Bulltin Board

January 29, 2015

Losing the Waiting Game
It's common for a young athlete who suffers an ACL tear to need reconstruction surgery. When the procedure is put off for non-medical reasons, such as household income or insurance type, the child is at risk for further injury, a recent study found.

Presented at the Arthroscopy Association of North America's annual meeting in May and published in the journal Arthroscopy in June 2014, researchers from the University of Colorado showed that a delay in reconstruction surgery of three months or more following an ACL tear was a predictive factor in a young patient requiring additional procedures. Waiting more than five months correlated with an increased severity of future knee injuries.

The retrospective chart review looked at 272 youth and adolescent patients who underwent ACL reconstruction procedures over a seven-year period. According to the data, patients who waited more than three months for surgery were 4.75 times more likely to require another procedure. When the wait exceeded five months, the athletes were nearly eight times more likely to sustain a post-recovery chondral or meniscal injury that necessitated further surgery.

"In our study, ACL surgery occurred more rapidly among pediatric and adolescent subjects who were more affluent, covered by commercial insurance, and who were older when first seen," Justin T. Newman, MD, lead author of the study and Orthopaedic Surgery Chief Resident at the University of Colorado School of Medicine, said in a press release.

"Insurance type may delay the time from injury to surgery," Newman added. "However, it is also important to note that oftentimes the delay to have surgery is driven by the patient and family members rather than orthopaedic evidence and research."

The full text of the study, "Anterior Cruciate Ligament Injuries in a Pediatric Population: Delay to Reconstruction and Concomitant Pathology," can be found by searching the title at: www.arthroscopyjournal.org.

Triad Guidelines Released
By now, most athletic trainers are familiar with the dangers posed by the female athlete triad. However, there is continued confusion in the larger medical community about treatment protocols. In response, the Female Athlete Triad Coalition recently released the "2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad."

Published in both the Clinical Journal of Sport Medicine and the British Journal of Sports Medicine in February 2014, the guidelines call for a multidisciplinary approach when treating an athlete with the condition. According to the Coalition, a female athlete triad assessment and treatment team should include a physician, a sports dietitian, and a mental health professional if disordered eating symptoms or a clinical eating disorder is present. Also, when applicable, teams should enlist the services of any athletic trainers and strength and conditioning coaches who work with an affected athlete.

In addition, the assessment guidelines recommend a point-based risk stratification system based on the athlete's history and preparticipation physical exam, which should include a triad-specific self-report questionnaire. If any component of the triad is revealed, more in-depth evaluation should be conducted.

"The hope is that the implementation of these guidelines improves bone health and reduces the risk of stress fractures, as well as the progression of disordered eating into a more serious eating disorder," said Aurelia Nattiv, MD, co-author of the new guidelines and Director of the UCLA Osteoporosis Center, during a presentation at the annual meeting of the American Medical Society for Sports Medicine. "In addition, athletes who are under fueling will be flagged to see a dietitian and follow up with the physician to ensure increase in energy intake."

The full text of the "2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad," can be found by searching the title at: bjsm.bmj.com.

A Better Test for PEDs
A new method has been devised for detecting PEDs, and its creators say it's as much as 1,000 times more sensitive than current tests. During the national meeting of the American Chemical Society in March, Daniel Armstrong, PhD, Professor and Chair in Chemistry at the University of Texas at Arlington, provided details about the new protocol, which is called paired ion electrospray ionization or PIESI (pronounced "PIE-zee").

Developed by a team of researchers at UTA, PIESI enhances the effectiveness of mass spectrometry. Scientists have long used this method to find broken-down bits of doping compounds--known as metabolites--left over in athletes' urine or blood. The traditional limitation with mass spectrometry in drug testing, however, is that it is not as effective at detecting extremely small particles, especially when they have a negative charge like the metabolites of steroids and amphetamines.

PIESI makes it easier to detect these metabolites by adding a positively charged chemical binding agent to the sample. This pulls the negatively charged compounds together into larger groupings, making it easier for them to be identified by the mass spectrometer. In some cases, PIESI can detect concentrations of one part per billion of a banned substance in urine, which is up to 1,000 times more sensitive than current methods.

"How much of a drug someone took or how long ago they took it are beyond the analyst's control," Armstrong said in a press release. "The only thing you can control is how sensitive your method is. Our goal is to develop ultra-sensitive methods that will extend the window of detection, and we have maybe the most sensitive method in the world."

While no sports governing organizations have yet to employ PIESI, Armstrong says he has been in contact with several testing agencies. A scientific paper addressing PIESI is under development.

To watch a video of the presentation on PIESI at the American Chemical Society's annual meeting, go to: www.ustream.tv/recorded/45066065.

A Friend Indeed
After Christina Gordon, a standout soccer player from Texas, tore her ACL, MCL, and meniscus during a match in September 2011, the injury and rehabilitation took an emotional toll. Struggling to find support online, she created a website called FriendsInKneed.com in 2012 to share her story and offer a place where other injured athletes could do the same.

The site contains testimonials from Gordon and other high school and professional athletes who have suffered knee or leg injuries. They submit their stories using an online form, and Gordon draws on her own experience in posts such as "Tips for the Kneedy," which discusses the importance of setting short-term goals and remaining confident when rehabbing.

"The website is a great tool for young patients to address the psychological side of going through an injury," James Montgomery, MD, the orthopaedic surgeon at Texas Orthopaedic Associates who operated on Gordon's knee, said in a press release. "Teenagers don't want to listen to adults. They want to listen to each other, so it provides a great format for teen athletes to share their experiences and support one another."

Friends In Kneed also provides expert information about the injury and rehabilitation process. One page lists a series of questions suggested by medical professionals for injured athletes to ask their doctor, physical therapist, and athletic trainer to increase communication.
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