A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens.

Purpose: To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule. Methods: Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci). Results: In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root). Conclusions: In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age. Clinical Relevance: The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.

Effects of Glucagon-Like Peptide-1 Receptor Agonists on Atrial Fibrillation Recurrence After Catheter Ablation.

BACKGROUND: Relationship between glucagon-like peptide-1 receptor agonist (GLP-1 RA) use prior to atrial fibrillation (AF) ablation and subsequent AF recurrence is not well-understood. OBJECTIVES: This study investigated the effects of GLP-1 RA use within 1 year before ablation and its association with AF recurrence and associated outcomes. METHODS: The TriNetX research database was used to identify patients aged ≥18 years undergoing AF ablation (2014-2023). Patients were categorized into 2 groups, and propensity score matching (1:1) between preablation GLP-1 RA users and nonusers was performed based on demographics, comorbidities, body mass index, laboratory tests, AF subtype, and medications. Primary outcome was composite of cardioversion, new antiarrhythmic drug therapy, or repeat AF ablation after a 3-month blanking period following the index ablation. Additional outcomes included ischemic stroke, all-cause hospitalization, and mortality during 12-month follow-up period. RESULTS: After 1:1 propensity score matching, the study cohort comprised 1,625 GLP-1 RA users and 1,625 matched GLP-1 RA nonusers. Preablation GLP-1 RA therapy was not associated with a lower risk of cardioversion, new AAD therapy, and repeat AF ablation after the index procedure (HR: 1.04 [95% CI: 0.92-1.19]; log-rank P = 0.51). Furthermore, the risk of ischemic stroke, all-cause hospitalization, and mortality during the 12-month follow-up period did not differ between the 2 groups. CONCLUSIONS: These findings suggest that preprocedural use of GLP-1 RAs is not associated with a reduced risk of AF recurrence or associated adverse outcomes following ablation, and underscore the need for future research to determine whether these agents improve outcome in AF patients.

National Incidence, Outcomes, and Management Strategies for Pre- and Post-Transplant Atrial Fibrillation in Heart Transplant Recipients.

Background: Among heart transplant candidates, atrial fibrillation (AF) is a common comorbidity; however, little is known about the impact of pre-transplant AF on incidence of post-transplant AF or other transplant outcomes. Methods: Adult heart transplant recipients transplanted from 07/01/2012 to 07/01/2021 with data available in both the Scientific Registry of Transplant Recipients and Symphony Health pharmacy databases were included. Recipients were categorized by presence of pre-transplant AF using prescription fill data. Perioperative outcomes and survival out to 5 years post-transplant were compared between those with and without pre-transplant AF. Results: Of the 11,789 heart transplant recipients, 2,477 (21.0%) had pre-transplant AF. Pre-transplant AF was associated with an increased likelihood of pre-discharge stroke (aOR 2.13 [95%CI: 1.07-4.26], p=0.03) and dialysis (aOR 1.45 [1.05-2.00], p=0.02), as well as of post-transplant AF at 6 months (aOR 2.42 [1.44-1.48], p=0.001) and 1 year (aOR 2.81 [1.72-4.56], p<0.001). Pre-transplant AF was associated with increased post-transplant mortality at 30 days (aHR 2.39 [1.29-4.44], p=0.006) and 1 year (aHR 1.46 [95% CI: 1.01-2.13], p=0.04), but similar mortality at 5 years (aHR 1.23 [0.96-1.58], p=0.11). Conclusion: Heart transplant recipients with pre-transplant AF had worse short-term outcomes and increased risk of developing post-transplant AF but comparable survival at 5 years post-transplant. Our findings emphasize the importance of increased monitoring for perioperative complications and highlight the long-term safety of heart transplantation in this population. What Is New?: Patients with atrial fibrillation who undergo heart transplantation have worse short term survival (30-days and 1-year) but similar long term survival (5-years) compared to recipients without pre-transplant atrial fibrillation.Pre-transplant atrial fibrillation increases the risk of clinically significant post-transplant atrial fibrillation and peri-operative stroke.Rate vs rhythm control pharmacotherapy for atrial fibrillation is not associated with differences in survival in heart transplant recipients with pre-transplant atrial fibrillation. What are the Clinical Implications?: Atrial fibrillation should not deter heart transplantation in appropriate candidates, though cardiovascular and stroke risk adjustment may be warranted.Use of amiodarone at doses ≤ 200 mg/day is not associated with reduced survival in heart transplant recipients with pre-transplant atrial fibrillation.

Cervicofacial Pediatric Tissue Expansion: Aesthetic Unit-Based Algorithm.

BACKGROUND: Tissue expansion is a powerful tool for reconstruction of pediatric soft-tissue pathologies, but complication rates for children have been reported as high as 40%. Infection and implant extrusion lead to premature removal and delays in reconstruction. Expanding the head and neck is uniquely challenging because the confluence of facial aesthetic units must be respected. These challenges have prompted the senior author's creation of an aesthetic-unit based algorithm. METHODS: A retrospective study of pediatric patients who underwent cervicofacial tissue expander placement by the senior author (R.J.R) was performed over a 17-year period. Predictor variables included age, sex, race, indication, number of expanders placed at each operation, serial expansion, expander type, expander size, home versus clinic inflation, and prophylactic antibiotics. Univariate and multivariate analyses were performed to identify risk factors for complications. RESULTS: An aesthetic-unit based reconstructive algorithm is proposed. Forty-eight pediatric patients had 111 cervicofacial tissue expanders placed. Twenty expanders were associated with complications (18%) for surgical site-infection (12.6%), extrusion (4.5%), and expander deflation (6.3%). Expanders placed for congenital nevi (p=0.042) and use of textured expander (p=0.027) were significantly associated with decreased complications. When controlling for covariates, serial expansion of the same site was associated with increased rates of readmission (p=0.027) after having just one prior expander. Iatrogenic ectropion occurred in 13.5% of the study population; expanders with at least one complication during tissue expansion were significantly associated with incidence of iatrogenic ectropion (p=0.026). CONCLUSION: By using an aesthetic-unit based algorithm, reconstructive outcomes can be optimized for pediatric cervicofacial tissue expansion.

Outcomes of Lung Transplant Candidates Aged ≥70 Years During the Lung Allocation Score Era.

BACKGROUND: With the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era. METHODS: Adult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed. RESULTS: A total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years. CONCLUSIONS: Candidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.

CHCHD4-TRIAP1 regulation of innate immune signaling mediates skeletal muscle adaptation to exercise.

Exercise training can stimulate the formation of fatty-acid-oxidizing slow-twitch skeletal muscle fibers, which are inversely correlated with obesity, but the molecular mechanism underlying this transformation requires further elucidation. Here, we report that the downregulation of the mitochondrial disulfide relay carrier CHCHD4 by exercise training decreases the import of TP53-regulated inhibitor of apoptosis 1 (TRIAP1) into mitochondria, which can reduce cardiolipin levels and promote VDAC oligomerization in skeletal muscle. VDAC oligomerization, known to facilitate mtDNA release, can activate cGAS-STING/NFKB innate immune signaling and downregulate MyoD in skeletal muscle, thereby promoting the formation of oxidative slow-twitch fibers. In mice, CHCHD4 haploinsufficiency is sufficient to activate this pathway, leading to increased oxidative muscle fibers and decreased fat accumulation with aging. The identification of a specific mediator regulating muscle fiber transformation provides an opportunity to understand further the molecular underpinnings of complex metabolic conditions such as obesity and could have therapeutic implications.

Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care.

BACKGROUND: Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature. METHODS: A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics. RESULTS: Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency). CONCLUSIONS: Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.

Prior COVID-19 Infection Predisposes to Worse Outcomes After Autologous Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Major shifts in health care systems worldwide have occurred because of coronavirus disease 2019 (COVID-19). With nearly half of all Americans now having a history of COVID-19 infection, there is a pressing need to better understand the importance of prior COVID-19 infection as a potential surgical risk factor. The aim of this study was to investigate the impact of a history of prior COVID-19 infection on patient outcomes after autologous breast reconstruction. METHODS: We performed a retrospective study using the TriNetX research database, which contains deidentified patient records from 58 participating international health care organizations. All patients who underwent autologous breast reconstruction between March 1, 2020, and April 9, 2022, were included and were grouped based on history of a prior COVID-19 infection. Demographic, preoperative risk factors, and 90-day postoperative complication data were compared. Data were analyzed by propensity score-matched analysis on TriNetX. Statistical analyses were performed by Fisher exact, χ2, and Mann-Whitney U tests as appropriate. Significance was set at P values of <0.05. RESULTS: Patients with a history of autologous breast reconstruction within our temporal study window (N = 3215) were divided into groups with (n = 281) and without (n = 3603) a prior COVID-19 diagnosis. Nonmatched patients with prior COVID-19 had increased rates of select 90-day postoperative complications, including wound dehiscence, contour deformities, thrombotic events, any surgical site complications, and any complications overall. Use of anticoagulant, antimicrobial, and opioid medications was also found to be higher in those with prior COVID-19.After performing propensity-score matching, each cohort consisted of 281 patients without statistically significant differences between any baseline characteristics. When comparing outcomes between matched cohorts, patients with a history of COVID-19 had increased rates of wound dehiscence (odds ratio [OR], 1.90; P = 0.030), thrombotic events (OR, 2.83; P = 0.0031), and any complications (OR, 1.52; P = 0.037). CONCLUSIONS: Our results suggest that prior COVID-19 infection is a significant risk factor for adverse outcomes after autologous breast reconstruction. Patients with a history of COVID-19 have 183% higher odds of postoperative thromboembolic events, warranting careful patient selection and postoperative management.

Early United States experience with lung donation after circulatory death using thoracoabdominal normothermic regional perfusion.

Thoracoabdominal normothermic regional perfusion (TA-NRP) has recently begun being utilized in the United States for recovery of cardiothoracic allografts from some donors after circulatory death (DCD), but data on lungs recovered in this method is limited to case reports. We conducted a national retrospective review of lung transplants from DCD donors recovered using TA-NRP. Of the 434 total DCD lung transplants performed between January 2020 and March 2022, 17 were recovered using TA-NRP. Compared to direct recovery DCD transplants, recipients of TA-NRP DCD transplants had lower likelihood of ventilation >48 hours (23.5% vs 51.3%, p = 0.027) and similar likelihood of predischarge acute rejection, requirement for extracorporeal membrane oxygenation at 72 hours, hospital lengths of stay, and survival at 30, 60, and 90 days post-transplant. These early data suggest that DCD lung recovery using TA-NRP might be a safe way to further expand the donor pool and warrant further study.

Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction.

BACKGROUND: Age is a poor predictor of postoperative outcomes in breast reconstruction necessitating new methods for risk-stratifying patients preoperatively. The 5-item modified frailty index (mFI-5) is a validated measure of frailty which assesses patients' global health. The purpose of this study was to compare the effectiveness of mFI-5 and age as independent predictors of 30-day postoperative complications following autologous breast reconstruction. METHODS: Patients who underwent autologous breast reconstruction between 2005 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients were stratified based on presence of major, minor, both minor and major, and no complications. Univariate and multivariate logistic regression were performed to determine the predictive power of mFI-5, age, and other preoperative risk factors for development of minor and major 30-day postoperative complications in all patients and stratified by flap type. RESULTS: A total of 25,215 patients were included: 20,366 (80.8%) had no complications, 2,009 (8.0%) had minor complications, 1,531 (6.1%) had major complications, and 1,309 (5.2%) had both minor and major complications. Multivariate regression demonstrated age was not a predictor of minor (odds ratio [OR]: 1.0, p = 0.045), major (OR: 1.0, p = 0.367), or both minor and major (OR: 1.0, p = 0.908) postoperative complications. mFI-5 was a significant predictor of minor complications for mFI-5 scores 1 (OR: 1.3, p < 0.001), 2 (OR: 1.8, p < 0.001), and 3 (OR: 2.8, p = 0.043). For major complications, mFI-5 was a significant predictor for scores 1 (OR: 1.2, p = 0.011) and 2 (OR: 1.3, p = 0.03). CONCLUSION: Compared with age, mFI-5 scores were better predictors of 30-day postoperative complications following autologous breast reconstruction regardless of flap type. Additionally, higher mFI-5 scores were associated with increased odds of minor and major complications. Our findings indicate that reconstructive breast surgeons should consider using the mFI-5 in lieu of age to risk-stratify patients prior to autologous breast reconstruction surgery.

Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic.

BACKGROUND: Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic. METHODS: We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic. RESULTS: Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81). CONCLUSION: Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps.

BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial.

BACKGROUND: Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures. METHODS: A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics. RESULTS: One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores ( P <0.001) and anxiety scores ( P =0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others. CONCLUSION: VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices. LEVEL OF EVIDENCE: Level I.

Scoliosis in Pediatric Patients With Acute Flaccid Myelitis.

BACKGROUND: Acute flaccid myelitis (AFM) is an anterior horn disorder that manifests as rapid onset muscle weakness or paralysis. Development of scoliosis in pediatric AFM patients has been anecdotally reported, but associated risk factors or incidence have yet to be determined. METHODS: Pediatric AFM patients treated over a 10-year period at a tertiary care center were identified. Patients were considered to have scoliosis if there was radiographic evidence of coronal curvature ≥15 degrees. Number of limbs affected, independent ambulation and head control, ventilator requirement at initial admission, and long-term ventilatory support (≥1 year) were recorded. Muscle strength and functional status were assessed by manual muscle testing (MMT) and Physical Abilities and Mobility Scale (PAMS), respectively. Areas of spinal cord lesion on initial MRI were recorded. Bivariate analyses were performed, with alpha set to 0.05. RESULTS: Fifty-six AFM patients (27 scoliosis, 29 no scoliosis) were identified. Mean time from AFM presentation to scoliosis diagnosis was 0.93 years. Mean major Cobb angle at first radiograph was 31.7 ± 14.3 degrees. Lack of independent ambulation, ventilator dependence at time of admission or long term, number of limbs affected, and decreased MMT and PAMS scores were more common in patients who developed scoliosis (all, p < .05). Patients who developed scoliosis had more extensive thoracic spinal cord involvement on initial MRI (p = .03). CONCLUSION: AFM patients who develop scoliosis are more likely to be ventilator dependent, lack independent ambulation, and have more extensive thoracic SCI.

Opiate prescribing patterns in the adolescent population following anterior cruciate ligament reconstruction.

OBJECTIVE: We sought to determine prescribing patterns for opioid analgesia following anterior cruciate ligament (ACL) reconstruction among age- and gender-stratified adolescents in a nationally representative database. DESIGN: A retrospective study. SETTING: PearlDiver Patient Records. PATIENTS, PARTICIPANTS: Outpatient opioid claims within 30 days of surgery were extracted. The patients were defined into age groups 10-14 ("younger") and 15-19 ("older"). A total of 1,139 patients were included in this study (536 female and 603 males) with 108 patients in the 10-14 age category and 1,034 patients in the 15-19 category. MAIN OUTCOME MEASURE(S): The primary study outcome measures the average number of opioid pills administered, average total morphine milligram equivalents (MMEs) prescribed, and the average prescription strength (MMEs/pill). RESULTS: No difference was found in the average number of pills (p = 0.26) or normalized total MMEs (p = 0.312) prescribed by age group. Normalized total morphine equivalents per prescription was significantly lower in females than males (p = 0.005). Multivariate linear regression analysis demonstrated that increasing patient age was predictive of fewer total pills (p = 0.017), after accounting for gender. CONCLUSIONS: There are age- and gender-based disparities in prescription patterns for adolescent ACL reconstruction. Our findings indicate that patients in the older age group on average received fewer pills than the younger age group, which consequently trended toward receiving higher total MMEs prescribed. This suggests that surgeons may be inadvertently overprescribing in the younger cohort. Additional studies that account for concurrent factors should be conducted to observe potentially similar trends.

Deciding without data: clinical decision-making in pediatric orthopedic surgery.

OBJECTIVE: Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic. DESIGN/SETTING/PARTICIPANTS/INTERVENTION(S)/MAIN OUTCOME MEASURE(S): We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study'). RESULTS: Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions. CONCLUSIONS: With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.