Kevin G. Shea

Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data.

Injury claims from an insurance company specializing in soccer coverage were reviewed for a 5-year period. A total of 8215 injury claims (3340 females, 4875 males) were divided into three categories: (1) all injury, (2) knee injury, and (3) ACL injury. Knee injuries accounted for 22% of all injuries (30% female, 16% male). ACL injury claims represented 31% of total knee injury claims (37% female, 24% males). The youngest ACL injury was age 5. The ratio of knee injury/all injury increased with age. Compared with males, females demonstrated a higher ratio of knee injury/all injury and a higher ratio of ACL injury/all injury. This study demonstrates that ACL injury occurs in skeletally immature soccer players and that females appear to have an increased risk of ACL injury and knee injury compared with males, even in the skeletally immature. Future research related to ACL injury in females will need to consider skeletally immature patients.

Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury

BACKGROUND Studies have suggested that exercise programs can reduce the incidence of noncontact injuries of the anterior cruciate ligament in female athletes. We conducted a two-year prospective study to assess the effects of a knee ligament injury prevention exercise program on the incidence of noncontact anterior cruciate ligament injuries in high-school female athletes. METHODS A prospective cohort design was used to study high-school female athletes (playing soccer, basketball, and volleyball) from fifteen schools (112 teams) for two consecutive seasons. The schools were divided into treatment and control groups. The treatment group participated in a plyometric-based exercise program twice a week throughout the season. Practice and game exposures and compliance with the exercise program were recorded on a weekly basis. Suspected noncontact anterior cruciate ligament injuries were confirmed on the basis of the history as well as at the time of surgery and/or with magnetic resonance imaging. RESULTS A total of 1439 athletes (862 in the control group and 577 in the treatment group) were monitored. There were six confirmed noncontact anterior cruciate ligament injuries: three in the treatment group, and three in the control group. The incidence of noncontact anterior cruciate ligament injuries per 1000 exposures was 0.167 in the treatment group and 0.078 in the control group, yielding an odds ratio of 2.05, which was not significant (p > 0.05). CONCLUSIONS Our results suggest that a twenty-minute plyometric-based exercise program that focuses on the mechanics of landing from a jump and deceleration when running performed twice a week throughout the season will not reduce the rate of noncontact anterior cruciate ligament injuries in high-school female athletes.

Defining the pediatric spinal thoracoscopy learning curve: sixty-five consecutive cases.

Study Design. Consecutive case prospective chart and radiographic review. Objectives. The purpose of this study was to define the learning curve of spinal thoracoscopy. Summary of Background Data. Thoracoscopy is an alternative to open thoracotomy in the treatment of pediatric spinal deformity. The learning curve for spinal thoracoscopy has not been described. Methods. In this prospective study 65 consecutive cases of thoracoscopic anterior release with discectomy and fusion performed by one surgeon for the treatment of pediatric spinal deformity were reviewed. The patients were, on average, 14 ± 3 years old and had the following diagnoses: idiopathic scoliosis (n = 13), Scheuermann’s kyphosis (n = 9), neuromuscular spinal deformity (n = 35), congenital scoliosis (n = 4), and tumor/syrinx (n = 4). Results. The average operative time for the thoracoscopic procedure was 161 ± 41 minutes (range, 50–240 minutes). There was a slight decrease in the average operative time as the series progressed. The average number of discs excised was 6.5 ± 1.5 (range, 3–10), and the number increased as the series progressed. The average operative time per disc was 29.3 ± 7.7 minutes in the first 30 patients compared with 22.3 ± 4.7 minutes in the next 35 patients (P < 0.01). The average blood loss during the thoracoscopic procedure was 301 ± 322 mL (range, 25–2000 mL) and did not decrease as the series progressed. Initial postoperative scoliosis and kyphosis corrections were 59% ± 17% and 92% ± 12%, respectively. Complications occurred in six patients (cases 4, 8, 17, 31, 39, and 46) and were evenly distributed throughout the series. Conclusions. The learning curve for thoracoscopy is substantial, but not prohibitive. This technique provides a safe and effective alternative to thoracotomy in the treatment of pediatric spinal deformity.

Effects of a knee ligament injury prevention exercise program on impact forces in women.

Previous research suggests high impact forces generated during landings contribute to noncontact anterior cruciate ligament (ACL) injuries. In women, neuromuscular differences appear to modify the ability to dissipate landing forces when compared to men. This study examined peak vertical impact forces (Fp) and rate of force development (RFD) following a 9-week, low-intensity (simple jump-landing-jump tasks) and volume (number of foot contacts per workout) plyometric-based knee ligament injury prevention (KLIP) program. Female subjects were randomly assigned into control (n = 14) and treatment (n = 14) groups. Treatment subjects attended KLIP sessions twice a week for 9 weeks, and control subjects received no intervention. Ground reaction forces (Fp and RFD) generated during a step-land protocol were assessed at study onset and termination. Significant reductions in Fp (p = 0.0004) and RFD (p = 0.0205) were observed in the treatment group. Our results indicate that 9 weeks of KLIP training altered landing strategies in women to lower Fp and RFD. These changes are considered conducive to a reduced risk of knee injury while landing.

Analysis of particles in acetabular components from patients with osteolysis.

Acetabular polyethylene components were quantitatively analyzed for the presence of third body particles from 38 consecutively retrieved components. Backscattered electron imaging and correlated energy dispersive x-ray analysis were used for the assessments. Retrievals were divided into 4 groups based on methods of fixation and metal alloy types: 8 hydroxyapatite coated, 6 cobalt chrome porous coated, 17 titanium porous coated, and 7 cemented implants were evaluated. The backscattered electron imaging data showed that the components from the hydroxyapatite coated implants had larger particles than did the components from the cemented group. The hydroxyapatite group had 51 +/- 52 particles per mm2. The cobalt chrome alloy group had 10 +/- 9 particles per mm2, and the titanium alloy group had 9 +/- 16 particles per mm2. The cemented group had 5 +/- 4 particles per mm2. The difference between the cement group and the hydroxyapatite group was statistically significant. The elemental analysis showed that 70% of the particles in the hydroxyapatite group had calcium and phosphorus elements. Third body particles likely contribute to particulate generation. The results suggest that the hydroxyapatite coated components have the potential for producing greater amounts of particulate debris. Continued analysis of retrieved components for the presence of the third body particles is required.

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Corrective Osteotomy for Malunited, Volarly Displaced Fractures of the Distal End of the Radius*

Twenty-five patients who had had an opening-wedge osteotomy for the treatment of a malunited, volarly displaced fracture of the distal end of the radius were studied retrospectively. The indications for the operation were pain and functional limitations rather than the degree of anatomical deformity. Fifteen patients were men and ten were women; their average age was forty-six years (range, twenty-one to eighty-four years). Preoperative radiographs revealed an average ulnar inclination of 14 degrees, an average ulnar variance of five millimeters, and an average volar inclination of 24 degrees. Extension of the wrist averaged 25 degrees; flexion of the wrist, 53 degrees; supination of the forearm, 41 degrees; and pronation of the forearm, 64 degrees. The average grip strength was a force of seventeen kilograms compared with a force of forty kilograms in the contralateral hand. At an average of sixty-one months (range, eighteen to 114 months) after the osteotomy, supination of the forearm had improved to an average of 69 degrees and pronation had improved to an average of 75 degrees (p < 0.05 for both). Extension of the wrist had improved to an average of 55 degrees, and grip strength had improved to a force of thirty kilograms (p < 0.05 for both). Volar inclination averaged 5 degrees; ulnar variance, zero millimeters; and ulnar inclination, 22 degrees. A reoperation was performed in eleven patients. Seven patients had removal of the hardware only, two had a procedure involving the distal radioulnar joint, one had a procedure because the site of the osteotomy had not healed, and one had a median-nerve release. The functional result was rated as very good in ten patients, good in eight, fair in three, and poor in four.

Anterior Cruciate Ligament Injury in Paediatric and Adolescent Patients A Review of Basic Science and Clinical Research

Anterior cruciate ligament (ACL) injuries are recognised with greater frequency in children and adolescents. Non-operative treatment of ACL injuries in children may lead to knee instability and secondary injuries, especially in those who return to sports. ACL reconstruction is controversial in skeletally immature patients because of potential damage to the proximal tibial and distal femoral physes, which may lead to premature arrest and/or leg length discrepancies. This paper reviews studies of ACL injuries in children and adolescents, and examines basic science and clinical studies concerning physeal arrest secondary to ACL reconstruction tunnels. Some animal studies support the conclusion that ACL reconstructions in children have the potential to cause growth disturbances, and there are reports of growth plate complications due to ACL reconstruction in skeletally immature patients. There is evidence that ACL reconstruction can be performed in select skeletally immature patients, but the risk of growth plate complications must be considered.

The Effects of a Commercially Available Warm-Up Program on Landing Mechanics in Female Youth Soccer Players

The purpose of this study was to examine lower extremity kinematics following implementation of the Sportsmetrics Warm-Up for Injury Prevention and Performance (WIPP) training program. The hypothesis was that there would be no difference in landing mechanics between 2 groups of female youth soccer players (9–11 years of age), with 1 group (Treatment) completing the 8-week–duration (2 days per week) WIPP program and the other serving as a Control group. We recruited 21 female youth soccer players. Treatment (n = 12) and Control (n = 9) groups were established. Using the Sportsmetrics Software for Analysis of Jumping Mechanics, we analyzed lower extremity movement during landing after subjects jumped off a 30.5-cm box and immediately went into a vertical jump. No significant changes in knee separation values were observed in the Treatment group after 8 weeks of WIPP training. The results indicate that 8 weeks of WIPP training did not significantly alter landing strategies.

Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor resection.

A microvascularized free fibular graft was used to reconstruct a skeletal defect after tumor reconstruction in 13 consecutive patients. The patients were evaluated at an average follow-up of 53 months (range, 30-71). The status of each graft was evaluated for time to union, hypertrophy, functional evaluation, and complications. The average time to union was 6.5 months, and significant graft hypertrophy occurred in eight of 13 patients. Complications occurred in seven patients. Two of the 13 patients required removal of the microvascularized graft. Functional evaluation according the the Musculoskeletal Tumor Society yielded an average score of 90 (range, 83-97). The results were rated good or excellent in 11 of 13 patients, and two were rated failures. The microvascularized fibular graft provides an attractive option for the reconstruction of skeletal defects after tumor resection. The results of this procedure are especially good in skeletally immature patients.