Improvement in balance from diagnosis to return-to-play initiation following a sport-related concussion: BESS scores vs center-of-pressure measures.

OBJECTIVE: Accurate assessment of balance recovery throughout treatment of a sport-related concussion is imperative. This study examined differences in balance from diagnosis to return-to-play initiation in adolescent patients post-concussion. Second, this study investigated the extent to which the Balance Error Scoring System (BESS) correlated with center-of-pressure (COP) measures. METHODS: Forty participants performed the BESS while standing on a force platform such that COP data were obtained simultaneously. Spatial and velocity COP-based measures were computed for the double-stance conditions. RESULTS: BESS scores and COP-based measures indicated improved balance performance between visits. Specifically, 62.5/65.0% of participants exhibited improved firm/foam BESS final scores, respectively, and 56.4-71.8% exhibited improved COP-based measures. However, once normative ranges were referenced to identify maintained performance, the percentage of participants who substantially improved differed from initial findings (BESS: 2.5/7.5%, COP: 48.7-69.2%). Additionally, positive correlations between balance measures were primarily found at diagnosis (r=0.33-0.53), while only three correlations were maintained at return-to-play initiation (r=0.34-0.39). CONCLUSIONS: BESS scores successfully identified poor balance performance at diagnosis when symptoms were most pronounced, but failed to accurately depict performance once balance impairment, indicated by COP-based measures, became less apparent. Further work is needed to implement more advanced balance assessments into clinical environments.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients.

Purpose: Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Methods: Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. Results: A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Conclusions: Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Level of evidence: Retrospective level III.

Faster Rate of Correction with Distal Femoral Transphyseal Screws Versus Plates in Hemiepiphysiodesis for Coronal-Plane Knee Deformity: Age- and Sex-Matched Cohorts of Skeletally Immature Patients.

BACKGROUND: Hemiepiphysiodesis (guided-growth) procedures have become the primary method of treatment for coronal-plane knee deformities in skeletally immature patients. Two leading techniques involve the use of a transphyseal screw or a growth modulation plate. However, clinical references for the estimation of correction are lacking, and no consensus has been reached regarding the superiority of one technique over the other. Therefore, the purpose of this study was to compare the rates of correction for distal femoral transphyseal screws and growth modulation plates in age- and sex-matched cohorts with coronal deformities. METHODS: Thirty-one knees were included in each cohort on the basis of propensity scoring by chronological age and sex, and radiographic images were retrospectively reviewed preoperatively and postoperatively. Each case was measured for limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (LDFA), and bone age. RESULTS: Both the MAD and LDFA rate of correction significantly differed between the screw and plate cohorts. The MAD rate of correction was observed to be 0.42 ± 0.37 mm/week (1.69 mm/month) in the plate cohort and 0.66 ± 0.51 mm/week (2.64 mm/month) in the screw cohort. The LDFA rate of correction was observed to be 0.12° ± 0.13°/week (0.50°/month) in the plate cohort and 0.19° ± 0.19°/week (0.77°/month) in the screw cohort. CONCLUSIONS: The current study provides simple clinical references for the rate of correction of MAD and the LDFA for 2 methods of hemiepiphysiodesis. The results suggest that transphyseal screws may correct coronal knee deformities during the initial treatment stage more quickly than growth modulation plates in distal femoral guided growth. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Differences in athletic identity, sport participation, and psychosocial factors following anterior cruciate ligament rehabilitation in youth athletes.

Introduction: While youth sports benefits the developing athlete, athletes may also be subject to injury and subsequent return-to-sport protocols. The current return-to-sport criteria emphasize physical measures; however, psychological measures may also be valuable to inform providers of an athlete's readiness. One such measure is athletic identity defined as the degree to which an individual identifies with the athlete role. To better understand athletic identity in return-to-sport, this study aimed to identify relationships and trends between the Athletic Identity Measurement Scale (AIMS), demographic variables, sport participation measures, and the Athletic Coping Skills Inventory-28 (ACSI-28) in youth athletes during rehabilitation following anterior cruciate ligament reconstruction (ACLR). Methods: A retrospective review was completed of patients who underwent ACLR at a sports medicine clinic between October 2019 and May 2021. Patients responded to a series of patient reported outcomes (PROs) regarding physical and psychological function at a pre-surgical baseline and after 1 year of rehabilitation. Patients were then divided into groups of high/low AIMS and an increased/decreased AIMS between 1 year and baseline for comparison. Independent samples t-tests and ANOVAs were performed as appropriate with a 95% confidence interval. Results: In the final sample, 87 patients (15.3 ± 1.8 years) were included, with 51.7% being females. Total AIMS scores decreased from 50.3 to 47.5 over rehabilitation (p = 0.019). Furthermore, results indicated that nearly all AIMS scores decreased during rehabilitation, with none showing an increase; however, not all domains were significant. Conversely, all sport participation and coping ability PROs increased over time points except for ACSI-Confidence and Achievement Motivation. Generally, those in the groups with high AIMS and an increase in AIMS also had higher scores in physical function and coping ability PROs, with the groups separated by high/low AIMS exhibiting more frequent statistical significance. Discussion: Given these results, it appears that athletes may lose identification with the athlete role after ACLR and struggle even 1 year for rehabilitation, but those who recover athletic identity the best may also be those able to cope most effectively with the stressors induced by injury.

Position comparison of sport-related concussions in female youth soccer players.

OBJECTIVES: Youth soccer participation, particularly among females, continues to grow worldwide. With the high incidence of sport-related concussion (SRC) in soccer, it is important to investigate if SRC occurs disproportionally by positions. Our hypothesis was to see no positional differences in SRCs, SRC-related characteristics, and outcomes among in female youth soccer athletes. METHODS: Data were prospectively collected from participants at a single sports medicine institution between August 2015-April 2021. Female participants aged 8-18 diagnosed with SRC sustained during an organized soccer practice, scrimmage, or game were separated into 4 groups based on position: Forward, Midfielder, Defender, and Goalkeeper. Demographics, medical history, injury-related details, and outcomes were reviewed. A chi-square test or Fisher's exact test was used for categorical variables. Continuous variables were compared with Mann-Whitney or Kruskal-Wallis test. RESULTS: Two hundred fourteen participants were included: 52 Forwards, 65 Midfielders, 63 Defenders, and 34 Goalkeepers. There were no significant differences between the groups in age, race, ethnicity, or previous concussion history. Differences in mechanism existed with Goalkeepers most commonly reporting Head to Body Part. Goalkeepers, which make up 1/11 of the total positions on the field, had a significantly higher proportion of SRCs compared to Field Positions. (9.1% vs 15.9%)At 3-month post-enrollment, there were no significant differences in reported symptoms or return-to-play between the different positions. CONCLUSION: In youth female soccer players, goalkeepers sustained a higher proportion of sport-related concussions compared to field players based upon the composition of a soccer team. The mechanism of injury also differed among the different soccer positions. However, no differences in concussion characteristics, outcomes, or RTP were seen across the different soccer positions.

Setup Uncertainty of Pediatric Brain Tumor Patients Receiving Proton Therapy: A Prospective Study.

This study quantifies setup uncertainty in brain tumor patients who received image-guided proton therapy. Patients analyzed include 165 children, adolescents, and young adults (median age at radiotherapy: 9 years (range: 10 months to 24 years); 80 anesthetized and 85 awake) enrolled in a single-institution prospective study from 2020 to 2023. Cone-beam computed tomography (CBCT) was performed daily to calculate and correct manual setup errors, once per course after setup correction to measure residual errors, and weekly after treatments to assess intrafractional motion. Orthogonal radiographs were acquired consecutively with CBCT for paired comparisons of 40 patients. Translational and rotational errors were converted from 6 degrees of freedom to a scalar by a statistical approach that considers the distance from the target to the isocenter. The 95th percentile of setup uncertainty was reduced by daily CBCT from 10 mm (manual positioning) to 1-1.5 mm (after correction) and increased to 2 mm by the end of fractional treatment. A larger variation existed between the roll corrections reported by radiographs vs. CBCT than for pitch and yaw, while there was no statistically significant difference in translational variation. A quantile mixed regression model showed that the 95th percentile of intrafractional motion was 0.40 mm lower for anesthetized patients (p=0.0016). Considering additional uncertainty in radiation-imaging isocentricity, the commonly used total plan robustness of 3 mm against positional uncertainty would be appropriate for our study cohort.

Sport Participation and Psychosocial Factors Which Influence Athletic Identity in Youth Athletes With Anterior Cruciate Ligament Injury.

Athletic identity, or the degree with which individuals identify with the athlete role, is an important rehabilitation factor for sports care providers to consider; however, it lacks extensive study in youth. The purpose of this study was to identify demographic, sport participation, and psychosocial measures which correlate with youth athletic identity after anterior cruciate ligament injury. Participants completed standardized sports medicine intake and patient-reported outcome measures, including the Athletic Identity Measurement Scale (AIMS). A total of 226 participants were included, and two groups were created based on high or low total AIMS score. Results indicated that sex (p = 0.002), years active in sport (p = 0.049), activity level (p = 0.038), and ACSI-Coachability (p = 0.027) differed by AIMS score. While youth athletes appear resilient, these results emphasize that they identify strongly with the athlete role and may suffer psychosocial consequences after injury. Future work should evaluate similar factors over course of recovery in a larger, diversified population.

Continued play following adolescent sport-related concussion: Prospective data from the North Texas Concussion Registry (ConTex).

Our study aims were to identify the frequency of continued play following sport-related concussion (SRC), defined as continuing athletic activity on the same day following a suspected SRC, characteristics associated with continued play, and whether continued play was associated with worse outcomes. A prospective study of participants ages 13-18 years diagnosed with SRC at a pediatric sports medicine clinic over a 4-year period was conducted. A comparison was performed between athletes who reported continued play following SRC (PLAY) and those who did not (NO PLAY). Of 441 participants, 231 (52.4%) were in the PLAY group. The PLAY group recalled less severe balance problems from the day of injury (p = 0.02), but reported greater symptoms of trouble falling asleep, concentrating, and remembering at their initial clinic visit (p < 0.05). There was no difference in recovery time between groups. Greater symptom severity score at the initial clinic visit and longer time to presentation were associated with prolonged recovery in both groups (p < 0.01). In conclusion, more than half of the athletes in this sample continued to play on the same day following SRC. Our results indicate the need for a heightened focus on education and additional efforts to reduce continued play following SRC in adolescents.

Secondary Surgery and Residual Dysplasia Following Late Closed or Open Reduction of Developmental Dysplasia of the Hip.

BACKGROUND: Outcomes studies following successful closed reduction of late-detected developmental dysplasia of the hip (DDH) reveal high rates of secondary reconstructive surgery with limited comparative data demonstrating lower rates of residual dysplasia with open reduction. The purpose of this study was to compare long-term outcomes, with regard to radiographic evidence of residual dysplasia and secondary reconstructive procedures, between late closed and late open reduction for DDH in patients 6 to 24 months of age at reduction. METHODS: We identified all patients between 6 and 24 months of age who underwent closed or open reduction for DDH between 1980 and 2008 and were followed until at least 10 years of age. Outcomes included radiographic measurement of acetabular dysplasia after triradiate cartilage closure, development of osteonecrosis, and the need for secondary procedures for residual dysplasia. RESULTS: One hundred and four hips underwent index closed reduction and 54 hips underwent index open reduction. There was no significant difference in the age at reduction (p = 0.07). Among the 116 hips for which initial anteroposterior pelvic radiographs were available, most closed reductions (55%) were performed in International Hip Dysplasia Institute (IHDI) grade-III hips whereas most open reductions (71%) were performed in IHDI grade-IV hips. Analysis of the hips that did not undergo a secondary procedure showed that those with an index open reduction had a greater lateral center-edge angle (mean and standard deviation, 27.2° ± 10.0° versus 22.4° ± 6.8° in the closed reduction cohort; p = 0.02), lower femoral head extrusion index (22.2% ± 8.9% versus 26.0% ± 6.2%; p = 0.04), and lower Sharp angle (43.3° ± 6.0° versus 46.6° ± 3.1°; p = 0.002) at triradiate closure. There was no difference in the prevalence of osteonecrosis (Bucholz-Ogden grades II, III, and IV) between the closed and open reduction cohorts (22% versus 19%, respectively; p = 0.60). Secondary procedures were performed more frequently after closed reduction than after open reduction (47% versus 30%, respectively; p = 0.03). CONCLUSIONS: In patients with late reduction of DDH, closed reduction was associated with increased residual dysplasia and it was associated with a higher rate of secondary surgery in those >12 months old despite a decreased severity of displacement based on the IHDI classification. Additional, prospective studies with assessment of functional outcomes are needed to validate these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.