Exercise-Induced Vision Dysfunction Early After Sport-Related Concussion Is Associated With Persistent Postconcussive Symptoms.

OBJECTIVE: The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS. DESIGN: Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program. SETTING: Three university-associated sports medicine clinical programs. PARTICIPANTS: Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury. INDEPENDENT VARIABLE: King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test. MAIN OUTCOME MEASURE: Persistent post-concussive symptoms. RESULTS: Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS. CONCLUSIONS: Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction.

Adolescents With More Oculomotor and Vestibular Signs of Sport-Related Concussion Benefit from Aerobic Exercise: An Exploratory Analysis.

Abstract Early targeted heart rate (HR) aerobic exercise has been shown to reduce the duration of recovery from sport-related concussion (SRC) as well as the incidence of persistent post-concussive symptoms (PPCS). It is not known, however, if more severe oculomotor and vestibular presentations of SRC benefit from a prescription of aerobic exercise. The current study is an exploratory analysis of two published randomized controlled trials that compared aerobic exercise within 10 days of injury with a placebo-like stretching intervention. Combining the two studies yielded a larger sample size to stratify severity of concussion based on the number of abnormal physical examination signs present at the initial office evaluation, which were confirmed with self-reported symptoms and recovery outcomes. The most discriminant cut-off was between those who had ≤3 oculomotor and vestibular signs and those who had >3 signs. Aerobic exercise (hazard ratio = 0.621 [0.412, 0.936], p = 0.023) reduced recovery times even when controlling for site (hazard ratio = 0.461 [0.303, 0.701], p < 0.001), severity (hazard ratio = 0.528 [0.325, 0.858], p = 0.010) and the interaction term of intervention and severity (hazard ratio = 0.972 [0.495, 1.909], p = 0.935). Adolescents who presented with >3 signs and were assigned to the placebo-like stretching group had a PPCS incidence of 38%, which was the highest of all subgroups (aerobic exercise and ≤3 findings: 8%; stretching and ≤3 findings: 11%; aerobic exercise and >3 findings: 21%). This exploratory study provides pilot evidence that prescribed sub-symptom threshold aerobic exercise treatment early after SRC may be effective for adolescents with more oculomotor and vestibular physical examination signs and should be validated in future adequately powered trials.

Influence of concussion history and age of first concussion on visio-vestibular function.

OBJECTIVES: To assess if abnormalities on visio-vestibular examination (VVE) are associated with concussion history (first vs. repeat) or age of first concussion in acutely concussed adolescents. DESIGN: Cross-sectional. METHODS: Data were queried from the Children's Hospital of Philadelphia Minds Matter concussion registry. Patients aged 14-18 years old presenting for their initial visit to the specialty care concussion program within 28 days of injury were included. Demographics, including age, sex, concussion history, and age of first concussion, were collected before the exam. The VVE consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and vestibulo-ocular reflex (VOR), binocular convergence, left/right monocular accommodation, and complex tandem gait. Primary outcomes included VVE subtests (normal/abnormal), and total VVE score (abnormal = 2+ abnormal subtests). RESULTS: Among 1051 patients included (female = 604(57.5 %); age = 15.6 ±â€¯1.2; median lifetime concussions = 1 [IQR = 1,3]), 518 had repeat concussion. Controlling for age and sex, first vs. repeat concussion was not associated with any VVE subtest or total score (Total VVE Score RR = 1.35, 99.5%CI = 0.70,2.61). Of those with repeat concussion, 190 had valid age of first concussion data. Controlling for age, sex, and number of lifetime concussions, age of first concussion was not significantly associated with any VVE subtest or total score (Total VVE Score RR = 1.11, 99.5%CI = 0.78,1.57). CONCLUSIONS: Adolescents with concussion history present with similar visio-vestibular function to those with no concussion history. Additionally, clinical effects of early age of first concussion may not be evident in children. This study provides foundational data regarding potential cumulative effects of concussion in younger athletes.

Adolescents with Sport-Related Concussion Who Adhere to Aerobic Exercise Prescriptions Recover Faster.

PURPOSE: There is growing evidence that subsymptom threshold aerobic exercise speeds recovery from sport-related concussion (SRC). It is not known whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden affects adherence to the prescription. METHODS: This study was a planned secondary analysis of one arm of a randomized controlled trial. Male and female adolescent athletes (age 13-18 yr) presenting within 10 d of SRC were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test. Adherence was determined objectively with HR monitors and compared against time to recovery. Participants who completed at least two-thirds of their aerobic exercise prescription were considered to be adherent. RESULTS: Sixty-one percent of adolescents met the adherence criterion. Those who were adherent were more symptomatic and were more exercise intolerant at their initial visit, yet they recovered faster than those who were not adherent (median recovery time, 12 (interquartile range, 9-22) d vs 21.5 (interquartile range, 13-29.8) d; P = 0.016). On linear regression, adherence during week 1 was inversely related to recovery time ( ß = -0.002 (-0.003, 0.0), P = 0.046) and to initial exercise tolerance ( ß = -0.886 (-1.385, -0.387), P < 0.001), but not to initial symptom severity ( ß = 0.545 (-0.232, 1.323), P = 0.146). No adverse events or near misses were reported. CONCLUSIONS: Adherence to individualized subsymptom threshold aerobic exercise within the first week of evaluation is associated with faster recovery from SRC. The data suggest that initial degree of exercise intolerance, but not initial symptom severity, affects adherence to aerobic exercise prescribed to adolescents within 10 d of SRC.

Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion.

OBJECTIVE: To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents. DESIGN: Cross-sectional. SETTING: Suburban high school and academic pediatric tertiary care center. PARTICIPANTS: Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion. ASSESSMENT OF INDEPENDENT VARIABLES: Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions. MAIN OUTCOME MEASURES: Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment. RESULTS: Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%). CONCLUSIONS: A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions. CLINICAL RELEVANCE: The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.

Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial.

BACKGROUND: Sport-related concussion is a public health problem, particularly in adolescents. Quality of life is reduced in adolescents with persistent post-concussive symptoms (symptoms >28 days). We replicated a previous randomised controlled trial to validate the safety, efficacy, and generalisability of, and objective adherence to, prescribed early targeted heart rate subsymptom threshold aerobic exercise compared with placebo-like stretching exercise for adolescent recovery from sport-related concussion and for reducing the risk of persistent post-concussive symptoms. METHODS: This randomised controlled trial was done at three community and hospital-affiliated sports medicine concussion centres in the USA. Male and female adolescent athletes (aged 13-18 years) presenting within 10 days of sport-related concussion were randomly assigned to individualised subsymptom threshold aerobic or stretching exercise at least 20 min daily, for up to 4 weeks after injury. Exercise adherence and intensity were measured by heart rate monitors. The primary outcome was clinical recovery (ie, return to baseline symptoms, normal exercise tolerance, and a normal physical examination) within the 4-week intervention period, and development of persistent post-concussive symptoms beyond 28 days after injury. This study is registered with ClinicalTrials.gov, NCT02959216. FINDINGS: Between Aug 1, 2018, and March 31, 2020, 118 adolescents were recruited (61 were randomly assigned to the aerobic exercise group and 57 to the stretching exercise group) and included in the intention-to-treat analysis. On survival analysis, controlling for sex, site, and mean daily exercise time, patients assigned to aerobic exercise were more likely to recover within 4 weeks after injury compared with those assigned to stretching exercise, with a 48% reduced risk of persistent post-concussive symptoms (hazard ratio for stretching vs aerobic exercise of 0·52 [95% CI 0·28-0·97], p=0·039). No adverse events were reported. INTERPRETATION: This multicentre study found that early treatment with subsymptom threshold aerobic exercise safely speeds recovery from sport-related concussion and reduces the risk for persistent post-concussive symptoms, an important result given the impact of delayed recovery on adolescent quality of life. Adherence was good and there were no adverse events from this non-pharmacological treatment. These results suggest that physicians should not only permit, but consider prescribing, early subsymptom threshold physical activity to adolescents as treatment for sport-related concussion and to reduce the risk of persistent post-concussive symptoms. FUNDING: American Medical Society for Sports Medicine.

Symptoms upon postural change and orthostatic hypotension in adolescents with concussion.

Objective: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls.Participants: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male).Methods: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury).Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p < .001) but did not differ in meeting standard OH criteria (3% vs 5%, p = .32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, p = .65).Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.

Providing pharmacy services in a basketball arena: Reflections on building a pharmacy in a COVID-19 surge facility.

PURPOSE: As Coronavirus disease 19 (COVID-19) has spread globally, hospital systems have seen an increasing strain on their ability to accommodate the growing caseload. This demand has led countries to adopt varying surge-facility or alternate care site (ACS) models to manage patient overflow. This report describes the experience of setting up pharmacy services at a city-run surge facility in Philadelphia. SUMMARY: The COVID-19 Surge Facility at the Liacouras Center (CSF-L) was initially developed to serve as a site for patients convalescing from acute inpatient stays in order to free up healthcare resources in surrounding hospitals. The CSF-L site required a distinct set of services to provide the desired level of care. This report details the preparations and challenges faced by the CSF-L pharmacy team in this endeavor, including identifying a pharmacy location that met regulatory requirements, obtaining proper licenses, coordinating drug procurement, filling staffing requirements, developing a formulary, defining the pharmacy and medication management workflow, and ensuring safety protocols were followed. This report explains the rational for developing certain processes and suggests alternative options and ideal plans for developing future pharmacy services in an ACS. CONCLUSION: Identifying a pharmacy leadership team early in the ACS planning process can lead to more efficient plans for pharmacy services. This report details the important steps taken, decisions made, and challenges faced in setting up pharmaceutical services at a COVID-19 field hospital.

Changes in Driving Behaviors After Concussion in Adolescents.

PURPOSE: Although return to learn, exercise, and sports have evidence-based guidelines, there is limited research investigating return to driving after concussion. The purpose was to characterize and compare adolescent driving behaviors after concussion. METHODS: Using the Minds Matter Concussion Registry, we queried data of adolescents, aged 16-19 years, diagnosed with a concussion ≤28 days of injury and seen between January 31, 2017 and August 31, 2018 at the specialty care concussion program. Outcomes included patient report of: changes postinjury driving behaviors; Post-Concussion Symptom Inventory; return to school, and exercise and sports. Provider recommendations for return to school after initial clinical assessment were also examined. Descriptive statistics, analysis of covariance, and chi-square tests were performed. RESULTS: Of the 332 drivers (46.1% female; mean age 17.5 years, 95% confidence interval [CI], 17.4-17.6), 46.9% had returned to driving since injury. Of those who returned to driving, 58.9% reported "Driving with No Changes." The Post-Concussion Symptom Inventory score was higher among "Driving with Changes" (48.7, 95% CI: 42.2-55.2) than "Driving with No Changes" (27.4, 95% CI: 22.3-32.5, p < .01) and "Has Not Driven Since Injury" (42.3, 95% CI: 38.4-46.3, p < .01). Among the 332 drivers, few had returned to exercise (15.4%) or organized sports (6.0%). Of those in school (n = 291), only 8.9% were provider recommended to return to full school days after clinical assessment. CONCLUSION: Many adolescents continued to drive after concussion, despite not yet having returned to exercise or sport. Nine of 10 were advised to return to school with accommodations to begin a gradual increase in cognitive activity, suggesting a gradual increase in driving may be justified.

Opportunities at the intersection of work and health: Developing the occupational data for health information model.

OBJECTIVE: The study sought to develop an information model of data describing a person's work for use by health information technology (IT) systems to support clinical care, population health, and public health. MATERIALS AND METHODS: Researchers from the National Institute for Occupational Safety and Health worked with stakeholders to define relationships and structure, vocabulary, and interoperability standards that would be useful and collectable in health IT systems. RESULTS: The Occupational Data for Health (ODH) information model illustrates relationships and attributes for a person's employment status, retirement dates, past and present jobs, usual work, and combat zone periods. Key data about the work of a household member that could be relevant to the health of a minor were also modeled. Existing occupation and industry classification systems were extended to create more detailed value sets that enable self-reporting and support patient care. An ODH code system, available in the Public Health Information Network Vocabulary Access and Distribution System, was established to identify the remaining value sets. ODH templates were prepared in all 3 Health Level 7 Internationalinteroperability standard formats. DISCUSSION: The ODH information model suggests data elements ready for use by health IT systems in the United States. As new data elements and values are better defined and refined by stakeholders and feedback is obtained through experience using ODH in clinical settings, the model will be updated. CONCLUSION: The ODH information model suggests standardized work information for trial use in health IT systems to support patient care, population health, and public health.

A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures.

BACKGROUND: Simulation-based training is one way to improve basic competence for surgical trainees and thus improve patient safety. Closed reduction and percutaneous pinning of a supracondylar humerus fracture is a common procedure that encompasses many basic orthopaedic skills and has been identified as a residency milestone. Despite this, no quantitative tools exist to help learners attain this basic skill. This study seeks to validate a quantitative, low-cost simulation-based training tool for teaching orthopaedic surgery trainees the fundamentals of fracture stabilization with pins. METHODS: Two low-cost models were developed with simulated cancellous bone blocks and cortical bone sheets: a pinning agility tool to teach pin placement and redirection, and a low-cost construct stability tool to replicate pinning. A high-cost construct stability tool was cut using a pediatric supracondylar humerus model to simulate pinning a real fracture. Construct stability was assessed by adding weight until ∼1.6 mm of displacement was observed. Participants were tested naively on all 3 models and then completed a training session using only the low-cost models. Performance following training was then assessed and compared with fellowship-trained pediatric orthopaedic surgeons. Participants also rated their preintervention and postintervention confidence, skill, and knowledgeability. RESULTS: A total of 18 novice trainees participated (10 PGY1 and PGY2 orthopaedic surgery residents and 8 medical student members of the orthopaedic surgery interest club), whereas the reference group consisted of 7 orthopaedic surgery attendings. The subjects significantly improved their scores on both the low-cost (P=0.002) and high-cost (P<0.001) construct stability tools after the training with only the low-cost tools. Compared with the attending benchmark, trainee scores improved on the high-fidelity model from 31% preintervention to 86% postintervention and their pinning times decreased by 38%. Trainees reported increased knowledge, skill, and confidence after the intervention (P<0.001). CONCLUSIONS: A novel, low-cost simulation model and training session for supracondylar humerus fracture pinning resulted in improved performance in stabilizing a supracondylar humerus model and increased trainee knowledgeability, confidence, and skill. LEVEL OF EVIDENCE: Level II-economic.

Weight Gain After ACL Reconstruction in Pediatric and Adolescent Patients.

BACKGROUND: Adolescent athletes who sustain an anterior cruciate ligament (ACL) tear have significantly reduced activity levels during recovery. Activity level is linked to body mass index (BMI); however, it is unclear how recovery from an ACL reconstruction (ACLR) affects relative BMI and whether these changes persist after return to activity. HYPOTHESIS: Patients' BMI percentile will significantly increase after ACLR, but will trend toward baseline after return to activity. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: A retrospective review of 666 pediatric and adolescent patients who underwent ACLR was performed. Body mass was assessed by evaluating change in BMI percentile at 8 standard-of-care time windows relative to BMI percentile at time of surgery. Linear regression and bivariate and multivariate analyses were used to assess the effect of time window and other demographic factors on the change in BMI percentile. These analyses were rerun after dividing patients by clinical obesity categorization (underweight, normal, overweight, or obese) at time of surgery to assess the effect of preinjury body mass levels. RESULTS: BMI percentile of all BMI categories tended to increase postoperatively, peaking 6 to 9 months after surgery, with a median increase of 1.83 percentile points. After this peak, BMI approached baseline but remained elevated at 0.95 percentile points 2 years postoperatively. Beginning 3 months after surgery, the normal-weight group had significantly larger changes in BMI percentile at each time window, peaking at 4.15 points above baseline at 9 months. This BMI increase among normal-weight patients persisted in the second postoperative year, with a median percentile increase of 2.63 points. CONCLUSION: Pediatric and adolescent patients, especially those with a normal BMI, undergo significant changes to their BMI during recovery from ACLR. CLINICAL RELEVANCE: Patients' failure to return to their presurgical BMI percentile 2 years postoperatively suggests that ACLR may have long-reaching and often unappreciated effects on body mass.

Pediatric ACL Reconstruction and Return to the Operating Room: Revision Is Less Than Half of the Story.

BACKGROUND: Although there are several causes of unplanned return to the operating room (RTOR) following pediatric anterior cruciate ligament (ACL) reconstruction (ACLR), prior outcomes studies focus primarily on the risk of graft failure. We sought to comprehensively describe indications for RTOR in pediatric primary ACLR patients, estimate associated rates of RTOR, and assess the impact of concomitant meniscal procedures on these rates. METHODS: This retrospective cohort study considered patients who underwent primary ACLR at an urban, pediatric tertiary care hospital between 2013 and 2015. Cohorts were defined based on the presence or absence of a concomitant surgical meniscal procedure with the index ACLR. The primary outcome was RTOR for an indication pertaining to ACLR or a potential predilection for knee injury. Cases of RTOR were cataloged and classified according to indication. Survival analyses were performed using the Kaplan-Meier estimation and competing-risks regression. Comparisons of any-cause RTOR rates were done using log-rank tests. RESULTS: After exclusion criteria were applied, 419 subjects were analyzed. RTOR indications were organized into 5 categories. The overall rate for any RTOR by 3 years after surgery was 16.5%. Graft failure and contralateral ACL tear were the most common indications for RTOR, with predicted rates of 10.3% and 7.1%, respectively. ACL graft failure accounted for less than half of RTOR cases cataloged. Patients who had a concomitant meniscus procedure had lower rates of RTOR. CONCLUSIONS: Approximately 1 in 6 pediatric ACLR patients underwent ≥1 repeat surgery within 3 postoperative years for indications ranging from wound breakdown to contralateral ACL rupture. While previous studies revealed high rates of complication after pediatric ACLR due primarily to graft failure, we found that re-tear is responsible for less than half of the 3-year RTOR risk. As almost half of re-tears in our sample occurred before clearance to return to full activities, we suspect that the high rate of complication is largely attributable to pediatric patients' high activity levels and difficulties adhering to postoperative restrictions. Early treatment of meniscus pathology may reduce rates of RTOR. LEVEL OF EVIDENCE: Level III-therapeutic.

The Surgical Management of Tibial Spine Fractures in Children: A Survey of the Pediatric Orthopaedic Society of North America (POSNA).

BACKGROUND: Tibial spine fractures are rare, complex injuries. Management remains varied given a lack of consensus about the optimal approach. Thus, the purpose of this study is to determine prevailing strategies among pediatric orthopaedists and establish areas of agreement and ongoing controversy in the management of tibial spine fractures. METHODS: An electronic survey was distributed to the Pediatric Orthopaedic Society of North America (POSNA) membership. Surgeon demographics, experience, and responses to clinical vignettes were collected. Surgeons were grouped according to how frequently they treat tibial spine fractures and responses were compared. RESULTS: Of the 180 POSNA members who completed the survey, all were attending surgeons and nearly all (90.4%) had academic affiliations, treated mostly skeletally immature patients (88.5%), and 3 or fewer fractures per year (62.4%). In younger patients, respondents were more likely to treat type II fractures closed and less likely to cross the physis. Arthrofibrosis was the most commonly reported complication and postoperative duration of immobilization was identified as a risk factor by most. However, high-frequency surgeons identified this risk factor more often (P=0.015) and recommended immobilization for <2 weeks more frequently (P=0.018). There was, however, considerable discrepancy regarding the duration of immobilization. Although there were areas of agreement on general principles, there continues to be disagreement regarding specific treatment strategies. CONCLUSIONS: Surgeons within POSNA agree on general principles of treatment for tibial spine fractures. Members, regardless of high-volume or low-volume caseload, are all less likely to pursue surgical options when treating younger patients and treating arthrofibrosis during the first 2 postoperative months. The most commonly reported adverse outcome after treatment was arthrofibrosis, for which high-frequency surgeons identified length of immobilization as a significant risk factor more often and thus, recommended shorter periods of immobilization. Although surgeons may agree on general principles in some cases, there continues to be disagreement regarding specific strategies suggesting that a prospective multicenter study of this topic is warranted. LEVEL OF EVIDENCE: Level V.

Anterior Cruciate Ligament Reconstruction Rehabilitation Clinical Practice Patterns: A Survey of the PRiSM Society.

BACKGROUND: Recovery after anterior cruciate ligament (ACL) reconstruction (ACLR) requires extensive postoperative rehabilitation. Although no ideal rehabilitation procedure exists, most experts recommend a fusion of time and strength and functional measures to guide decision making for activity progression during rehabilitation. This process is often directed by surgeon protocols; however, the adoption of contemporary rehabilitation recommendations among surgeons is unknown. PURPOSE: To understand the current landscape of surgeon practice as it relates to ACLR rehabilitation recommendations in adolescent athletes. STUDY DESIGN: Cross-sectional study. METHODS: An online survey was distributed among members of the Pediatric Research in Sports Medicine (PRiSM) Society in January 2017. The survey was designed to identify clinical practice patterns during 3 key transitional points of rehabilitation after ACLR: progression to jogging, modified sports activity, and unrestricted return to sports. RESULTS: Responses from 60 orthopaedic surgeons were analyzed. While 80% of surgeons agreed upon initiating jogging within a 1-month range (3-4 months postoperatively), similar levels of agreement were only captured when including a wider 4-month (4-8 months) and 6-month range (6-12 months) for modified sports activity and unrestricted return to sports, respectively. All respondents (100%) reported using knee strength as a determinant to progress to modified sports activity; however, the mode of testing varied, with most using manual muscle testing (60%), followed by isokinetic (28%) or isometric (12%) testing. Most surgeons (68%) reported using some form of functional testing to return to modified sports activity, but the mode of testing and required progression criteria varied considerably among all reported testing procedures. The use of patient-reported outcome measures was limited to 20% of the sample, and no respondents reported using fear or self-efficacy questionnaires. Upon completion of rehabilitation, 73% recommended injury prevention programs, and 50% recommended the use of a functional ACL brace. CONCLUSION: Rehabilitation progression practices in adolescent athletes are variable and become more inconsistent as the time from surgery increases. While the majority of the sample considered strength and functional testing important, the mode of testing and criteria thresholds for activity advancement varied considerably.

Epidemiology, Injury Patterns, and Treatment of Meniscal Tears in Pediatric Patients: A 16-Year Experience of a Single Center.

BACKGROUND: Meniscal injuries in children continue to increase, which may be attributable to increasing levels of athletic participation and may be associated with additional injuries or need for additional surgeries. PURPOSE: To better understand the patterns of pediatric meniscal injuries by analyzing tear location, morphologic features, and associated injury patterns over a 16-year period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Pediatric patients were identified and were included in the study if age at the time of initial surgery for meniscal tear was between 5 and 14 years for female patients and 5 and 16 years for male patients. Patients were observed until age 18, and any subsequent surgeries were noted. Demographic factors, tear type and location, associated injuries, and treatment type were analyzed. RESULTS: Mean patient age at surgery was 13.3 years, and 37% of patients were female. A total of 1040 arthroscopic meniscal surgeries in 880 pediatric patients were evaluated. There were 160 reoperations in 138 patients, representing a reoperation rate of 15%. These included 98 reoperations on the ipsilateral knee in 88 patients and 62 operations for injuries to the contralateral knee in 50 patients; 53% of surgeries were meniscal repair, as opposed to partial meniscectomy, and the most common technique was an all-inside repair (91%). Significant differences were identified between male and female patients. Male patients were more likely to have lateral meniscus (74% vs 65%), posterior horn (71% vs 60%), peripheral (45% vs 30%), and vertical tears (31% vs 21%); concomitant ACL injury (50% vs 40%); and an associated osteochondritis dissecans lesion (7% vs 4%). Female patients were more likely to have medial meniscus (24% vs 17%), anterior horn (25% vs 15%), and degenerative tears (34% vs 26%); discoid meniscus (33% vs 24%); and isolated meniscal tears (47% vs 33%). CONCLUSION: This evaluation of a large series of patients has helped characterize injury patterns associated with pediatric meniscal surgeries. Most meniscal tears were repaired (53%) and were associated with additional injuries (62%), especially anterior cruciate ligament injuries (48%). More than 25% of patients had a discoid meniscus. Injury patterns differed significantly between male and female patients.

Work Practices and Respiratory Health Status of Appalachian Coal Miners With Progressive Massive Fibrosis.

OBJECTIVE: The aim of this study was to characterize workplace practices and respiratory health among coal miners with large opacities consistent with progressive massive fibrosis (PMF) who received care at a federally funded black lung clinic network in Virginia. METHODS: Participants were interviewed about their workplace practices and respiratory health. Medical records were reviewed. RESULTS: Nineteen former coal miners were included. Miners reported cutting rock, working downwind of dust-generating equipment, nonadherence to mine ventilation plans (including dust controls), improper sampling of respirable coal mine dust exposures, working after developing respiratory illness, and suffering from debilitating respiratory symptoms. CONCLUSION: Consistent themes of suboptimal workplace practices contributing to development of PMF emerged during the interviews. Some of the practices reported were unsafe and unacceptable. Further research is needed to determine the prevalence of these factors and how best to address them.

Progressive Massive Fibrosis Resurgence Identified in U.S. Coal Miners Filing for Black Lung Benefits, 1970-2016.

RATIONALE: There has been a resurgence of progressive massive fibrosis (PMF) in the United States, particularly among central Appalachian miners. OBJECTIVES: We characterized the proportion of PMF among former U.S. coal miners applying for Federal Black Lung Program benefits, 1970-2016. METHODS: Data from the U.S. Department of Labor were used to characterize trends in proportion of PMF cases, defined as an approved black lung claim with a determination of PMF, among all miners who filed for federal benefits between January 1, 1970, and December 31, 2016. Joinpoint, logistic, and linear regression models were used to identify changes in the proportion of claimants with PMF over time. RESULTS: There were 4,679 unique PMF cases among claimants for federal black lung benefits between 1970 and 2016, with 2,474 miners determined to have PMF since 1996. The number of PMF cases among Federal Black Lung Program claimants fell from 404 (0.5% of claimants) in 1978 to a low of 18 cases (0.6%) in 1988, and then increased to 353 cases (8.3%) in 2014. The proportion of federal black lung benefits claimants with PMF has been increasing since 1978 (0.06% annual percent change [APC]; 95% confidence interval [CI], 0.05-0.07%; P < 0.0001), and began increasing at a significantly increased rate after 1996 (0.26% APC; 95% CI, 0.25-0.28%; P < 0.0001). Most miners with PMF (84%) last mined in West Virginia, Kentucky, Pennsylvania, or Virginia. Since 1970, the proportion of claimants with PMF has increased significantly among miners who last worked in Kentucky (16.6% APC; 95% CI, 16.5-16.7%), Pennsylvania (4.7% APC; 95% CI, 4.6-4.8%), Tennessee (16.1% APC; 95% CI, 15.7-16.4%), West Virginia (16.8% APC; 95% CI, 16.6-16.9%), and most sharply among miners last working in Virginia (31.5% APC; 95% CI, 31.2-31.7%), where in 2009, more than 17% of claimants received a PMF determination. The proportion of PMF determinations for the rest of the United States has not exceeded 4%. CONCLUSIONS: There has been a resurgence of PMF, particularly in central Appalachian miners. The resurgence of this preventable disease points to the need for improved primary and secondary prevention of dust-related lung disease in U.S. coal miners.

Objective Eye Tracking Deficits Following Concussion for Youth Seen in a Sports Medicine Setting.

Quantification of visual deficits may help to identify dysfunction following concussion. We evaluated eye-tracking measurements among adolescents within 10 days of concussion and healthy control participants. Patients who reported to 2 tertiary care sport concussion clinics within 10 days of concussion completed an objective eye tracking assessment. Seventy-nine participants completed the study, 44 with concussion (mean age = 14.1 ± 2.2 years, 39% female) and 35 controls (mean age = 14.3 ± 2.4 years, 57% female). Right eye skew along the bottom of the screen was significantly higher for the concussion group compared to controls (median = 0.022 [interquartile range = -0.263, 0.482] vs 0.377 [interquartile range = -0.574, -0.031]; P = .002), but not the left eye. Among the variables investigated, right eye skew was altered for adolescents with a concussion. Visual function is an important component in the postconcussion evaluation, and identifying deficits soon after injury may allow for earlier specialist referral and intervention.