Special Surgery Pediatric Functional Activity Research Articles

Psychosocial Benefits of Sport Participation During COVID-19 Are Only Partially Explained by Increased Physical Activity.

Although the return to sports during COVID-19 has been associated with improvements in quality of life (QOL) and mental health, it is unknown whether these benefits are primarily due to increases in physical activity (PA). The purpose of this study was to determine whether PA increases were responsible for the improvements in mental health and QOL among adolescents who returned to sport during the COVID-19 pandemic. Cross-sectional. Wisconsin secondary schools. 559 adolescent athletes (15.7+1.2 yrs., female = 43.6%) from 44 schools completed a survey in October 2020. Demographic information, whether they had returned to sport participation (no [DNP], yes [PLY]), school instruction type, anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), QOL (Pediatric Quality of Life Inventory 4.0), and PA (Hospital for Special Surgery Pediatric Functional Activity Brief Scale). Mediation analysis assessed whether the relationship between sport status and anxiety, depression, and QOL was mediated by PA. Of the 559 total athletes included, 171 (31%) athletes had returned to play, while 388 had not. PLY athletes had significantly lower anxiety (3.6±0.4 v 8.2±0.6, p<0.001) and depression (4.2±0.4 v 7.3±0.6, p<0.001), and significantly higher QOL (88.1±1.0 v 80.2±1.4, p<0.001) and PA (24.0±0.5 v 16.3±0.7, p<0.001). PA explained a significant, but small proportion of the difference in depression (22.1%, p=0.02) and QOL (16.0%, p=0.048) between PLY and DNP athletes, but not anxiety (6.6%, p=0.20). Increased PA is only responsible for a small portion of the improvements in depression and QOL among athletes who returned to sports. This suggests that most of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic are independent of the benefits of increased PA.

Association of Grit With Postoperative Knee Outcomes and Physical Function After ACL Reconstruction in Adolescent Athletes.

Grit is the disposition to strive for long-term goals despite setbacks and challenges. Given the lengthy, arduous process of rehabilitation after anterior cruciate ligament reconstruction (ACLR), an athlete's grit may predict postoperative outcomes across time. The primary aim of the study was to evaluate the relationships between baseline (preoperative) grit and postoperative knee outcomes across the year after ACLR among adolescents. We hypothesized that athletes with more grit would achieve better postoperative outcomes over time than less gritty athletes. Cohort study; Level of evidence, 2. All participants completed the Short Grit Scale, the Pediatric International Knee Documentation Committee (Pedi-IKDC) Scale, the Lysholm Knee Scoring Scale, the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric scale for pain interference and mobility, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), and the Quality of Life in Neurological Disorders (NeuroQoL) Lower Extremity Function Short Form at a preoperative appointment and then again at approximately 3, 6, and 12 months after ACLR. We constructed linear mixed models to assess the relationships between baseline grit, time, age, sex, and postoperative outcome measures (statistical significance of α = .05). We included 137 participants (mean age 15.8 ± 2.74 years, 70% female) from a prospective registry of athletes undergoing ACLR by 1 surgeon at a single institution. There were no statistically significant changes in grit over time or differences in grit between age and sex. Higher baseline grit was significantly associated with greater postoperative HSS Pedi-FABS scores (β = 3.72 ± 1.46; P = .01; 95% CI, 0.85-6.59) and NeuroQoL scores across time (β = 3.37 ± 0.93; P < .001; 95% CI, 1.55-5.20). There were no significant associations between baseline grit and Pedi-IKDC, Lysholm, and PROMIS pain interference or mobility scores. Athletes with higher baseline grit reported superior postoperative physical function and activity level over the course of 1 year after ACLR compared with less gritty athletes. Grit may be a useful measure in predicting success in regaining physical function across time after ACLR in adolescent athletes.

Poster 347: PSYCHOLOGICAL READINESS AFTER REVISION ACL RECONSTRUCTION: A ROAR STUDY

Objectives: Background: Revision ACL reconstruction (ACLR) has demonstrated worse functional outcomes and higher reinjury rates in young patients. Psychological associations with revision surgery have not previously been evaluated. Purpose: To investigate levels of psychological readiness and psychological stress in young patients after revision ACLR Methods: Patients, ages 10-35, were enrolled who underwent revision ACLR at one center by one of six surgeons. Psychological readiness and psychological stress was assessed 6-months post- operatively with the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) and PROMIS- Psychological Stress Experiences (PROMIS-PSE), respectively. The International Knee Documentation Committee (IKDC/Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Scale (HSS Pedi-FABS) were also collected. Patient reported outcomes of revision ACLR patients were compared to a cohort of primary ACLR patients. Propensity score matching 3:1 was performed for age, sex, and graft type. Results: Matching resulted in 81 ACLR patients (57 primary and 24 revision). Mean age in the revision group was 18.6 ± 3.2 (66.7% female). The most common graft type in both the primary and revision group was BTB (65% and 67%, respectively) (Table 1). Mild negative correlation was detected between IKDC and PROMIS PSE (r=-0.31; 95% CI=-0.49, -0.10; p=0.005) and a moderate positive correlation was detected between IKDC and ACL-RSI scores (r=0.56; 95% CI=0.39, 0.70; p&lt;0.001). Revision ACLR patients had lower psychological readiness scores (47 vs. 64, p=0.004) and lower IKDC/Pedi-IKDC scores (72 vs 78, p=0.05), compared to primary ACLR patients. Revision ACLR patients also had longer return to sports clearance compared to primary ACLR (median, 10 months vs 8 months; p=0.02). Regression analysis showed revision patients could expect a 15-point decrease in ACL RSI scores compared to patients who underwent primary ACLR surgery (95% CI=-25.30, -4.21; p=0.007). Furthermore, revision patients also could expect a 1.4 month longer return to sports clearance date compared to primary ACLR patients (95% CI=0.29, 2.60; p=0.01). No differences were noted in Pedi- FABS or PROMIS-PSE scores between revision and primary patients (Table 2). Conclusions: This study is the first to date to examine psychological readiness to return to sport in young patients after revision ACLR. At 6-months post-surgery, revision ACLR patients had lower psychological readiness scores, inferior knee functional outcomes scores, and delayed return to sport clearance. Greater attention to the psychological aspects of recovery in the revision ACLR setting may be important to help optimize post-operative care and outcomes. [Table: see text][Table: see text]

Highly Active Middle School Athletes Demonstrate Poor Motor Skill Proficiency.

Fundamental movement skills (FMS) are critical components to lifelong participation in sports and physical activity. With the rise in early sports specialization, mastery of motor skills may be limited in youth athletes. The purpose of this study was to assess FMS proficiency in highly active middle school athletes and determine whether proficiency differed between specialization levels and sex. (1) Most athletes would fail to achieve proficiency in all domains of the Test of Gross Motor Development (TGMD-2), (2) highly specialized athletes would demonstrate lower proficiency in all domains of the TGMD-2, and (3) male athletes would demonstrate higher proficiency than female athletes. Cross-sectional. Level 4. A total of 91 athletes were recruited (44 male, 12.6 ± 0.9 years). Activity level was quantified using the Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (Pedi-FABS), specialization level was determined using the Jayanthi Specialization Scale, and the TGMD-2 was used to assess FMS proficiency. Descriptive statistics were used to describe gross motor, locomotor, and object control percentile rank. A 1-way analysis of variance (ANOVA) was used to assess differences in percentile rank between low, moderate, and high specialization groups and independent samples t tests were used to compare sexes (α < 0.05). Mean Pedi-FABS score was 23.6 ± 4.9. In total, 24.2%, 38.5%, and 37.4% of athletes classified as low, moderate, and highly specialized, respectively. Mean percentile ranks were 56.2%, 64.7%, and 62.6% for locomotor, object control, and gross motor domains, respectively. No athlete achieved a percentile rank >99% in any domain of the TGMD-2, and there was no significant difference between specialization groups or sex. Despite high activity levels, no athlete demonstrated proficiency in any domain of the TGMD-2, and there was no difference in proficiency between specialization levels or by sex. Sport participation, regardless of level, does not ensure adequate mastery of FMS.

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

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. 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. Prospective cohort study; Level of evidence, 2. 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. 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). 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.

A Modified Lemaire Lateral Extra-articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: 2-Year Clinical Outcomes

Background: The incidence of anterior cruciate ligament (ACL) reconstruction (ACLR) in children and adolescents has increased significantly, and many such patients are at increased risk for ACL retear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL retear. Purpose: To evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft performed with a concomitant LET using a modified Lemaire technique in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: A consecutive series of adolescent patients who underwent QUAD autograft ACLR and LET with a minimum of 2 years of follow-up data were analyzed retrospectively. ACLR techniques, including all-epiphyseal and complete transphyseal, were indicated based on skeletal age. Outcome measures included return to sports, concomitant or subsequent surgical procedures, and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores. Results: The final cohort included 49 consecutive adolescent patients aged 11 to 16 years (mean, 14.2 ± 1 years) with a minimum follow-up of 2 years. One patient was lost to follow-up. Of the patients included in the study (N = 48; 27 male, 21 female), 98% participated in high-risk competitive sports. Two (4%) patients were undergoing revision ACLR. Thirty-eight (79%) patients underwent complete transphyseal, and 10 (21%) patients underwent all-epiphyseal ACLR. Sixteen (33%) patients had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscal surgery, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each), and 3 hardware removal (2 for hemi-epiphysiodesis and 1 tibial socket button removal) procedures. The rate of graft rupture was 0%. At a mean follow-up of 3.4 ± 1.2 years (range, 2-7 range), the mean SANE score was 93, the mean Pedi-IKDC score was 89, and the mean HSS Pedi-FABS score was 23. The return-to-sports rate was 100%. Conclusion: An LET performed concomitantly with an ACLR is safe and should be considered as a concomitant procedure for adolescent patients with nonmodifiable risk factors who are at high risk of retear.

An Activity Scale for All Youth Athletes? Clinical Considerations for the HSS Pedi-FABS

The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) has demonstrated normally distributed scores in children aged 10 to 18 years. It has been used to evaluate knee injuries; however, there is limited information regarding its use in evaluating other injury types. To (1) assess the validity and utility of HSS Pedi-FABS in youth athletes with injuries to different parts of the body and (2) evaluate the association between the HSS Pedi-FABS and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health 7 (PGH), as well as PROMIS-Pain Interference (PGH-PI) and PROMIS-Fatigue (PGH-F) components. Cohort study (diagnosis); Level of evidence, 3. The authors performed a retrospective review of youth athletes aged 10 to 18 years who completed the HSS Pedi-FABS as part of their previsit intake questionnaire between April 2016 and July 2020. HSS Pedi-FABS score distributions were compared and evaluated for ceiling effects in cohorts determined by demographic, injury characteristic, and sports participation variables; a ceiling effect was determined to be present if >15% of respondents received the highest possible score. HSS Pedi-FABS scores were analyzed for a correlation with PGH, PGH-PI, and PGH-F components. Included were 2274 patients (mean age, 14.6 ± 2.1 years; 53.0% female) participating in 21 distinct primary sports for 9.6 ± 7.9 hours per week. The mean HSS Pedi-FABS scores by injury group were as follows: elbow (22.7 ± 6.7), shoulder (21.0 ± 8.7), ankle (20.2 ± 8.8), knee (19.5 ± 9.1), and hip (15.4 ± 10.4) (P < .001). Broad distribution was seen in each cohort, with no floor or ceiling effects. The HSS Pedi-FABS score correlated with patient-reported hours per week (r = 0.33), days per week (r = 0.33), and years of participation (r = 0.21) (P < .001 for all). All 3 PROMIS components correlated with HSS Pedi-FABS: PGH (r = 0.28), PGH-PI (r = -0.11), and PGH-F (r = -0.15) (P < .001). Study findings indicated that the HSS Pedi-FABS is a valid tool for measuring physical activity level in most injured youth athletes, not just those with knee injuries. The correlation of HSS Pedi-FABS with the PGH suggests a positive relationship of childhood physical activity with general health.

Impact of COVID-19 on the physical activity, quality of life and mental health of adolescent athletes: a 2-year evaluation of over 17 000 athletes

PurposeTo evaluate the changes in mental health, quality of life (QOL) and physical activity (PA) among adolescent athletes during the COVID-19 pandemic as organised sports resumed.MethodsAdolescent athletes completed surveys including...

Successful Fixation of Traumatic Articular Cartilage-Only Fragments in the Juvenile and Adolescent Knee: A Case Series.

Some surgeons are now considering fixation of traumatic chondral-only fragments in juvenile knees, but few data remain to guide treatment. To determine if surgical fixation of chondral-only fragments in the juvenile knee results in an adequate healing response with successful imaging and clinical outcomes. Case series; Level of evidence, 4. Data were collected on 16 skeletally immature patients treated with fixation of chondral-only fragments with a minimum 1-year follow-up. Patients were selected by the operating surgeons based on the quality and size of the chondral fragment. Demographic data, lesion characteristics, surgical procedure details, complications, and postoperative imaging were assessed. Validated outcome measures were collected pre- and postoperatively and included the following scores: International Knee Documentation Committee (IKDC), Marx Activity Scale, Knee injury and Osteoarthritis Outcome Score (KOOS), Hospital for Special Surgery Pediatric Functional Activity-Brief Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Health and PROMIS-Psychological Health, and Tegner. The mean age of our patient cohort was 14.9 years. The mean size of the repaired defects measured 3.2 cm2. Injury sites included the patella (n = 1), medial femoral condyle (n = 3), trochlea (n = 4), and lateral femoral condyle (n = 8). Within the mean follow-up time of 42.3 months (range, 15-145), there was 1 clinical failure with loosening of the chondral fragment and the need for reoperation. At a mean follow-up of 3.5 years, the mean (interquartile range) patient-reported outcome scores were as follows: IKDC, 95.2 (94.3-100); Marx Activity Scale, 11.5 (11.5-16); KOOS, 95.81 (93.5-95.81); HSS Pedi-FABS, 16.94 (11.5-26); PROMIS-Physical Health, 93.75% (90%-100%); PROMIS-Psychological Health, 90% (88.75%-100%); and Tegner, 5.69 (4.75-7). All patients who were engaged in sports before injury returned to the same or higher level of competition with the exception of 1 patient. Primary repair of chondral-only injuries with internal fixation can be a successful treatment option in selected patients. Clinical and imaging results at final follow-up suggest that reintegration of the cartilage fragment is achievable and leads to excellent clinical function and a high return-to-sports rate.

Cross-cultural Adaptation and Validation of the Japanese Version of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS).

Background:The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) is a specifically designed scoring system for children and has been translated into several languages. However, to date, no validated Japanese version of this scoring system is available.Purpose:To translate the HSS Pedi-FABS into Japanese and assess its reliability and validity.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:The HSS Pedi-FABS was translated into Japanese and back-translated into English to confirm the appropriateness of the translation. A total of 764 children aged 9 to 15 years participated in the validation study. The participants answered the Japanese version of the HSS Pedi-FABS along with 2 other questionnaires in Japanese (the Physical Activity Questionnaire for Older Children [PAQ-C] and the physical activity questionnaire of the World Health Organization’s Health Behavior in School-aged Children [HBSC PAQ]). At 1 month after the first assessment, the children answered the Japanese version of the HSS Pedi-FABS again. We evaluated reliability using the Cronbach alpha and the intraclass correlation coefficient. Validity was evaluated by quantifying floor and ceiling effects, correlations between the HSS Pedi-FABS and the PAQ-C, the HSS Pedi-FABS discrepancy between active and inactive groups divided by the HBSC PAQ, and correlation between the HSS Pedi-FABS and body mass index.Results:HSS Pedi-FABS scores were slightly but significantly higher in male participants (mean = 16.7) than in female participants (mean = 13.2). The Cronbach alpha coefficient was .90, and the intraclass correlation coefficient value was 0.90, indicating excellent internal consistency and test-retest reliability, respectively. No floor (2.6%) or ceiling effect (1.0%) was observed. The HSS Pedi-FABS was significantly correlated with the PAQ-C (r = 0.70). The active group demonstrated a significantly higher score on the HSS Pedi-FABS (mean = 18.9) than did the inactive group (mean = 11.2). In terms of discriminative validity, the HSS Pedi-FABS was not correlated with body mass index (r = –0.15).Conclusion:The Japanese version of the HSS Pedi-FABS demonstrated appropriate reliability and validity, indicating that it is a useful tool to assess physical activity levels in Japanese children.

The influence of COVID-19 pandemic on the incidence of knee pain and physical activity level in children and adolescents in Japan: A prospective observation study

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on children's lifestyles. Some studies have reported psychological changes in children after the pandemic, but information on musculoskeletal problems is scarce. This study aimed to investigate the incidence of knee pain and changes in physical activity after the spread of COVID-19 among elementary and junior high school students in Japan. MethodsKnee pain and amount of physical activity were recorded on a monthly basis between August 2019 and February 2021 in children aged 8–14 years using a self-administered questionnaire. The amount of physical activity was scored using the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). The period until February 2020 was defined as “Before pandemic,” and the period from March 2020 was defined as “After pandemic.” The incidences of knee pain and HSS Pedi-FABS scores before and after the COVID-19 pandemic were compared. Additionally, we compared the prevalence of knee pain and HSS Pedi-FABS scores according to sex and age. ResultsWe enrolled 886 and 881 participants before and after the pandemic, respectively. The prevalence of knee pain among the participants before and after the pandemic was 6.7% and 7.9%, respectively (p = 0.032). The mean HSS Pedi-FABS scores before and after the pandemic were 14.8 and 14.5, respectively (p = 0.005). Participants aged 14 years had a significantly lower incidence of knee pain (p = 0.013) and significantly higher HSS Pedi-FABS scores (p < 0.001) after the spread of COVID-19. ConclusionsIn elementary and junior high school students, increase in the incidence of knee pain and decrease in the amount of physical activity after the spread of COVID-19 were observed.

Translation and Cross-Cultural Adaptation of the Pediatric Outcomes Data Collection Instrument into the Italian Language.

(1) Background: The Pediatric Outcomes Data Collection Instrument (PODCI) is an English-language questionnaire specifically designed to assess health-related quality of life in children and adolescents with musculoskeletal disorders. This scoring system has been translated into several languages. Given the lack of an Italian version of the PODCI, this study aimed to translate, cross-culturally adapt, and assess the psychometric properties of the PODCI score in the Italian pediatric population. (2) Methods: The PODCI questionnaire was culturally adapted to Italian patients in accordance with the literature guidelines. The study included 59 participants from a single orthopedic institution who underwent orthopedic surgery for various skeletal conditions. The questionnaire was administered to participants at multiple time-points (T0, T1, T2). Internal consistency was evaluated using Cronbach’s alpha. Reproducibility was assessed using the intraclass correlation coefficient (ICC) between T0 and T1 assessment. Criterion validity was assessed using Spearman’s correlation coefficients between PODCI and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Responsiveness was evaluated by the difference between T0 and T2 using the effect size (ES) and the standardized response mean (SRM) calculation. (3) Results: Cronbach’s alpha was acceptable in both the self- and parent-reported versions with values of 0.78 (0.68–0.90) and 0.84 (0.60–0.92), respectively. The ICC fluctuated between 0.31 and 0.89 for self-reported and 0.49 to 0.87 for pediatrics. The Spearman’s r showed a moderate correlation between HSS Pedi-FABS and the “Sport & Physical Functioning” and “Global Functioning” domains. ES and SRM varied from small to moderate across all the domains. (4) Conclusions: This study demonstrates that the Italian version of the PODCI, translated following the international standardized guidelines, is reliable, valid, and responsive in pediatric patients who underwent orthopedic surgery.

Grit After Acl Reconstruction: Sex Differences and Association with Knee Outcomes Among Adolescent Athletes

Background: Grit reflects perseverance for pursuing long-term goals. Recovery from ACL reconstruction requires a long and challenging rehabilitation process. While grit has previously been used to predict success in education and military settings, little is known about the association between grit and the rehabilitation process among adolescent athletes after ACL reconstruction. Purpose: The primary aim of the study was to determine differences in GRIT-S scores between male and female athletes pre-operatively to 6 months post-ACL reconstruction. The second aim of the study was to assess the relationship between pre-operative GRIT-S scores and knee outcome measures 6 months post-operatively. Methods: All participants completed the GRIT-S questionnaire, the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective knee form, and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) at a pre-operative appointment and then again approximately 6 months after ACL reconstruction. We conducted a linear mixed model analysis to assess the effects of sex and time on GRIT-S scores. We then conducted a linear regression analysis to determine if pre-operative GRIT-S scores predicted IKDC and HSS Pedi-FABS scores at 6 months post-operatively. We defined statistical significance as p &lt; 0.05. Results: We included 83 participants (mean age 16.0 +/- 2.3 years, 70% female) from a prospective registry of pediatric athletes undergoing ACL reconstruction by one surgeon at a single institution. For the entire study population, there was no statistically significant change in GRIT-S scores from the pre-operative assessment to 6 months post-operatively. However, there was a statistically significant effect of sex (p=0.03) on GRIT-S scores from pre-operative assessment to 6 months post-operatively, with female athletes demonstrating more grit than male athletes across both assessments (Figure 1). Additionally, there was no significant association between pre-operative GRIT-S scores and Pedi-IKDC and HSS Pedi-FABS scores 6 months post-operatively for the entire group (Figure 2). Conclusion: In our study population, female athletes reported higher GRIT-S scores than male athletes across the first 6 months of rehabilitation after ACL reconstruction. Pre-operative GRIT-S scores do not appear to be significantly associated with knee outcome measures 6 months post-operatively, which could suggest that grit may not necessarily predict success in the rehabilitation process after ACL reconstruction. However, future studies will examine how grit is associated with return-to-sport outcomes to determine if grit is a useful marker in predicting successful return-to-sport after ACL reconstruction in adolescent athletes. [Figure: see text][Figure: see text]

Risk factors for the occurrence and protraction of patellar and patellar tendon pain in children and adolescents: a prospective cohort study of 3\u2009years

BackgroundPatellar and patellar tendon pain is a common limitation to children’s participation in social and physical activities. Some factors have been implicated in the occurrence and protraction of knee pain, but the causal relationship is unknown. The purpose of this study was to investigate whether participants’ physical characteristics and activity level are risk factors for the occurrence and protraction of patellar and patellar tendon pain in children and adolescents.MethodsA three-year prospective cohort study was conducted with healthy students who were aged 8–14 years old, in Japan. Height, weight, heel-buttock distance, straight leg raising angle, and dorsiflexion angle of the ankle joint were collected as individual physical factors at the beginning of each year. The presence of self-reported patellar and patellar tendon pain and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) was collected every month. Protraction was defined as either (1) pain lasting for more than three continuous months or (2) recurrent pain after more than three months of complete recovery. Participants who did not have any pain at the beginning of the observation period were included in the analysis. We analyzed the odds ratio (OR) of pain occurrence within a year of registration and protraction throughout the study period for all physical factors and HSS Pedi-FABS.ResultsWe included 1133 participants in the analysis and 252 participants developed knee pain within a year. 34.8% of participants with pain experienced protraction during the follow-up period. A high HSS Pedi-FABS significantly predicted knee pain occurrence (OR 1.03, 95% confidence interval [CI] 1.01–1.05) and protraction (OR 1.03, 95% CI 1.00–1.05). In addition, younger children and girls were at a significantly higher risk of patellar and patellar tendon pain protraction (age, OR 0.81, 95% CI, 0.73–0.90; sex, OR 1.69, 95% CI, 1.09–2.64). Other physical factors did not significantly predict the occurrence or protraction of knee pain.ConclusionsThis study showed that a greater physical activity level was a risk factor for the occurrence and protraction of patellar and patellar tendon pain in childhood. In addition, younger age and female sex predicted higher risk of protraction of pain.

A Multiyear Assessment of the Effect of Sport Participation on the Health of Adolescent Athletes During the COVID-19 Pandemic.

Sport cancellations early in the COVID-19 pandemic had a significant negative effect on the health of US adolescents. The effect of restarting sports during the pandemic has not been described. To identify the effect of sport participation on the health of adolescents before and during the COVID-19 pandemic. Cross-sectional study. Sample recruited via social media. Wisconsin adolescent athletes. Participants provided information regarding their age, sex, and sport(s) involvement and completed the Patient Health Questionnaire-9 Item to assess depression symptoms, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale to measure physical activity, and the Pediatric Quality of Life Inventory 4.0 to measure quality of life (QoL). Data were collected in spring 2021 (Spring21; n = 1906, age = 16.0 ± 1.2 years, females = 48.8%), when interscholastic sports had fully resumed, and were compared with similar cohorts of adolescent athletes at 2 time points: (1) spring 2020 (Spring20; n = 3243, age = 16.2 ± 1.2 years, females = 57.9%) when sports were cancelled and (2) 2016-2018 (PreCOVID-19) before the pandemic (n = 5231, age = 15.7 ± 1.1 years, females = 65.0%). Comparisons were conducted via analysis-of-variance models and ordinal regressions with age and sex as covariates. The prevalence of moderate to severe depression was lower in Spring21 than in Spring20 but higher than in PreCOVID-19 (PreCOVID-19 = 5.3%, Spring20 = 37.8%, Spring21 = 22.8%; P < .001). Physical activity scores (mean [95% CI]) were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 23.1 [22.7, 23.5], Spring20 = 13.5 [13.3, 13.7], Spring21 = 21.9 [21.6, 22.2]). Similarly, QoL scores were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 92.8 [92.5, 93.1], Spring20 = 80.7 [80.3, 81.1], Spring21 = 84.3 [83.8, 84.8]). Although sports have restarted, clinicians should be aware that physical activity, mental health, and QoL are still significantly affected in adolescent athletes by the ongoing pandemic.

Outcomes After Surgical Excision of Knee Osteochondromas

Source: Wu M, Zheng ET, Anderson ME, et al Surgical treatment of solitary periarticular osteochondromas about the knee in pediatric and adolescent patients: complications and functional outcomes. J Bone Joint Surg Am. 2021;103(14):1276-1283; doi:10.2106/JBJS.20.00998Investigators from multiple institutions conducted a cohort study to assess outcomes in children after surgical excision of solitary knee osteochondromas (SKO). Patients ≤19 years old who underwent surgery for histology-confirmed SKO at the study hospital from 2003–2016 were included. Demographics and clinical features, such as SKO chief presenting symptom, type (sessile or pedunculated), and site (distal femur, proximal tibia, or proximal fibula), were abstracted from the medical record.The primary outcomes were major surgical complications and post-surgical functional outcomes. Major complications were obtained from the medical record and defined as Clavien-Dindo Grade III complications, such as recurrence-required surgical excision, deep wound infection, intraoperative vascular injury, and persistent pain. Post-surgical functional outcomes were assessed by administering 2 validated functional outcome measures (Pediatric International Knee Documentation Committee measure, or Pedi-IKDC, and Hospital for Special Surgery Pediatric Functional Activity Brief Scale, or Pedi-FABS) among those who could be reached by letter and/or telephone post-surgery. The Pedi-IKDC is scored from 0-100, and the Pedi-FABS is scored 0-30, with higher scores on each measure suggesting better functional ability. Investigators used multivariate regression to assess the association between demographic and clinical features with outcomes after adjusting for potential confounders.There were 264 patients included in analysis, 43% of whom provided post-surgical functional outcome data at a mean duration of follow-up of 5.8 years. Overall, most patients were male (58%), were athletes (81.4%), and had a chief presenting symptom of pain (90%). Most SKOs were pedunculated (65%) and were located in the distal femur (59%).There were 6 patients (2%) who had major complications, including 3 with recurrence requiring surgical excision. The mean Pedi-IKDC and Pedi-FABS scores were 97 and 16.7, respectively. The odds of a major complication were significantly lower in older children, pedunculated lesions, and lesions in the proximal tibia.The investigators conclude that surgical excision of SKOs was associated with infrequent major complications and good functional outcomes.Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.A solitary osteochondroma is the most common benign bone tumor in children and adolescents.1 The tumor stems from a developmental disorder in the growth plate resulting in a metaphyseal bony projection with a cartilaginous cap. The tumor can be pedunculated or sessile.2 In approximately 15 % of cases, multiple tumors occur due to the autosomal dominant disorder, multiple hereditary exostoses.3As the child grows, the osteochondroma also grows. The osteochondroma can cause symptoms due to irritation of adjacent tendons, nerves, or arteries.4 In children and adolescents, surgical excision is indicated if symptoms such as pain, swelling, or snapping are present. In rare cases, if the osteochondroma has not been excised in childhood, malignant transformation as an adult can occur.5The current study is the largest consecutive series of patients from 1 institution investigating the peri-operative complications and functional outcomes following surgical excision of solitary knee osteochondromas in pediatric and adolescent patients. A total of 264 cases were reviewed over a 14-year study period. All had radiographic diagnosis and histologic confirmation of the diagnosis by a pathologist. Sixty-five percent of tumors were pedunculated, and 35% were sessile. Fifty-nine percent were located at the distal femur, and 41% were at the proximal tibia or fibula. Sixty-nine percent were located on the medial knee, and 31 % were lateral. Ninety-six percent of patients returned to sports at an average of 2.5 months. Patient-reported outcome scores were excellent. Only 6 patients had a complication requiring re-operation, including 3 who had a recurrence of the tumor due to inadequate excision.The authors concluded that regardless of the orthopaedic surgeon’s fellowship training (oncologist, sports medicine, or pediatrics) or the location of the osteochondroma, surgical excision of the benign tumor resulted in excellent outcomes with minimal complications.Surgical excision of solitary osteochondromas about the knee in children and adolescents is safe and effective. As these benign tumors commonly present in adolescent athletes, pediatricians need to keep osteochondromas in the differential diagnosis of causes of knee pain.

Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans.

Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes. Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared. Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics. RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents.

During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown. To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes. Cross-sectional study. Sample recruited via email. A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP). Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch. The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001). Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

Surgical Treatment of Solitary Periarticular Osteochondromas About the Knee in Pediatric and Adolescent Patients: Complications and Functional Outcomes.

Solitary osteochondromas, or osteocartilaginous exostoses (OCEs), represent the most common benign bone tumor. Despite frequently causing symptoms about the knee in younger populations, there is minimal previous literature investigating surgical treatment. We retrospectively reviewed the records of patients <20 years old who had undergone surgical treatment of symptomatic, pathologically confirmed, solitary periarticular knee OCE at a single pediatric center between 2003 and 2016. The clinical course, radiographic and pathological features, and complications were assessed. Prospective outreach was performed to investigate patient-reported functional outcomes. Two hundred and sixty-four patients (58% male, 81% athletes) underwent excision of a solitary OCE about the knee at a mean age (and standard deviation) of 14.3 ± 2.24 years. Fifty-five percent of the procedures were performed by orthopaedic oncologists, 25% were performed by pediatric orthopaedic surgeons, and 20% were performed by pediatric orthopaedic sports medicine surgeons, with no difference in outcomes or complications based on training. Of the 264 lesions, 171 (65%) were pedunculated (versus sessile), 157 (59%) were in the distal part of the femur (versus the proximal part of the tibia or proximal part of the fibula), and 182 (69%) were medial (versus lateral). Postoperatively, 96% of the patients returned to sports at a median of 2.5 months (interquartile range, 1.9 to 4.0 months). Forty-two patients (16%) experienced minor complications not requiring operative intervention. Six patients (2%) experienced major complications (symptoms or disability at >6 months or requiring reoperation), which were more common in patients with sessile osteochondromas (p = 0.01), younger age (p = 0.01), and distal femoral lesions as compared with proximal tibial lesions (p = 0.003). Lesion recurrence was identified in 3 patients (1.1%). Overall, the median Pediatric International Knee Documentation Committee (Pedi-IKDC) and mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores were 97 (interquartile range, 93 to 99) and 16.7 ± 8.15, respectively, at a median duration of follow-up of 5.8 years. In our large cohort of pediatric patients who underwent excision of solitary knee osteochondromas, most patients were male adolescent athletes. Most commonly, the lesions were pedunculated, were located in the distal part of the femur, and arose from the medial aspect of the knee. Regardless of surgeon training or lesion location, patients demonstrated excellent functional outcomes, with minimal clinically important postoperative complications and recurrences, although patients with sessile lesions and younger age may be at higher risk for complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Age Is More Predictive of Safe Movement Patterns Than Are Physical Activity or Sports Specialization: A Prospective Motion Analysis Study of Young Athletes

Background: Movement quality and neuromuscular balance are noted predictors of acute injury. Early sports specialization and extremely high activity levels have been linked to elevated risk of injury. Purpose: To investigate for any relationships among quality of physical movement, quantity of physical activity, and degree of sports specialization in a healthy cohort of active children and adolescents. Study Design: Cross-sectional study with prospectively collected data. Methods: Healthy children between the ages of 10 and 18 years were recruited and completed the Hospital for Special Surgery Pediatric Functional Activity Brief Scale to assess quantity of physical activity and the Jayanthi scale to assess degree of sports specialization (high, score of 2 or 3; low, score of 0 or 1). Movement quality was assessed using motion analysis sensors during 5 repetitions of 4 different jumping and squatting motions, with a maximum score of 100 per participant. Independent-samples t tests were used to compare participants with high versus low specialization on physical activity and movement quality. A Spearman correlation was used to determine the relationship between quantity of physical activity and movement quality, and linear regression was used to assess for the effect of participant age on relevant covariables. Results: Final analyses included 147 participants (72% male) with a mean ± SD age of 13.4 ± 2.2 years. Participants who were highly specialized displayed better movement quality than did participants with low sports specialization (27.6 ± 14.0 vs 19.8 ± 10.1; P < .01). Participants who were highly specialized had significantly higher activity levels (24.6 ± 5.9 vs 18.1 ± 6.9; P < .001). Movement quality was moderately correlated with physical activity level (r = 0.335; P < .001). Physical activity; hours of organized sports activity; hours of free, unorganized physical activity; and specialization level were not significant predictors of movement quality when controlling for age. Age alone predicted 24.2% of the variance in the overall movement quality score (R2 = 0.242; B = 3.0; P < .001). Conclusion: This study found that sports specialization and physical activity levels were not associated with movement quality when controlling for age, which was the most important variable predicting athletic movement quality. Although all participants displayed movement patterns that were associated with high risk for injury, overall movement quality improved with advancing chronological age. Clinical Relevance: All young athletes should ensure that neuromuscular training accompanies sport-specific training to reduce risk of injury.