Knee Documentation Committee (IKDC) subjective scores were determined at 6 and 24 months post-surgery. The associations between traditional outcomes and MRI measures of normalized signal intensity, mean cross-sectional area (CSA), volume, and estimated failure load of the healing ACL were evaluated based on bivariate correlations and multivariable regression analyses, which considered the potential effects of age, sex, and body mass index. RESULTS: CSA (r = 0.44, p = 0.01), volume (r = 0.44, p = 0.01), and estimated failure load (r = 0.48, p = 0.01) at 6 months were predictive of the change in single-leg hop ratio from 6 to 24 months in bivariate analysis. CSA (ßstandardized = 0.42, p = 0.01), volume (ßstandardized = 0.42, p = 0.01), and estimated failure load (ßstandardized = 0.48, p = 0.01) remained significant predictors when considering the demographic variables. No significant associations were observed between MRI variables and either knee laxity or IKDC when adjusting for demographic variables. Signal intensity was also not significant at any timepoint. CONCLUSION: The qMRI-based measures of CSA, volume, and estimated failure load were predictive of a positive functional outcome trajectory from 6 to 24 months post-surgery. These variables measured using qMRI at 6 months post-surgery could serve as prospective markers of the functional outcome trajectory from 6 to 24 months post-surgery, aiding in rehabilitation programming and return-to-sport decisions to improve surgical outcomes and reduce the risk of reinjury. LEVEL OF EVIDENCE: Level II.

Changes in the Cross-Sectional Profile of Treated Anterior Cruciate Ligament Within 2 Years After Surgery.

Background: The cross-sectional area (CSA) of the anterior cruciate ligament (ACL) and reconstructed graft has direct implications on its strength and knee function. Little is known regarding how the CSA changes along the ligament length and how those changes vary between treated and native ligaments over time. Hypothesis: It was hypothesized that (1) the CSA of reconstructed ACLs and restored ACLs via bridge-enhanced ACL restoration (BEAR) is heterogeneous along the length. (2) Differences in CSA between treated and native ACLs decrease over time. (3) CSA of the surgically treated ACLs is correlated significantly with body size (ie, height, weight, body mass index) and knee size (ie, bicondylar and notch width). Study Design: Cohort study; Level of evidence, 2. Methods: Magnetic resonance imaging scans of treated and contralateral knees of 98 patients (n = 33 ACL reconstruction, 65 BEAR) at 6, 12, and 24 months post-operation were used to measure the ligament CSA at 1% increments along the ACL length (tibial insertion, 0%; femoral insertion, 100%). Statistical parametric mapping was used to evaluate the differences in CSA between 6 and 24 months. Correlations between body and knee size and treated ligament CSA along its length were also assessed. Results: Hamstring autografts had larger CSAs than native ACLs at all time points (P < .001), with region of difference decreasing from proximal 95% of length (6 months) to proximal 77% of length (24 months). Restored ACLs had larger CSAs than native ACLs at 6 and 12 months, with larger than native CSA only along a small midsubstance region at 24 months (P < .001). Graft CSA was correlated significantly with weight (6 and 12 months), bicondylar width (all time points), and notch width (24 months). Restored ACL CSA was significantly correlated with bicondylar width (6 months) and notch width (6 and 12 months). Conclusion: Surgically treated ACLs remodel continuously within the first 2 years after surgery, leading to ligaments/grafts with heterogeneous CSAs along the length, similar to the native ACL. While reconstructed ACLs remained significantly larger, the restored ACL had a CSA profile comparable with that of the contralateral native ACL. In addition to size and morphology differences, there were fundamental differences in factors contributing to CSA profile between the ACL reconstruction and BEAR procedures. Registration: NCT02664545 (ClinicalTrials.gov identifier).