Opioids and Youth Athletes.

CONTEXT: The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion. OBJECTIVE: This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed. DATA SOURCES: A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present. STUDY SELECTION: Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies. STUDY DESIGN: Narrative review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted. RESULTS: Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse. CONCLUSION: The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

Prospective evaluation of in situ screw fixation for stable slipped capital femoral epiphysis.

Purpose: We aimed to determine which variables were associated with persistent symptoms or need for further surgery in patients treated with in situ fixation for stable slipped capital femoral epiphysis. We hypothesized that patients with greater proximal femoral deformity would require revision surgical intervention. Methods: We prospectively collected data on stable slipped capital femoral epiphysis patients who underwent in situ screw fixation at a single institution. Demographic and radiographic information, as well as patient-reported outcomes, were collected. Results: Forty-six patients (54 hips) with an average follow-up of 3.5 years (range: 2.0-8.5) and mean pre-op Southwick slip angle of 40.5° ± 19.4° were studied. We observed one complication following the index procedure (2%). Twelve hips (22%) went on to have a secondary procedure 2.7 ± 2.2 years after the index surgery. Severe slips were 14.8× more likely to undergo a secondary procedure than mild and moderate slips (p < 0.001). We found no correlation between slip severity and patient-reported outcomes (p > 0.6). Hips requiring a secondary procedure had significantly lower Hip disability and Osteoarthritis Outcome scores (76.8 ± 18.4) at final follow-up compared to hips that did not require additional surgery (86.8 ± 15.7) (p = 0.042). Conclusion: With minimum 2-year follow-up, 22% of patients required a secondary surgery. Patient-reported outcomes did not correlate with slip severity, but were found to be significantly higher in slipped capital femoral epiphysis patients that did not require a secondary procedure. Prophylactic treatment of all slip-related cam deformity was not found to be necessary in this prospective cohort. Patients with moderate-to-severe slips may require secondary surgery. Level of Evidence: Level II.

Prevalence of Trochlear Dysplasia and Associations with Patellofemoral Pain and Instability in a Skeletally Mature Population.

BACKGROUND: Patellar instability among adolescents has an incidence of 29 to 43 per 100,000 per year. Trochlear dysplasia has been found in up to 85% of those with recurrent patellar instability. The prevalence of trochlear dysplasia in the general population has not yet been defined. The purpose of the present study was to determine the prevalence of trochlear dysplasia as defined by ultrasound in a skeletally mature population and to characterize associations of trochlear dysplasia with a history of patellofemoral instability or pain. METHODS: Skeletally mature adolescents and parents of patients (≤50 years of age) who had presented to orthopaedic clinics were prospectively enrolled from 2019 to 2020. Those presenting with knee pain, open physes, prior intra-articular fracture, total knee arthroplasty, and syndromic ligamentous laxity or neuromuscular disease were excluded. Information regarding a history of anterior knee pain, patellar instability, and/or surgery was obtained, and an abbreviated Anterior Knee Pain Scale (AKPS) was collected. An AKPS score of ≥4 was considered positive. Bilateral ultrasound of the knee was performed, and the osseous sulcus angle of the trochlea and the trochlear depth were measured. Basic descriptive statistics are reported. RESULTS: One hundred and two patients (203 knees) were studied. The mean sulcus angle was 144.1° ± 6.8°, and the mean trochlear depth was 5.5 ± 1.4 mm. High-grade trochlear dysplasia was defined as the 95th percentile and above, which was shown to be a sulcus angle of ≥154° or a trochlear depth of ≤3 mm for female patients and ≤4 mm for male patients. The prevalence of high-grade trochlear dysplasia was 5.4% based on the sulcus angle and 9.9% based on trochlear depth. Knees with high-grade trochlear dysplasia based on the sulcus angle were 11 times more likely to have had previous patellar instability (p = 0.013). CONCLUSIONS: The prevalence of high-grade trochlear dysplasia in the general population is approximately 10%, and there may be an association with patellar instability. The use of ultrasound to diagnose trochlear dysplasia may prove to be a rapid and useful tool for guiding patient education and treatment decisions. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of trochlear dysplasia in infants evaluated for developmental dysplasia of the hip.

PURPOSE: The purpose of this study was to define the incidence of trochlear dysplasia in an infant cohort being screened for developmental dysplasia of the hip (DDH). METHODS: Newborns screened for DDH that were evaluated with ultrasound for the presence of trochlear dysplasia were retrospectively reviewed. The sulcus angle and trochlear depth were measured. Based on previous work, trochlear dysplasia was defined as a sulcus angle of > 159°. Our newborn cohort was then analyzed to identify potential risk factors for trochlear dysplasia. RESULTS: A total of 383 knees in 196 infants were studied. In total, 52% were referred for breech intrauterine positioning and 21% were ultimately diagnosed with DDH and had treatment initiated with a Pavlik harness. Of the entire cohort, 8% of knees were deemed to have trochlear dysplasia. Breech patients were found to have a flatter sulcus angle than those that were not breech (149.5° (sd 7.2°) versus 147.9° (sd 7.5°); p = 0.028). Similarly, a shallower trochlear depth was identified in breech patients versus non-breech patients (1.6 mm (sd 0.4) versus 1.8 mm (sd 0.4); p = 0.019). Those with trochlear dysplasia (as defined by sulcus angle > 159°) did show a smaller alpha angle (i.e. more dysplastic hip) as compared with those without trochlear dysplasia (59.2° (sd 10.2°) versus 65.9° (sd 7.5°); p < 0.001). Hips with DDH were 2.4-times more likely to have knees with trochlear dysplasia (95% confidence interval 1.1 to 5.3). CONCLUSION: Ultrasound screening of newborn knees reveals that trochlear dysplasia is relatively common in breech babies with DDH. LEVEL OF EVIDENCE: III.

Medialization of the Hip's Center with Periacetabular Osteotomy: Validation of Assessment with Plain Radiographs.

BACKGROUND: Periacetabular osteotomy (PAO) increases acetabular coverage of the femoral head and medializes the hip's center, restoring normal joint biomechanics. Past studies have reported data regarding the degree of medialization achieved by PAO, but measurement of medialization has never been validated through a comparison of imaging modalities or measurement techniques. The ilioischial line appears to be altered by PAO and may be better visualized at the level of the inferior one-third of the femoral head, thus, an alternative method of measuring medialization that begins at the inferior one-third of the femoral head may be beneficial. QUESTIONS/PURPOSES: (1) What is the true amount and variability of medialization of the hip's center that is achieved with PAO? (2) Which radiographic factors (such as lateral center-edge angle [LCEA] and acetabular inclination [AI]) correlate with the degree of medialization achieved? (3) Does measurement of medialization on plain radiographs at the center of the femoral head (traditional method) or inferior one-third of the femoral head (alternative method) better correlate with true medialization? (4) Are intraoperative fluoroscopy images different than postoperative radiographs for measuring hip medialization? METHODS: We performed a retrospective study using a previously established cohort of patients who underwent low-dose CT after PAO. Inclusion criteria for this study included PAO as indicated for symptomatic acetabular dysplasia, preoperative CT scan, and follow-up between 9 months and 5 years. A total of 333 patients who underwent PAO from February 2009 to July 2018 met these criteria. Additionally, only patients who were between 16 and 50 years old at the time of surgery were included. Exclusion criteria included prior ipsilateral surgery, femoroacetabular impingement (FAI), pregnancy, neuromuscular disorder, Perthes-like deformity, inadequate preoperative CT, and inability to participate. Thirty-nine hips in 39 patients were included in the final study group; 87% (34 of 39) were in female patients and 13% (5 of 39 hips) were in male patients. The median (range) age at the time of surgery was 27 years (16 to 49). Low-dose CT images were obtained preoperatively and at the time of enrollment postoperatively; we also obtained preoperative and postoperative radiographs and intraoperative fluoroscopic images. The LCEA and AI were assessed on plain radiographs. Hip medialization was assessed on all imaging modalities by an independent, blinded assessor. On plain radiographs, the traditional and alternative methods of measuring hip medialization were used. Subgroups of good and fair radiographs, which were determined by the amount of pelvic rotation that was visible, were used for subgroup analyses. To answer our first question, medialization of all hips was assessed via measurements made on three-dimensional (3-D) CT hip reconstruction models. For our second question, Pearson correlation coefficients, one-way ANOVA, and the Student t-test were calculated to assess the correlation between radiographic parameters (such as LCEA and AI) and the amount of medialization achieved. For our third question, statistical analyses were performed that included a linear regression analysis to determine the correlation between the two radiographic methods of measuring medialization and the true medialization on CT using Pearson correlation coefficients, as well as 95% confidence intervals and standard error of the estimate. For our fourth question, Pearson correlation coefficients were calculated to determine whether using intraoperative fluoroscopy to make medialization measurements differs from measurements made on radiographs. RESULTS: The true amount of medialization of the hip center achieved by PAO in our study as assessed by reference-standard CT measurements was 4 ± 3 mm; 46% (18 of 39 hips) were medialized 0 to 5 mm, 36% (14 hips) were medialized 5 to 10 mm, and 5% (2 hips) were medialized greater than 10 mm. Thirteen percent (5 hips) were lateralized (medialized < 0 mm). There were small differences in medialization between LCEA subgroups (6 ± 3 mm for an LCEA of ≤ 15°, 4 ± 4 mm for an LCEA between 15° and 20°, and 2 ± 3 mm for an LCEA of 20° to 25° [p = 0.04]). Hips with AI ≥ 15° (6 ± 3 mm) achieved greater amounts of medialization than did hips with AI of < 15° (2 ± 3 mm; p < 0.001). Measurement of medialization on plain radiographs at the center of the femoral head (traditional method) had a weaker correlation than using the inferior one-third of the femoral head (alternative method) when compared with CT scan measurements, which were used as the reference standard. The traditional method was not correlated across all radiographs or only good radiographs (r = 0.16 [95% CI -0.17 to 0.45]; p = 0.34 and r = 0.26 [95% CI -0.06 to 0.53]; p = 0.30), whereas the alternative method had strong and very strong correlations when assessed across all radiographs and only good radiographs, respectively (r = 0.71 [95% CI 0.51 to 0.84]; p < 0.001 and r = 0.80 [95% CI 0.64 to 0.89]; p < 0.001). Measurements of hip medialization made on intraoperative fluoroscopic images were not found to be different than measurements made on postoperative radiographs (r = 0.85; p < 0.001 across all hips and r = 0.90; p < 0.001 across only good radiographs). CONCLUSION: Using measurements made on preoperative and postoperative CT, the current study demonstrates a mean true medialization achieved by PAO of 4 mm but with substantial variability. The traditional method of measuring medialization at the center of the femoral head may not be accurate; the alternate method of measuring medialization at the lower one-third of the femoral head is a superior way of assessing the hip center's location. We suggest transitioning to using this alternative method to obtain the best clinical and research data, with the realization that both methods using plain radiography appear to underestimate the true amount of medialization achieved with PAO. Lastly, this study provides evidence that the hip center's location and medialization can be accurately assessed intraoperatively using fluoroscopy. LEVEL OF EVIDENCE: Level III, diagnostic study.

Hoverboard injuries in children and adolescents: results of a multicenter study.

With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.

Pediatric Ankle Fractures: When to Operate and When to Leave Alone?

Ankle fractures are a common pediatric orthopaedic injury and are the second most common site of physeal injury after the distal radius. Concerns regarding these injuries include the risk of premature physeal closure and intra-articular incongruence with subsequent degenerative changes. Salter-Harris type I and II injuries have high rates of premature physeal closure especially in those with a physeal gap greater than 3 mm and pronation-abduction injuries. The authors of this chapter recommend surgical management if acceptable alignment cannot be obtained with closed reduction. A residual physeal gap is not an appropriate sole indicator for surgical management. Salter-Harris type III and IV injuries also have high rates of premature physeal closure and can result in articular incongruence given their intra-articular nature. The authors of this chapter recommend surgical management of these fractures when intra-articular displacement is greater than 2 mm. Transitional fractures (ie, Tillaux and triplane) occur in older patients during distal tibial physeal closure. Fracture lines travel through the relatively weaker lateral tibial physis, which is the last to close in the transitional period. These intra-articular fractures with displacement greater than 2 mm should be managed surgically to anatomically reduce the articular surface and prevent early degenerative changes.

Tibial Shaft Fractures in Children: What to Do When Casting Fails?

Tibial shaft fractures in children can often be successfully managed with a well-molded cast that controls length, alignment, and rotation of the fracture. Acceptable alignment of tibial shaft fractures in children is less than 10° of coronal and sagittal angulation, 50% translation, and 10 mm of shortening. Fractures of the tibial shaft without an associated fibular shaft fracture may fall into varus malalignment despite initial adequate reduction and should be followed closely during the first 3 weeks after injury. Surgical treatment should be considered in adolescent patients and those with open fractures, comminuted fractures, and fractures that cannot be adequately reduced and stabilized with a cast. The predominant modes of surgical stabilization of tibial shaft fractures in children are external fixation or internal fixation with flexible intramedullary nails or via minimally invasive plate osteosynthesis; both methods have reliable results.

Changes in the Practice of Pediatric Orthopaedic Surgeons Over the Past Decade: Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: There has been an increase in the number of the graduates of pediatric orthopaedic fellowship programs over the past decade creating the potential for increased competition in the field. The purpose of this study was to analyze the effect of increased number of pediatric orthopaedic fellowship graduates on case volume as well as the type of procedures performed by recent graduates of pediatric orthopaedic fellowship programs from 2004 to 2014. METHODS: Case logs submitted for the American Board of Orthopaedic Surgery Part II examination by applicants with the self-declared subspecialty of pediatric orthopaedics from 2004 to 2014 were analyzed. Cases were categorized as trauma (upper and lower extremity), spine, sports medicine, hip, deformity correction, foot and ankle, hardware removal, soft tissue procedures, and other. The period was divided into 3 sections: 2004-2007, 2008-2011, 2012-2014. Descriptive analysis was used to report the change in the volume and pattern of practices over the study period. RESULTS: Although the number of pediatric orthopaedic subspecialty applicants increased from 15 to 44 from 2004 to 2014, the average cases per year increased from 2142 in 2004-2007 to 2960 in 2007-2011, and to 4160 in 2012-2014. The number of cases performed per applicant remained stable over the study period. Upper extremity trauma cases were the largest category of cases reported and increased in case volume by 141% from 2004 to 2014. Sports medicine cases increased in volume by 175%. CONCLUSIONS: Despite a large increase in the number of pediatric orthopaedic surgeons over the past decade, there is a concomitant increased in case volume across almost all subspecialties within pediatric orthopaedics. As such, pediatric orthopaedic surgeons who start a new practice can expect to develop a robust practice with a diverse group of pathologies. LEVEL OF EVIDENCE: Level III.

Mechanism of a prototypical synthetic membrane-active antimicrobial: Efficient hole-punching via interaction with negative intrinsic curvature lipids.

Phenylene ethynylenes comprise a prototypical class of synthetic antimicrobial compounds that mimic antimicrobial peptides produced by eukaryotes and have broad-spectrum antimicrobial activity. We show unambiguously that bacterial membrane permeation by these antimicrobials depends on the presence of negative intrinsic curvature lipids, such as phosphatidylethanolamine (PE) lipids, found in high concentrations within bacterial membranes. Plate-killing assays indicate that a PE-knockout mutant strain of Escherichia coli drastically out-survives the wild type against the membrane-active phenylene ethynylene antimicrobials, whereas the opposite is true when challenged with traditional metabolic antibiotics. That the PE deletion is a lethal mutation in normative environments suggests that resistant bacterial strains do not evolve because a lethal mutation is required to gain immunity. PE lipids allow efficient generation of negative curvature required for the circumferential barrel of an induced membrane pore; an inverted hexagonal H(II) phase, which consists of arrays of water channels, is induced by a small number of antimicrobial molecules. The estimated antimicrobial occupation in these water channels is nonlinear and jumps from approximately 1 to 3 per 4 nm of induced water channel length as the global antimicrobial concentration is increased. By comparing to exactly solvable 1D spin models for magnetic systems, we quantify the cooperativity of these antimicrobials.