[Patellofemoral instability in children and adolescents]. / Patellofemorale Instabilität bei Kindern und Jugendlichen.

Patellofemoral instability is a common and clinically relevant disorder of multifactorial causes. Several concomitant problems such as genua valga, hyperlaxity, injuries or sports-related overuse may contribute to the development of instability and recurrent patellar dislocations. A thorough diagnosis is of paramount importance to delineate every contributing factor. This includes radiographic modalities and advanced imaging such as magnetic resonance imaging or torsional analyses. The authors recommend non-operative management (including physiotherapy, gait and proprioceptive training, orthoses) and, whenever non-operative measures fail, surgical patellar stabilization using, e.g. MPFL reconstruction.

Early Distal Radius Remodeling after Radius Dome Osteotomy in Madelung's Deformity.

Background Distal radius realignment procedures such as the dome osteotomy have been shown to reliably correct the geometry of this three-dimensional deformity. However, it has not been clarified whether the correction is durable over time. We thus reviewed a prospective Madelung's database and evaluated all patients who received a radius dome osteotomy to see whether there was any loss of correction over time. Patients and Methods A total of 16 patients with 19 operated wrists were included. Mean age at surgery was 14 years; the most recent radiograph that was considered for analysis was obtained at a mean of 20 months after the index surgery. Three established radiographic deformity parameters (ulnar tilt, lunate subsidence, palmar carpal displacement) were repetitively measured by an independent observer over the course of the postoperative follow-up and compared using the analysis of variance statistics. Results A mild but nonsignificant worsening of deformity parameters was observed in six patients (32%). Overall, ulnar tilt improved from 50 to 40 degrees after surgery and was 43 degrees at latest follow-up. The values for lunate subsidence were -5.5, 0, and -1.6 mm, respectively. Palmar carpal displacement did not recur after correction (21, 17, and 16 mm, respectively). Conclusions Frontal plane parameters remodeled to a certain degree, although not in a statistically significant manner, soon after corrective osteotomies in Madelung's deformity. Although mild surgical overcorrection may be warranted in younger patients, it remains unclear if a concomitant distal radial epiphysiodesis would generally be beneficial. Level of Evidence Level IV.

Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents.

PURPOSE: The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate. METHODS: In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined. RESULTS: Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed. CONCLUSION: Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.

Trigger thumb treatment approach: Results of a survey of EPOS members.

Purpose: The aim of this study is to analyze the clinical reality of pediatric trigger thumb among members of the European Paediatric Orthopaedic Society. Methods: A 35-question survey was sent to all European Paediatric Orthopaedic Society members, focusing on surgeon's profile and experience, trigger thumb diagnostic and trigger thumb treatment approach. Descriptive statistics were performed. Results: A total of 99 responses were analyzed. Most important factor considered in the therapeutic approach was the presence of a locked interphalangeal joint (52%). Regarding treatment, 41.4% opt for conservative approach as the first line of treatment, while 30.3% consider surgery and 28.3% just observe. Nevertheless, 76% mention to treat conservatively their patients and 99% to consider surgery at some stage. Regarding surgical technique, 96% do it open and 56% consider 2 years as the minimum age for procedure. Most surgeons perform this procedure in out-patient care (87%), don't administer prophylactic antibiotherapy (80%), use a tourniquet (75%), don't use any postoperative immobilization (64%), and report complications related to surgery (64%), mainly recurrence/incomplete division (59%) and superficial wound infection (30%). Conclusion: Our study shows a significant variability in the initial management of pediatric trigger thumb with a predominance of conservative management, followed by surgery and observation without treatment. The disparity in treatment options and timing, or waiting times before moving on to different therapeutic options, shows us that this is a controversial issue and that the development of prospective randomized controlled studies is needed to analyze the different treatment methods and determine which ones give the best outcomes.

Defining shoulder function and dysplasia in patients with longitudinal deficiencies of the upper limb.

BACKGROUND: Phenotypic differences and functional limitations in children with congenital radial and ulnar longitudinal deficiencies (RLD/ULD) are well understood for the forearm and hand. However, anatomical features of shoulder elements in these pathologies have only been scarcely reported. Moreover, shoulder function has not been assessed in this patient population. Therefore, we aimed to define radiologic features and shoulder function of these patients at a large tertiary referral center. METHODS: We prospectively enrolled all patients with RLD and ULD (minimum age: 7 years) for this study. Eighteen patients (12 RLD, 6 ULD) with a mean age of 17.9 years (range, 8.5-32.5) were evaluated using clinical examination (shoulder motion and stability), patient-reported outcome measures (Visual Analog Scale, Pediatric/Adolescent Shoulder Survey, Pediatric Outcomes Data Collection Instrument), and radiologic grading of shoulder dysplasia (including length and width discrepancy of the humerus, glenoid dysplasia in the anteroposterior and axial view [Waters classification], and scapular and acromioclavicular dysplasia assessment). Descriptive statistics and Spearman correlation analyses were performed. RESULTS: Despite five (28%) cases having anterioposterior shoulder instability and five (28%) cases with decreased motion, outcome scores indicated an overall excellent function of the shoulder girdle, with mean Visual Analog Scale of 0.3 (range, 0-5), mean Pediatric/Adolescent Shoulder Survey of 97 (range, 75-100), and mean Pediatric Outcomes Data Collection Instrument Global Functioning Scale of 93 (range, 76-100). The humerus was, on average, 15 mm shorter (range, 0-75), and metaphyseal and diaphyseal diameters both reached 94% of the contralateral side. Glenoid dysplasia was detected in nine (50%) cases, with increased retroversion evident in 10 (56%) cases. However, scapular (n = 2) and acromioclavicular (n = 1) dysplasia were rare. Based on radiographic findings, a radiologic classification system for dysplasia types IA, IB, and II was developed. CONCLUSIONS: Adolescent and adult patients with longitudinal deficiencies exhibit various mild-to-severe radiologic abnormalities around the shoulder girdle. Nevertheless, these findings did not seem to negatively affect shoulder function as the overall outcome scores were excellent.

Long-term results of index finger pollicization for congenital thumb anomalies: a systematic review.

This systematic review analyses the literature for long-term outcomes of index finger pollicization. This review includes all seven studies that reported outcomes of index finger pollicization for congenital thumb aplasia or hypoplasia for qualitative review. The seven studies included 108 index finger pollicizations with 54% male children. The studies did not describe the preoperative quality and function of the transposed index finger. Grip strength was in the range of 52%-76% of the contralateral hand. Lateral pinch and key grip strength were also approximately 50% of the contralateral hand. The main drawback of the collective literature is the lack of homogeneity of results and a standardized protocol for reporting postoperative outcomes. These factors need to be addressed to compare the long-term results of pollicizations accurately.

Chronic Exertional Compartment Syndrome in Athletes: An Overview of the Current Literature.

Chronic exertional compartment syndrome is an incapacitating condition that primarily affects athletes and individuals with high activity levels. The exact etiology of the condition is unknown to date, but multiple factors play a role in its occurrence. The clinical presentation includes pain, tightness, muscle weakness, paresthesia, and cramps. Common tools utilized during the diagnostic approach include intramuscular compartment pressure measurement, advanced imaging to exclude other disorder entities, near-infrared spectrometry, and shear wave elastography, with the clinical diagnosis being the gold standard. Management includes both conservative and surgical options. Conservative treatment includes gait re-training and botulinum toxin injections. Further, the operative treatment has variable approaches and may be combined with conservative modalities. This article reviews the literature on chronic exertional compartment syndrome and elucidates future recommendations.

State of the art review: The pathogenesis and management of Madelung deformity.

Madelung deformity remains a fascinating yet unresolved challenge. There is an increasing awareness for early diagnosis by healthcare providers with improvement in diagnostic modalities, however, the exact mechanisms for the development of the deformity have still to be clarified. While some corrective procedures have been described to effectively address an established deformity, the existing literature lacks clear and evidence-based treatment guidelines on how to proceed in daily practice. This review article aims to summarize the current best evidence on this topic, including particular areas of controversy and areas with need for future research.

Distal humeral corrective osteotomy for treatment of supracondylar fracture malunions in children.

Purpose: This study aimed to determine the functional and radiographic outcomes following corrective distal humeral osteotomies for the treatment of supracondylar fracture malunions in children. We hypothesized that such secondary reconstructive procedures could restore a reasonable and near-normal amount of functionality in a large patient cohort at a tertiary referral center. Methods: We retrospectively reviewed the clinical and radiological records of 38 children who underwent corrective osteotomy for posttraumatic supracondylar humeral malunion using K-wire fixation. All clinical data were extracted after chart review, including age, sex, dominant side whenever available, follow-up duration, and elbow range of motion preoperatively and at the final visit. Radiographic parameters, including Baumann's angle, humeroulnar angle, humerocondylar angle, and elbow range of motion were evaluated preoperatively, postoperatively, and at the final visit to identify the surgical correction outcomes. Results: The mean age of the patients at fracture was 5.6 (±2.7) years, and the mean age at surgical intervention was 8.6 (±2.6) years. The mean follow-up period of the current series was 28.2 (±31.1) months. Baumann's angle, humeroulnar angle, and humerocondylar angle were successfully restored to physiological ranges (72.6°, 5.4°, and 36.1°, respectively). Postoperatively, elbow extension improved from -22° (±5.7) to -2.7° (±7.2) versus flexion from 115° (±13.2) to 128.2° (±11.1). Three revision surgeries (8%) were encountered. Conclusions: Corrective osteotomy of the distal humerus with K-wire fixation is a reliable method to efficiently correct malunion of the distal humerus in different planes, thereby improving elbow range of motion and appearance. Level of evidence: level IV: Retrospective therapeutic study.

Autologous replacement of the head of the radius-proximal fibula versus second metatarsal base: an anatomic feasibility study.

INTRODUCTION: This study investigated the anatomic feasibility of a new surgical therapy option for radial head arthrosis using an autologous vascularized bone graft of the second metatarsal and proximal fibula to recreate the proximal radiohumeral joint. MATERIALS AND METHODS: Upper and lower extremities of eleven body donors were evaluated using CT prior to anatomic dissection. Several distinct anatomic parameters were measured on the ipsi- and contralateral radial and fibular head and the second metatarsal base: bone diameter, articular surface diameter, head height, metaphyseal (neck) diameter, articular surface radius, total articular surface area, and angulation of the articular surfaces (facet). Each dissection phase was photographed in a standardized fashion and all measurements were repeated by direct caliper-measurements. RESULTS: When comparing the proximal radius and fibula to search for anatomic similarities, similar values were found in the maximum articular surface diameter and minimum and maximum measures of the neck diameter. Comparing the proximal radius and the second metatarsal, statistically similar values were found in the maximum neck diameter performing direct measurements and CT evaluation, the maximum head diameter in CT evaluation and the articular facet angulation. CONCLUSIONS: Neither the proximal fibula nor the base of the second metatarsal are ideal bone grafts for replacement of the head of the radius. The base of the second metatarsal might be a bit more suitable as a potential donor since the angulation of the proximal articular facet is similar to that of the radius. LEVEL OF EVIDENCE: Level IV, anatomic study.

Ethical Conflicts in Healthcare Chaplaincy: Results of an Exploratory Survey Among Protestant Chaplains in Switzerland, Germany, and Austria.

The paper reports the results of an exploratory online survey among German, Austrian, and Swiss hospital chaplains (n = 158, response rate 17%) to identify the ethical conflicts they encounter in their work. Respondents indicated that questions surrounding end-of-life care are predominant among the conflicts faced. Chaplains get involved with these conflicts most often through the patients themselves or through nursing staff. Most encounters occur during pastoral care visits rather than in structured forms of ethics consultation such as clinical ethics committees. The results add to the ongoing discussion of chaplains as agents in ethics consultation within healthcare systems as well as their specific role and contribution.

Microsurgery in pediatric upper limb reconstructions: An overview.

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.

Does the way of weight-bearing matter? Single-leg and both-leg standing radiographic and pedobarographic differences in pediatric flatfoot.

BACKGROUND: An exact definition is lacking for the term "weight-bearing" or different standing modalities when implementing foot radiographs for children and adults; moreover, only few studies have investigated the relationship between radiographic and pedobarographic measurements. RESEARCH QUESTION: We hypothesized that the method of weight-bearing in single-leg and both-leg standing positions could influence the measurement results in radiographs and the distribution of foot pressure. METHODS: This prospective study evaluated 33 children (66 feet) with flexible flatfoot deformities scheduled for subtalar screw arthroereisis surgery. Radiographs in the lateral and anteroposterior (AP) views were assessed independently in the single-leg and both-leg standing positions. Static pedobarography was performed as that for measuring weight-bearing. Standardized radiographic angles and pedobarographic data were analysed and correlated. RESULTS: There were differences in radiographic measurements between the single-leg and both-leg standing positions, including the AP talocalcaneal angle (p = 0.032), AP talus-first metatarsal base angle (p = 0.003), AP talus-first metatarsal angle (p = 0.003), lateral calcaneal pitch angle (p = 0.001), talus-first metatarsal index (p = 0.004), and talocalcaneal index (p = 0.029). Moreover, differences between these two standing modalities were found in most of the static pedobarographic data, including the contact area (p = 0001), maximal force (p = 0.001), and peak pressure (p = 0.007). Overall, medial foot pressure increased more in both-leg standing than in the single-leg standing position, whereas radiographic measurements showed a more pronounced flatfoot deformity in the single-leg standing position. The AP talus-first metatarsal angle was the only angle or index with a significant association to some pedobarographic measurements in both standing modalities. SIGNIFICANCE: As there are significant differences between single-leg standing and both-leg standing radiographic and static pedobarographic values, observers have to be precise in the definition of "weight-bearing" to gain reproducible and comparable study values in children and adults. We recommend acquiring both-leg standing foot radiographs because children with flexible flatfeet can stand more steadily in this position than in the single-leg standing position.

The Hand in Distal Arthrogryposis.

Distal arthrogryposis is the second most common type of arthrogryposis after amyoplasia and is defined as arthrogryposis that affects hands and feet; it is mostly inherited in an autosomal-dominant fashion. This review discusses up-to-date background information, clinical features, and treatment of distal arthrogryposis in hands concentrating on camptodactyly, thumb-in-palm deformity, and windblown hand deformity, which are the most common and functionally limiting deformities. Treating these deformities should be individualized and follow a multidisciplinary approach. Most deformities can be initially treated nonoperatively, and if not responsive, operative treatment may be pursued to improve function. Surgery primarily aims to release soft-tissue contractures, rebalance muscle forces, and may need bony correction based on the deficits of each case. Current literature suggests that early treatment leads to better outcomes. However, reported cases are scarce, and no consensus or gold standard for treatment exists. Therefore, long-term (multicenter) studies are needed to assess outcomes and standardize the treatment of such deformities whenever possible.

Splinting for the treatment of pediatric trigger thumbs: a pilot study.

Controversy still exists whether conservative treatment may be a useful option for the treatment of pediatric trigger thumbs. We reviewed a random sample patient cohort with regard to success rates depending on whether flexible or fixed trigger thumbs were present. We performed a pilot study of 13 children (15 thumbs), who received a standardized treatment protocol including a custom-made thermoplastic splint for use during sleeping hours for a minimum of 3 months. Splinting was of only minor value for moderate and severe cases was but was beneficial for the majority of patients showing triggering symptoms only. It may thus be a reasonable option to delay surgery in infants with mild/flexible cases.

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months.

BACKGROUND: This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence. METHODS: 32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration. RESULTS: After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction. CONCLUSIONS: Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.

Age-related Outcomes and Complications of Osteodistraction in the Pediatric Upper Extremity: A Large Retrospective Single-center Study of 61 Cases.

BACKGROUND: The study purpose was to assess: (1) the complication rate of osteodistraction in the pediatric upper extremity, its severity and relation to patient-specific and treatment-specific parameters, and (2) dedicated patient-reported outcome scores after these procedures. METHODS: This retrospective study analyzed a chart of patients undergoing osteodistraction of the upper limb between 2003 and 2020. Demographics, distraction-specific parameters, healing index, and any complications graded according to the Sink grading scale (grades 1 to 5) were extracted. An additional phone interview was performed to assess patient satisfaction and functionality of the elongated limb using the Quick-DASH (Disabilities of Arm, Shoulder, and Hand) score. RESULTS: This study included 61 cases from 48 individual patients. The mean age at the start of distraction was 11.5±3.6 years. The ulna was the most frequently lengthened bone, with 21 (34.4%) cases. Ninety-four complications were observed, with an average complication rate of 77.0%. Based on the Sink grading scale (1 to 5), grade 3 complications were most common (n=29; 47.5%) followed by grade 1 (n=14; 23.0%), 2 (n=14; 23.0%), and 4 (n=4; 6.6%). A significantly lower and thus better bone healing index was observed for the age category less than 10 years compared with the 14 to 18 years group (P=0.006). The average satisfaction was 4.2±1.0 points of 5. The mean Quick-DASH score was 14.1±12.5, indicating very good clinical outcomes. CONCLUSIONS: Despite the occurrence of numerous complications, high patient satisfaction and good daily life functionality of the treated limb was observed. An age of more than 14 years at the beginning of therapy had a negative prognostic effect on bone healing during distraction. Thus, osteodistraction in the upper extremity may preferably be performed less than 10 years of age because of enhanced bone regeneration. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Open Release of Pediatric Trigger Thumb.

Open release of a trigger thumb has been shown to be the most reliable option to restore full interphalangeal (IP) joint extension and thus normal thumb-joint motion in children1. The aim of this procedure is to restore free gliding of the flexor pollicis longus (FPL) tendon in its canal in children with fixed IP joint flexion contractures or those in whom nonoperative treatment modalities have failed. Description: The surgical procedure is easy to perform and straightforward; however, attention must be given to several details in order to avoid surgical failure and complications. General anesthesia is required for this procedure. The extremity is prepared and draped in a sterile fashion with the patient in the supine position, and a tourniquet is utilized to facilitate surgical dissection. A transverse incision is gently made just adjacent to the thumb metacarpophalangeal (MP) flexion crease, above the so-called Notta nodule. The ulnar neurovascular bundle is retracted to the side, and the Notta nodule, a local enlargement of the FPL tendon2, is visualized at the A1 pulley. The pulley is incised longitudinally to allow for full IP joint extension. After verification of full passive motion, the tendon is inspected for any further abnormalities. Then, the tourniquet is released, and the wound is closed with absorbable sutures. We recommend the use of local anesthetics for postoperative pain control. In cases of a trigger thumb stuck in extension, full tenodesis flexion of the IP joint combined with smooth, full passive extension confirms a complete release. Alternatives: Nonoperative treatment modalities mainly include watchful waiting for spontaneous resolution3, occupational therapy (i.e., passive exercising)4,5, and splinting therapy6. However, prolonged stretching and splinting may move the nodule to a point distal to the stenotic pulley, thus resulting in a trigger thumb locked in extension with a loss of IP flexion. Alternative surgical treatment techniques involve percutaneous trigger thumb release or open release with alternative surgical approaches (e.g., an oblique or Brunner incision)7,8. Rationale: Several reports have shown that open release of a trigger thumb leads to the most reliable outcomes in terms of achievement of range of motion and complications1,9,10. The main advantage of this procedure is the perfect visualization of the FPL tendon beneath the stenotic A1 pulley, which allows for a complete A1 release with clear vision. Such visualization cannot be provided with use of percutaneous techniques, which position the neurovascular bundle in potential danger for iatrogenic injury or may lead to incomplete pulley release8. Moreover, the use of this procedure allows parents to avoid the prolonged therapy and splinting associated with nonoperative treatment. Formal rehabilitation is usually not necessary postoperatively. Expected Outcomes: Open release of a trigger thumb is a safe and reliable option that leads to full range of motion in 95% of children, which is substantially higher than for nonoperative treatment with therapy (55%) and splinting (67%)1. Even delayed open release may provide satisfactory outcomes9. Although spontaneous resolution without surgery has been reported in 63% of cases3, patients with a flexion contracture of >30° showed spontaneous resolution in only 2.5% of cases10. Furthermore, the open surgical technique has been shown to have a lower rate of complications (around 3.4%)11 compared with percutaneous techniques, which showed a 3.29 times increased risk of recurrence12 and relevant injury to the neurovascular bundle8. If the A1 is fully divided, recurrence is highly unlikely. Postoperative rehabilitation is very quick following open release of a trigger thumb because closure under local anesthesia provides a painless postoperative course, wounds heal within a few days, and children are allowed to resume play immediately once a bandage is applied. Important Tips: The use of surgical loupes is of paramount importance to safely perform this procedure.Place the skin incision adjacent but not directly onto the palmar MP flexion crease for better scar formation.Divide the skin very gently because the A1 pulley is located directly under the skin, and the FPL and radial nerve can be harmed easily. Retract the ulnar neurovascular bundle aside so as to allow for safe preparation until A1 division.Divide the A1 pulley until the Notta nodule on the FPL can safely glide distally into full IP extension. In some cases with large, distally-sitting nodules, the pulley incision must be extended distally into the oblique bundle.A sign that the entire A1 pulley is released is seeing the corner formed by the distal edge of the pulley and the longitudinal cut in the pulley. Additionally, the cut halves of the fully released pulley will rest completely in the sagittal plane of the thumb, no longer converging over the FPL tendon.Tight bands can exist proximal and distal to the A1 pulley and should be released as well if present.Check for a tight IP volar plate following A1 division, which may require postoperative splinting.For thumbs stuck in extension, tenodesis can be utilized to verify complete A1 release.Utilize absorbable sutures, local anesthesia, and a bulky dressing to allow a comfortable postoperative course. Acronyms and Abbreviations: IP = interphalangealMP = metacarpophalangealFPL = flexor pollicis longusROM = range of motionANOVA = analysis of variance.