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Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy

Borowski, Lauren E; Barchi, Elizabeth I; Han, Julie S; Friedman, David A; Carter, Cordelia W
There is little written in the orthopaedic literature regarding common musculoskeletal problems that women encounter in relation to pregnancy and their clinical and surgical management. Exercise and other physical activity are generally recommended for most women before, during, and after pregnancy. Unfortunately, a variety of musculoskeletal issues may keep women from starting, continuing, or resuming a healthy exercise regimen throughout a notable portion of their reproductive years. Untreated and undertreated orthopaedic conditions in female athletes may therefore have further unintended negative effects on maternal and fetal health. This article reviews the existing literature on musculoskeletal health considerations before, during, and after pregnancy to provide practical information to orthopaedic surgeons who treat women of all ages and athletic abilities.
PMID: 34043597
ISSN: 1940-5480
CID: 4888242

Characterizing Sport Specialization Patterns in Professional Women's Ice Hockey Players

Bloom, David A; Wolfert, Adam; Whitney, Darryl; Gonzalez-Lomas, Guillem; Carter, Cordelia
BACKGROUND:Early year-round training in a single sport has been associated with high rates of overuse injuries. Despite this increasingly well-known risk of early sport specialization, many young athletes elect to specialize in a single sport due to the perception that this practice gives them the best chance of attaining elite athletic status. However, early specialization in women's ice hockey has not previously been shown to be reliably associated with attainment of elite levels of performance. We hypothesized that professional women's ice hockey players specialize in mid-adolescence, at an age comparable to their male counterparts. METHODS:An anonymous survey was given to members of two National Women's Hockey League teams. The athletes were asked how many years they have been playing hockey, at what age they began playing only hockey on a year-round basis, how many sports they played in addition to hockey, and if they felt that playing multiple sports while growing up positively affected their hockey careers. RESULTS:Fifty-four players completed the survey. The players reported playing hockey for an average of 19.4 ± 3.4 years. They began specializing in ice hockey at an average of 16.1 ± 3.3 years of age, 2 years later than previously reported in male NHL and NCAA athletes. Before specializing in hockey, players played an average of 3.5 ± 1.4 other sports. Ninetyone percent of players reported feeling as though playing other sports positively affected their hockey career.
PMID: 34081885
ISSN: 2328-5273
CID: 4891882

Current Concept Review: Inclusion and Analysis of Diverse Study Populations in Orthopaedic Research

Beck, Jennifer J; Pandya, Nirav K; Carter, Cordelia W; Mulcahey, Mary K
As disparities in healthcare access and outcomes have been increasingly identified across medical specialties, the importance of recognizing and understanding the diversity of our patient populations and the influence of individual characteristics such as age, sex, gender, race, and ethnicity on clinical outcomes has been emphasized. Orthopaedic literature has advanced dramatically in the quality and quantity of research generated over the past 25 years, yet a consistent, sustained focus on studying musculoskeletal health in the context of these unique patient-specific variables has not been maintained. The result of this inattention may be the provision of orthopaedic care that is ill-suited for the individual patient whose biologic characteristics, life experiences, and cultural constructs differ from that of the typical research subject. The recent proliferation of meta-analyses-whose intention is to optimize statistical power-likely compounds the problem because improper, inconsistent, or absent categorization of patients in research articles precludes meaningful subgroup analysis. This article describes the current variability in demographic reporting in the orthopaedic literature, highlights the importance of complete, consistent demographic reporting and subgroup analysis, and reviews specific examples of orthopaedic conditions that illustrate how clinical outcomes may be affected by patient-specific variables such as age, sex, gender, race, and ethnicity.
PMID: 33443389
ISSN: 1940-5480
CID: 4873622

Clinical assessment of generalized ligamentous laxity using a single test: is thumb-to-forearm apposition enough?

Cahill, Sean V; Sharkey, Melinda S; Carter, Cordelia W
The complete Beighton criteria, commonly used to establish the diagnosis of generalized ligamentous laxity (GLL), include nine discrete examination maneuvers. However, busy examiners may perform only a single maneuver (e.g. passive apposition of the thumb to the forearm) as a rapid method of assessment. We hypothesize that the use of a single-joint hypermobility test does not reliably identify the presence of GLL. Healthy patients 2-18 years old presenting to a general pediatric orthopaedic clinic were screened for participation. Exclusion criteria included the presence of a systemic illness, neuromuscular disease, and inability to complete the examination. Subjects were assessed for GLL according to the Beighton criteria, using a cutoff score of 5. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio were calculated for the thumb-to-forearm apposition test with the composite Beighton score used as the gold standard. Two hundred and four patients were included in the study, 111 females and 93 males, with an average age of 10.7 years. The prevalence of GLL was 13.3%. When thumb-to-forearm apposition was performed unilaterally, the PPV was poor (34%). Conversely, the NPV was excellent (99%). Sensitivity of thumb-to-forearm motion was extremely high (99%), although the specificity of this test was modest (67%). The likelihood ratio was fair (+3.3). Performing the test bilaterally did not significantly change its utility. Thumb-to-forearm apposition testing was equally effective in identifying the presence of GLL in males and females. When performed in isolation, assessment of thumb-to-forearm apposition has a poor PPV, excellent NPV, and modest likelihood ratio. It is an extremely sensitive test, with only fair specificity. Other upper extremity tests of GLL perform similarly. Therefore, while single tests like thumb-to-forearm apposition may be helpful for 'ruling out' GLL, they are less reliable at identifying it correctly. When single tests are used to identify GLL in either clinical or research settings, the results should be interpreted with caution. Level of evidence Level I (diagnostic).
PMID: 32301823
ISSN: 1473-5865
CID: 4401822

Harassment, Discrimination, and Bullying in Orthopaedics: A Work Environment and Culture Survey

Balch Samora, Julie; Van Heest, Ann; Weber, Kristy; Ross, William; Huff, Tamara; Carter, Cordelia
INTRODUCTION/BACKGROUND:The presence of discrimination, bullying, sexual harassment, and harassment (DBSH) in the healthcare workplace negatively affects the health and well-being of providers and is associated with poor mental health, low self-esteem, high levels of absenteeism, and low levels of productivity. METHODS:The American Academy of Orthopaedic Surgeons (AAOS) developed and distributed a survey to a subset of AAOS members to assess the climate of workplace safety and overall workplace culture. Women and underrepresented minority (URM) AAOS members and an equal number of randomly selected non-URM men were invited to participate in the survey. RESULTS:Nine hundred twenty-seven of 5,638 (16.4%) members responded to the survey. Sixty-six percent of respondents reported experiencing DBSH behavior with specific exposures to DBSH of 79%, 55%, 47%, and 40%, respectively. Women (81%) were more likely than men (35%) to have experienced these behaviors. Fifty-eight percent of respondents reported that their workplaces were equipped to deal effectively with DBSH behaviors. DISCUSSION/CONCLUSIONS:DBSH behaviors occur in the orthopaedic workplace. More attention to these issues is necessary to ensure that all orthopaedic surgeons in training and in practice have a safe work environment that is inclusive, equitable, and health-promoting. LEVEL OF EVIDENCE/METHODS:N/A.
PMID: 32187075
ISSN: 1940-5480
CID: 4353612

Early Experience with Virtual Pediatric Orthopedics in New York CityPearls for Incorporating Telemedicine into Your Practice

Carter, Cordelia W.; Herrero, Christina P.; Bloom, David A.; Karamitopoulos, Mara; Castañeda, Pablo G.
BACKGROUND:The purpose of this study was to identify and characterize challenges and benefits to the use of tele-medicine for the treatment of pediatric orthopedic patients during and after the COVID-19 pandemic. METHODS:A novel survey was sent to all faculty members at an academic pediatric orthopedic practice in New York City regarding their use of telemedicine in response to the COVID-19 pandemic. RESULTS:Faculty members performed 227 unique tele-health visits with pediatric orthopedic patients over a 7-week period in early 2020, and this formed the basis for responses to the survey. The results of the faculty survey suggest that telemedicine has substantial clinical benefits for pediatric orthopedic surgeons and our patients that extend beyond the COVID-19 pandemic. Providers recognize the limits of conducting physical exams over telemedicine and should always use clinical judgment when evaluating patients, par-ticularly trauma patients who may require prompt referral for additional care. CONCLUSIONS:The ability to provide pediatric orthopedic care through telemedicine has allowed us to safely evaluate and treat pediatric patients with musculoskeletal problems in New York City and its environs despite the COVID-19 pandemic. The efficient evaluation of both new and exist-ing pediatric orthopedic patients via telehealth is viable. Physical examination is the most challenging aspect of the physician-patient encounter to replicate virtually. Targeted educational efforts for patients and their families before the visit about what to expect and how to prepare improves efficiency with virtual pediatric orthopedic visits. Efforts to limit disparities in access to telemedicine will be needed to allow all pediatric orthopedic patients to participate in telemedicine equitably.
PMID: 33207144
ISSN: 2328-5273
CID: 4730512

Revisiting the Beighton Criteria: Does Ligamentous Laxity Testing Correlate With Shoulder Range of Motion Norms in a North American, Pediatric Population?

Cahill, Sean V; Sharkey, Melinda S; Carter, Cordelia W
BACKGROUND:Ligamentous laxity testing using the Beighton score is frequently used as part of the pediatric shoulder examination. However, the relationship between generalized ligamentous laxity (GLL) and shoulder range of motion (ROM) remains unexamined in children, and normative data for these clinical tests have not been well established. In this study, we establish normative data for shoulder range of motion and GLL in a healthy, diverse pediatric population and investigate whether Beighton testing correlates with shoulder ROM in children. METHODS:Healthy subjects age 2 to 18 years with isolated lower extremity complaints were recruited. Passive shoulder ROM measurements for forward flexion (FF), abduction (ABD), internal rotation (IR), external rotation (ER), and extension (EXT) were obtained using a long-armed goniometer. The Beighton score was obtained, with a positive test defined as ≥5. Descriptive statistics were used to stratify data on the basis of age and sex. Interclass correlation coefficients (ICCs) were calculated. Spearman's r was calculated to determine correlations between the Beighton score and shoulder ROM. Predictive indices of a positive Beighton test to identify patients with high shoulder mobility (ROM in the top 15 percentile, or 1 SD above the mean) were calculated. RESULTS:A total of 202 subjects were enrolled and evaluated. Passive ROM norms by age and sex were determined. Intraclass correlation coefficients for all shoulder ROM measurements were substantial to excellent. Female individuals had greater ROM than age-matched male individuals, but this trend was largely statistically insignificant. Pearson's correlation between age and shoulder ROM was significant for FF, ABD, EXT, and ER (r=-0.52 to -0.20, P<0.001). Based on a Beighton score of ≥5, the prevalence of GLL was 10% in male and 15% in female individuals. Spearman's correlation between Beighton score and shoulder ROM was significant for 3 of 5 ROM measurements: FF, ER, and EXT (r=0.30 to 0.39, P<0.001). CONCLUSIONS:Normative pediatric shoulder ROM and joint laxity data have been established in a healthy, diverse population of children. Beighton testing exhibits only a weak to moderate correlation, despite statistical significance, with shoulder ROM and is poorly predictive for high ROM in children. LEVEL OF EVIDENCE/METHODS:Level I- Diagnostic.
PMID: 32555043
ISSN: 1539-2570
CID: 4496802

Characterizing Cam-type Hip Impingement in Professional Women's Ice Hockey Players

Carter, Cordelia W; Campbell, Abigail; Whitney, Darryl; Feder, Oren; Kingery, Matthew; Baron, Samuel; Youm, Thomas; Gonzalez-Lomas, Guillem
OBJECTIVE:There is a high prevalence of femoroacetabular impingement (FAI) amongst elite men's ice hockey players, yet little is known about the hips of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic cam-type FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the cam deformity and both menarchal age and hip range-of-motion (ROM). METHODS:Data were collected for NWHL players during pre-participation physicals. Alpha angles were measured on 45° Dunn radiographs, with alpha angles >55° defined as cam-positive. Pearson correlation coefficients (ρ) were performed to analyze the relationship between alpha angle and both ROM measurements and menarchal age, with statistical significance set at p<0.05. RESULTS:Twenty-six athletes were included. Twenty-four (92%) had alpha angles >55°; 20 players (77%) had bilateral cam deformity. Average menarchal age was 13.8 ±1.7 years. There was a significant association between age of menarche and alpha angle (ρ=0.36, p<0.02). There was no significant association between alpha angle and hip ROM, (p>0.05). CONCLUSION/CONCLUSIONS:Elite women's ice hockey players have a higher prevalence of cam-type morphology than the general population. The positive association between alpha angle and menarchal age lends additional support to the etiological hypothesis of the cam lesion resulting from activity-related stress at the proximal femoral physis during skeletal development. Professional women's ice hockey players have a high risk of developing cam-type morphology, although each player's menarchal age may mediate her individual risk for cam development.
PMID: 32799611
ISSN: 2326-3660
CID: 4566352

ACL Injuries Aren't Just for Girls: The Role of Age in Predicting Pediatric ACL Injury

Bloom, David A; Wolfert, Adam J; Michalowitz, Andrew; Jazrawi, Laith M; Carter, Cordelia W
BACKGROUND/UNASSIGNED:Female athletes have a higher rate of anterior cruciate ligament (ACL) injuries than male athletes; however, the role of age in mediating this injury risk has not been explored. The purpose of this study was to characterize the relationship between age and sex in predicting ACL injury in the pediatric population. HYPOTHESIS/UNASSIGNED:Prepubescent boys are more likely to sustain an ACL injury than prepubescent girls. STUDY DESIGN/UNASSIGNED:Descriptive epidemiological study. LEVEL OF EVIDENCE/UNASSIGNED:Level 4. METHODS/UNASSIGNED:< 0.05. RESULTS/UNASSIGNED:< 0.0001). CONCLUSION/UNASSIGNED:Prepubescent boys (aged <12 years) are more likely to sustain an ACL injury than same-aged female peers. CLINICAL RELEVANCE/UNASSIGNED:This study demonstrates that the risk of ACL injury varies with age and sex throughout childhood and adolescence, further guiding treatment and prevention for these pediatric athletes.
PMID: 32780637
ISSN: 1941-0921
CID: 4556272

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members

Carter, Cordelia W; Talwalkar, Vishwas; Weiss, Jennifer M; Schwend, Richard M; Goldberg, Michael J
BACKGROUND:There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout. METHODS:During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex. RESULTS:A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background. CONCLUSIONS:As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step. LEVEL OF EVIDENCE/METHODS:Level III.
PMID: 32501927
ISSN: 1539-2570
CID: 4475002