RESUMEN
CONTEXT: Palliative Care (PC) is poorly understood by laypersons. However, little is known about what ambulatory patients with cancer understand about PC or what barriers to access exist. METHODS: Outpatients undergoing cancer treatment completed a survey evaluating their familiarity and knowledge of PC, Palliative Care Knowledge Scale (PaCKS), feelings towards PC (before and after reading a definition of PC), barriers to PC, and prognostic understanding. We summarized responses descriptively and used logistic regression models to examine variables associated with familiarity and interest. RESULTS: The survey response rate was 32%. Of 151 participants, 58.9% reported familiarity with PC. The average PaCKs score was 11.9 out of 13 (standard deviation, 1.4), with 46.4% receiving a perfect score, indicating high knowledge of PC. Patients diagnosed more than one year ago had significantly increased odds of being familiar with PC (OR 2.93; 95% CI 1.37-6.25). More participants reported future interest in PC compared to current interest (74.2% vs 44.4%, respectively). Patients with stage III or IV cancer had significantly increased odds of having a current interest in receiving PC compared to patients with stage I or II disease (OR 2.66; 95% CI: 1.05, 6.76). Participants reported feeling significantly less anxious and more reassured after reading a standardized definition of PC (P < 0.05). CONCLUSION: Outpatients with cancer who are being treated at a large academic cancer center exhibit high awareness and knowledge of PC, but anxiety toward PC persists. Factors beyond knowledge may perpetuate the delayed or lack of involvement with PC. KEY MESSAGE: In this cross-sectional study of outpatients with cancer, findings suggest that high knowledge of PC may co-exist with a lingering uneasiness towards the service. Additionally, factors beyond knowledge, such as logistic barriers, anxiety, and oncologists' preference may be perpetuating the delay or lack of involvement in PC.
Asunto(s)
Enfermería de Cuidados Paliativos al Final de la Vida , Neoplasias , Humanos , Cuidados Paliativos , Pacientes Ambulatorios , Estudios Transversales , Neoplasias/terapia , Encuestas y CuestionariosRESUMEN
Importance: Intergenerational cycles of adversity likely increase one's risk of criminal legal system involvement, yet associations with potential contributors, such as parents' adverse childhood experiences (ACEs) and positive childhood experiences (PCEs), have not been explored. Objective: To investigate the association of parents' ACEs and PCEs with their adult children's involvement in US legal systems, from arrest to conviction. Design, Setting, and Participants: The study team analyzed data from the Panel Study of Income Dynamics (PSID), a nationally representative cohort study of families in the US. PSID-2013 survey data were merged with the 2014 PSID Childhood Retrospective Circumstances Study (CRCS), collected May 2014 to January 2015, which asked adults aged 18 to 97 years to retrospectively report on their childhood experiences. Parents and their adult children were linked in the data set. Data were analyzed from October 2022 to September 2023. Main Outcomes and Measures: The child arrest outcome was regressed on parents' ACE and PCE scores using logistic regression models. In addition, multinomial logistic regression models were used to assess the associations of parents' ACE and PCE scores with the number of times their child was arrested and convicted. Results: Of 12â¯985 eligible individuals, 8072 completed the CRCS. Among CRCS participants, there were 1854 eligible parent-child dyads (ie, parents and their adult children) that formed the analytic sample. The mean (SD) age of offspring at the time of CRCS completion was 38.5 (10.9) years, and 1076 offspring (51.3%) were female. Having 4 or more parental ACEs was associated with 1.91-fold (95% CI, 1.14-3.22) higher adjusted odds of arrest before age 26 and 3.22-fold (95% CI, 1.62-6.40) higher adjusted odds of conviction before age 26 years, compared with children of parents without ACEs. These associations persisted after controlling for parental PCEs. Conclusions and Relevance: In this nationally representative study, children of parents with higher ACEs were at greater risk of arrest during adolescence and young adulthood, even after controlling for parents' PCEs. Addressing and preventing childhood adversity through multigenerational life course approaches may help disrupt intergenerational pathways to the criminal legal system.
Asunto(s)
Criminales , Adolescente , Adulto , Humanos , Femenino , Adulto Joven , Masculino , Estudios de Cohortes , Estudios Retrospectivos , Hijos Adultos , PadresRESUMEN
Background: There are potential drawbacks and complications associated with using the anterior approach to harvest the hamstring tendon as an autograft source for anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstruction. A posterior harvest technique has been described as an alternative to an anterior approach in skeletally mature patients. The 2 approaches have not been compared in adolescents. Purpose: We sought to compare the incision size and harvested tendon length produced by anterior and posterior hamstring harvest techniques in an adolescent population. Methods: After obtaining consent, we prospectively collected data on a consecutive series of 115 adolescents undergoing ACL or MPFL reconstruction, including the length of the incision and of the harvested hamstring tendon. Demographic information including age, sex, and body mass index (BMI) was collected at the time of surgery. Results: The mean age at the time of surgery was 14.3 ± 1.8 years (range: 9-21 years), and 43% (N = 50) of participants were male. Of the 115 hamstring autografts, 26 were harvested anteriorly and 89 were harvested posteriorly. Neither mean semitendinosus length nor mean gracilis length was significantly different when harvested anteriorly versus posteriorly. The posterior harvest group had a mean incision length that was significantly smaller than that of the anterior harvest group. No iatrogenic nerve injuries or neurovascular complications were observed in either group. Conclusion: A posterior incision for hamstring autograft harvest provided an alternative approach in adolescents, which resulted in a 20% smaller incision than an anterior approach. For procedures such as MPFL reconstruction that do not require concomitant anteromedial work, posterior hamstring harvest may be used to improve cosmesis while producing viable hamstring autograft tissue for surgical reconstruction.
RESUMEN
Background: Osteochondral fractures can occur during patellar dislocation and often require treatment. The purpose of this study is to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction. Methods: A retrospective review of a cohort of 365 medial patellofemoral ligament reconstructions by a single surgeon from 2008 to 2019 was performed to identify patients who underwent simultaneous osteochondral fracture fixation with bioabsorbable nails. Demographic data, surgical details, clinical follow-up, and subsequent procedures were collected. Results: Forty medial patellofemoral ligament reconstructions with osteochondral fracture fixation were performed by a single surgeon from 2008 to 2019. The average age at surgery was 14.6 years (range 10.7-19.6 years). The average length of follow-up was 2.6 years (range 0.7-7.0 years). Eleven (28%) patients required a second surgery on the ipsilateral knee. One patient had recurrent instability and required revision medial patellofemoral ligament reconstruction and osteochondral allograft. The other 10 patients underwent a second surgery to address cartilage damage or debridement of nails. Of the four patients who required nail debridement, the average number of nails initially placed was 7 ± 1.7. This was significantly more than the patients who did not require second surgery related to nail debridement (4.1 ± 1.6, p < .05). Conclusion: 28% of patients required a second procedure, most of which involved debridement of unhealed portions of the osteochondral fracture. At 2.6-year follow-up, only 2% of patients had a failure of their osteochondral fracture fixation requiring a cartilage restoration procedure. Osteochondral fracture fixation in adolescents with patellofemoral instability can be effectively treated with fixation and simultaneous medial patellofemoral ligament reconstruction. Level of evidence: level IV.
RESUMEN
PURPOSE: To highlight important diagnostic and treatment considerations in patients who present with bifocal patellar tendon avulsion fractures from the tibial tubercle and inferior patellar pole. METHODS: Radiographic presentation, surgical technique, and complications of 5 children who sustained bifocal patellar tendon avulsion fractures with ≥6 months postoperative follow-up were retrospectively reviewed. Hospital for Special Surgery (HSS) Brief Functional Activity Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, PROMIS mobility, and Pediatric International Knee Documentation Committee Scale (Pedi-IKDC) were assessed at most recent follow-up. RESULTS: Five children (4 boys, 1 girl) presented with bifocal patellar tendon avulsion fractures with a median follow-up of 12.8 months (range 7.7 to 26.4). In 1 case, advanced imaging was not pursued, and the bifocal nature of injury was subsequently discovered intraoperatively. In all other cases, magnetic resonance imaging (MRI) correctly characterized the bifocal injuries and revealed the full extent of fractures and soft tissue injury. Surgical management involved suture anchor repair with heavy nonabsorbable sutures. Postoperative functional and patient-reported outcomes were within the range of population healthy/normative values (for those that were available for comparison, e.g., Pedi-IKDC), and clinically relevant improvement was noted when comparing preoperative and postoperative patient-reported outcome measures of both pain and mobility. CONCLUSIONS: Advanced imaging (e.g., MRI) is required to understand the full extent of injury and should be obtained in the setting of traumatic patella alta to evaluate for the presence of a bifocal lesion and plan surgical intervention accordingly. These patients demonstrate satisfactory functional and patient-reported outcomes after operative repair. LEVEL OF EVIDENCE: IV, therapeutic case series.
RESUMEN
PURPOSE: Tibiofemoral rotation through the knee joint, specifically relative external tibial rotation, has been identified as a potential contributing factor to patellar instability. The purpose of this study is to investigate the relationship between severity of instability with degree of tibiofemoral rotation in three clinical cohorts: fixed or obligatory dislocators (in which the patella either is constantly laterally dislocated or laterally dislocates with every instance of knee flexion, respectively), standard traumatic instability patients, and normal controls. METHODS: A retrospective study was performed with three cohorts from April 2009 to February 2019: fixed or obligatory dislocators, standard traumatic instability patients, and controls with normal magnetic resonance imaging (MRI) of the knee. All fixed or obligatory dislocation patients from the study time frame were analyzed; controls and standard traumatic instability patients were randomly selected. Inclusion criteria were age under 18 years and qualifying diagnosis; exclusion criteria were outside institution MRI and previous MPFL reconstruction or tibial tubercle osteotomy. Tibiofemoral rotation was measured blindly on initial axial MRI using the posterior femoral and tibial condylar lines. Tibial tubercle to trochlear groove distance (TT-TG) was measured. Intraclass correlation coefficient (ICC) was calculated among four measurers. RESULTS: A total of 100 patients were included, 20 fixed or obligatory dislocators, 40 standard traumatic instability patients, and 40 controls. Median age was 13.2 years (range 10-17 years), with 55 females. Age was significantly higher in the standard traumatic instability group than both the control (p < 0.001) and fixed or obligatory dislocator groups (p = 0.003). ICC for TT-TG and tibiofemoral rotation were 0.92 and 0.96, respectively. Fixed or obligatory dislocator patients averaged 8.5° external tibiofemoral rotation, standard traumatic instability patients 1.6° external tibiofemoral rotation, and controls 3.8° internal tibiofemoral rotation. Both tibiofemoral rotation and TT-TG were highest in the fixed or obligatory dislocator cohort, followed by the standard traumatic instability cohort, and lowest in the controls (p < 0.0001 for tibiofemoral rotation and TT-TG). Multivariate analysis showed no correlation between age and tibiofemoral rotation. CONCLUSIONS: Measurement of tibiofemoral rotation was reproducible with excellent interrater reliability. The degree of tibiofemoral rotation is correlated with severity of patellar instability, with the greatest external tibiofemoral rotation in fixed or obligatory dislocator patients, followed by standard traumatic instability patients, and slight internal tibiofemoral rotation in controls. High external tibiofemoral rotation may be an important pathoanatomic factor in fixed or obligatory dislocators, and with further understanding may become a prognostic factor or surgical target. LEVEL OF EVIDENCE: III.
Asunto(s)
Inestabilidad de la Articulación , Luxación de la Rótula , Articulación Patelofemoral , Adolescente , Niño , Femenino , Humanos , Inestabilidad de la Articulación/diagnóstico por imagen , Imagen por Resonancia Magnética , Rótula , Luxación de la Rótula/diagnóstico por imagen , Articulación Patelofemoral/diagnóstico por imagen , Reproducibilidad de los Resultados , Estudios Retrospectivos , Tibia/diagnóstico por imagenRESUMEN
Historically, one of the most common graft choices for anterior cruciate ligament (ACL) reconstruction in the pediatric population has been the hamstring autograft. Although pediatric ACL reconstructions with a hamstring autograft have allowed a majority of children and adolescents to return to athletics, it has been reported that anywhere between 6% and 38% of these patients will go on to experience subsequent graft rupture. The quadriceps tendon autograft is an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes, and we currently recommend it for skeletally immature patients undergoing primary and revision ACL reconstruction. This paper aims to describe our technique for an open full-thickness quadriceps tendon harvest with repair.
RESUMEN
BACKGROUND: Pre- and postoperative standing hip-to-ankle radiographs are critical for monitoring potential postoperative growth arrest and resultant deformities after pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine the prevalence of apparent preoperative leg-length discrepancies (LLDs) that resolve at the first postoperative radiographic examination in patients undergoing ACL reconstruction in order to understand what proportion of the noted preoperative deformities may have been inaccurate. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of prospectively collected preoperative and first postoperative full-length hip-to-ankle radiographs was performed in a cohort of skeletally immature patients who had an acute ACL injury and underwent subsequent surgical reconstruction. Leg length measurements for both the injured and the uninjured legs were obtained for comparison. RESULTS: A total of 112 patients (mean age, 12.7 ± 1.7 years) were included (79 boys and 33 girls). Leg-length measurement interrater reliability among 3 raters for 25 randomly chosen images was nearly perfect (intraclass correlation coefficient, 0.996; 95% CI, 0.994-0.998). At baseline, there was no apparent preoperative LLD (<5 mm) in 48% (n = 54) of participants, while 37% (n = 41) displayed a small apparent LLD (5 to <10 mm), 12% (n = 13) displayed a moderate apparent LLD (10 to <15 mm), and 4% (n = 4) displayed a large apparent LLD (≥15 mm). Of the patients with an apparent preoperative LLD, 66% (n = 38) of them tore their ACL on the leg measuring shorter. At first postoperative radiographs, 48% (n = 28) of patients with an apparent preoperative LLD showed resolution to no LLD: 46% (n = 19) of patients with a small apparent preoperative LLD, 54% (n = 7) of patients with a moderate apparent LLD, and 50% (n = 2) of patients with a large apparent LLD. CONCLUSION: A high percentage of patients (48%) with apparent preoperative LLDs showed resolution to no LLDs by their first postoperative imaging, indicating that preoperative hip-to-ankle radiographs display some false LLDs in patients with recent ACL tears who are unable to fully extend their injured leg and bear weight.
Asunto(s)
Lesiones del Ligamento Cruzado Anterior , Diferencia de Longitud de las Piernas , Pierna/anatomía & histología , Adolescente , Lesiones del Ligamento Cruzado Anterior/diagnóstico por imagen , Lesiones del Ligamento Cruzado Anterior/cirugía , Niño , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
Patellofemoral instability is a common problem affecting children and adolescents, with recurrent instability often requiring surgical intervention. Medial patellofemoral ligament (MPFL) reconstruction has become a mainstay for the treatment of patellofemoral instability because of the biomechanical importance of the MPFL against lateral dislocation as well as the high frequency of MPFL injury following traumatic patellar dislocation. The concern in managing skeletally immature patients is the potential for injury to the distal femoral physis. Here, we highlight 2 techniques for MPFL reconstruction. The first technique utilizes a hamstring autograft. The steps include: Step 1: Harvest the semitendinosus graft from a 2-cm posteromedial incision with use of an open tendon harvester proximally and a closed tendon harvester distally. Step 2: Prepare the graft for double-bundle reconstruction, allowing for approximately 50 to 60 mm for the reconstructed MPFL and 15 to 20 mm for graft placement within the patella and femoral sockets. Step 3: Use a guidewire and reamer to create 2 patellar sockets approximately 15 mm long each. Step 4: Use a guidewire under fluoroscopy to position and create a femoral socket distal to the distal femoral physis approximately 15 mm long. Step 5: Fix the graft on the femur with use of a tenodesis screw, pass the graft through the soft-tissue space between the fascia and synovium to the superior half of the patella, then dock the free ends of the graft onto the 2 patellar sockets with "PEEK (polyetheretherketone) SwiveLocks (Arthrex)" while the knee is in 30° of flexion. We also review a second technique of docking the hamstring graft onto the adductor tubercle and suturing it proximally to the deep distal medial aspect of the quadriceps tendon. Although only a limited number of studies have reported the outcomes of MPFL reconstruction in skeletally immature patients, such studies have demonstrated a high return to preoperative level of sports activity and a reduced prevalence of recurrent patellar instability.
RESUMEN
Recent literature has identified a population of active adolescents aged 13 to 15 years who are at high risk for anterior cruciate ligament graft rupture. Addressing the anterolateral complex during primary anterior cruciate ligament reconstruction has recently re-emerged in the literature, with various techniques available. This paper aims to describe a lateral extra-articular tenodesis procedure using the iliotibial band with a modified Lemaire technique. This procedure is recommended for active adolescents at a high risk of graft re-tear as an enhancement to primary anterior cruciate ligament reconstruction with soft-tissue graft.
RESUMEN
BACKGROUND: Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tubercle caused by repetitive strain and chronic avulsion from the patellar tendon. No widely accepted anatomic risk factors have been associated with OSD. PURPOSE: To determine if OSD is associated with increased posterior tibial slope (PTS). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Forty knees with OSD and 32 control knees examined by the senior author between 2008 and 2019 were included. Patients 10 to 15 years of age with a clinical diagnosis of OSD and available lateral radiograph and magnetic resonance imaging (MRI) were eligible. Age- and sex-matched patients with a history of knee pain but no evidence of OSD on clinical examination and without significant pathology on lateral radiograph and MRI were included in the control group. PTS was defined as the angle between a reference line perpendicular to the proximal anatomic axis and a line drawn tangent to the uppermost anterior and posterior edges of the medial tibial plateau. Measurements were carried out in duplicate on true lateral radiographs by 2 blinded investigators. Interrater reliability of PTS measurements was evaluated using intraclass correlation coefficient (ICC). The independent samples t test was used to compare PTS between the OSD and control knees. RESULTS: The mean age was 12.6 ± 1.6 years and 51% (37/72) of the knees were from male youth. There were no differences in age, sex, and laterality of knees between the OSD and control groups. The mean PTS was significantly higher in the OSD group (12.23°± 3.58°) compared with the control group (8.82°± 2.76°; P < .001). The ICC was 0.931 (95% CI, 0.890-0.957), indicating almost perfect interrater reliability. CONCLUSION: This study identifies an association between OSD and increased PTS. The clinical implications of this finding have not yet been elucidated. It may be speculated that in patients with OSD, stress from the extensor mechanism through the patellar tendon loads the anterior portion of the tibia disproportionately to the posterior segment, thereby resulting in asymmetric growth and an increased PTS.
Asunto(s)
Articulación de la Rodilla/patología , Osteocondrosis/fisiopatología , Tibia/patología , Adolescente , Niño , Estudios Transversales , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Dolor/etiología , Ligamento Rotuliano , Radiografía , Reproducibilidad de los ResultadosRESUMEN
Patellofemoral instability is a common orthopedic condition in children and adolescents, with recurrent instability often requiring surgical intervention. Age, bilateral instability, and various anatomic features such as trochlear dysplasia, patella alta, increased tibial tubercle to trochlear groove distance, and patellar tilt have all been described as risk factors for recurrent patellar instability. Medial patellofemoral ligament reconstruction has become the mainstay of treatment for addressing recurrent patellar instability in skeletally immature patients. For some patients, additional interventions such as distal realignment and guided growth procedures may be required to address anatomic pathology. This article discusses various risk factors associated with patellofemoral instability, reconstruction techniques, and a case example.