Gut colonization with multidrug resistant organisms in the intensive care unit: a systematic review and meta-analysis.

BACKGROUND: Gut colonization with multidrug-resistant organisms (MDRO) frequently precedes infection among patients in the intensive care unit (ICU), although the dynamics of colonization are not completely understood. We performed a systematic review and meta-analysis of ICU studies which described the cumulative incidence and rates of MDRO gut acquisition. METHODS: We systematically searched PubMed, Embase, and Web of Science for studies published from 2010 to 2023 reporting on gut acquisition of MDRO in the ICU. MDRO were defined as multidrug resistant non-Pseudomonas Gram-negative bacteria (NP-GN), Pseudomonas spp., and vancomycin-resistant Enterococcus (VRE). We included observational studies which obtained perianal or rectal swabs at ICU admission (within 48 h) and at one or more subsequent timepoints. Our primary outcome was the incidence rate of gut acquisition of MDRO, defined as any MDRO newly detected after ICU admission (i.e., not present at baseline) for all patient-time at risk. The study was registered with PROSPERO, CRD42023481569. RESULTS: Of 482 studies initially identified, 14 studies with 37,305 patients met criteria for inclusion. The pooled incidence of gut acquisition of MDRO during ICU hospitalization was 5% (range: 1-43%) with a pooled incidence rate of 12.2 (95% CI 8.1-18.6) per 1000 patient-days. Median time to acquisition ranged from 4 to 26 days after ICU admission. Results were similar for NP-GN and Pseudomonas spp., with insufficient data to assess VRE. Among six studies which provided sufficient data to perform curve fitting, there was a quasi-linear increase in gut MDRO colonization of 1.41% per day which was stable through 30 days of ICU hospitalization (R2 = 0.50, p < 0.01). CONCLUSIONS: Acquisition of gut MDRO was common in the ICU and increases with days spent in ICU through 30 days of follow-up. These data may guide future interventions seeking to prevent gut acquisition of MDRO in the ICU.

Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial.

BACKGROUND: In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. QUESTIONS/PURPOSES: Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? METHODS: This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. RESULTS: There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). CONCLUSION: During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. LEVEL OF EVIDENCE: Level I, therapeutic study.

Editorial Commentary: Supporting Patients Psychologically and Reducing Kinesiophobia May Improve Anterior Cruciate Ligament Reconstruction Outcomes.

Athletes face an uphill battle after an anterior cruciate ligament tear if they want to return to their sport. Almost one-third of patients never return to their preinjury level of sport involvement, and many athletes dread this outcome. Although this distress is an understandable reaction, it can be demotivating, and psychological engagement in the recovery process is crucial to achieving desired outcomes. In particular, psychological readiness to return to sport is associated with greater likelihood of returning to sport. However, other psychological factors, including kinesiophobia, can negatively impact readiness to return to sport preoperatively and postoperatively. Supporting patients psychologically and reducing kinesiophobia throughout the recovery process may be essential to improving outcomes after an anterior cruciate ligament tear.

Many Radiographic and Magnetic Resonance Imaging Assessments for Surgical Decision Making in Pediatric Patellofemoral Instability Patients Demonstrate Poor Interrater Reliability.

PURPOSE: To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training. METHODS: Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]: <0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable. RESULTS: Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961). CONCLUSIONS: With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability. LEVEL OF EVIDENCE: II, prospective diagnostic study.

Normal Humeral Head Ossification in Pediatric and Adolescent Shoulders Can Mimic Hill-Sachs Lesions: A Magnetic Resonance Imaging-based Study.

BACKGROUND: The sequential maturation of the humeral head (HH) as viewed on magnetic resonance imaging (MRI) has not been described to date. Proper assessment may be complicated by the presence of physeal tissue in pediatric patients. Past studies suggest that skeletally immature patients may also have a higher risk of a false-positive diagnosis of Hill-Sachs lesion on MRI. The purpose of this study was to define pediatric HH developmental patterns using MRI and to investigate for any associations with findings of known false-positive Hill-Sachs. METHODS: Picture Archiving and Communication System (PACS) records at an urban academic tertiary care musculoskeletal facility from 2014 to 2020 were queried for shoulder MRI in patients aged 0 to 15 years. Patients were excluded if they had a history of glenohumeral instability, fracture, growth arrest, brachial plexus injury, surgery, or infection. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Each HH was staged based on skeletal maturity. RESULTS: For both sexes, HHs matured in a predictable manner with increasing chronological age associated with a higher ossification stage. False Hill-Sachs lesions were observed in girls aged 4 to 7 and boys aged 5 to 14, exclusively during stage I to II ossification. CONCLUSIONS: False Hill-Sachs lesions were visualized on MRI in stage I to II proximal humerus ossification. Due to differential timing of skeletal maturation, males present with false Hill-Sachs lesions at a later age than females on average. When interpreting shoulder MRI for glenohumeral instability, clinicians should be cautious of false Hill-Sachs lesions, especially in younger patients with distinct greater tuberosity and HH ossification centers (stage I to II ossification). LEVEL OF EVIDENCE: Level III.

Normal Glenoid Ossification in Pediatric and Adolescent Shoulders Mimics Bankart Lesions: A Magnetic Resonance Imaging-Based Study.

PURPOSE: The purpose of this descriptive study was to define patterns of ossification and fusion of growth centers around the pediatric and adolescent glenoid as a function of age using 3-dimensional, frequency-selective, fat-suppressed spoiled gradient recalled echo magnetic resonance (MR) imaging sequences, with a particular focus on the anterior glenoid rim because of its clinical relevance as a potential confounder of glenohumeral instability. METHODS: Picture Archiving and Communication System records at an urban academic tertiary care orthopaedic facility from October 2005 to December 2018 were queried for shoulder MRI in patients aged 9 to 17 years. Patients were excluded if they had any diagnoses that could alter glenoid development. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Secondary ossification centers were characterized as cartilage anlage, ossified, or fused at 3 anatomic sites: the anterior glenoid rim, coracoid, and superior glenoid rim. RESULTS: A total of 250 MR examinations (143 males, 107 females) were assessed in this study. The glenoid develops in a predictably sequential manner with ossification at the anterior glenoid rim lagging behind the coracoid and superior glenoid rim. The earliest age of anterior glenoid rim ossification was 11 years for both males (range 11-17) and females (range 11-12). Anterior glenoid rim ossification peaked at age 16 among males (34.8%, 8/23) and age 11 among females (27.3%, 3/11). CONCLUSIONS: Glenoid ossification and fusion progress in a predictable and chronological manner. This pattern should be used as a guideline when interpreting pediatric shoulder MRI examinations. In particular, an anterior glenoid ossification center should not be confused with an anterior glenoid injury (e.g., Bankart lesion), particularly in males 11 to 17 years old and females 11 to 12 years old. LEVEL OF EVIDENCE: IV (case series).

Pediatric and adolescent ankle instability: diagnosis and treatment options.

PURPOSE OF REVIEW: The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and treatment for lateral ankle instability in pediatric patients. RECENT FINDINGS: Chronic ankle instability is a common sequela of lateral ankle sprain in young athletes. Incidence is increasing, possibly due in part to inadequate treatment of first-time ankle sprains, as well as increased youth participation in organized and competitive sports. The anterior talofibular ligament (ATFL) is injured in every case, whereas the calcaneofibular ligament (CFL) and syndesmosis may be involved in severe cases. A clinical history, focused physical exam, and appropriate radiographic studies aid in diagnosis, and predisposing factors must be identified. Early treatment of ankle sprains involves bracing or immobilization, followed by a course of physical therapy. Surgery involves anatomic repair of the torn ligaments, and may be required in cases of severe functional and mechanical instability with recurrent sprains refractory to nonsurgical management. Intraarticular disorders should be identified and may be addressed with ankle arthroscopy. SUMMARY: Prompt treatment of lateral ankle instability in young athletes is important to prevent chronic ankle instability. Many patients are successfully treated without surgery, and those requiring operative intervention improve function postoperatively.

No difference in patient reported outcomes between cohorts undergoing lesion-specific surgery for osteochondritis dissecans of the knee.

Introduction: There is a paucity of data on patient reported outcome measures (PROMs) associated with surgical treatment of osteochondritis dissecans (OCD). As a result, preoperative patient and family counseling regarding expected outcomes is difficult. The purpose of this study was to compare pre-to post-operative changes in PROMs amongst cohorts of patients with OCD that underwent one of three lesion-specific surgical treatments: 1) transarticular drilling for stable lesions, 2) drilling and fixation for unstable lesions 3) grafting for unsalvageable lesions. Methods: The electronic medical records of pediatric and adolescent patients with knee OCD, at a single institution between January 2017 and August 2019, were reviewed. Patients were categorized into one of three surgical groups, with initial determination confirmed at the time of surgery during diagnostic knee arthroscopy. Differences between groups were assessed with one-way analysis of variance (ANOVA). Results: Of the 78 patients included in this study, 49 (62.8%) were male with a mean age of 13.5 ± 2.2 years. There was no significant difference between the surgical groups for baseline HSS Pedi-FABS (P = 0.58) or PROMIS Mobility (P = 0.47). There were no significant differences in PROMIS PI scores at baseline (P = 0.32), at latest follow-up (P = 0.72), or in interval change from baseline to follow-up (P = 0.42), between the three surgical groups. Conclusion: Lesion-specific surgical management of OCD led to similar improvements in PROMIS PI at a minimum of one-year follow-up. These results may better allow surgeons to reassure patients and families that outcomes are similar when lesions are treated through a lesion-specific algorithm. Level of evidence: Level IV: Retrospective cohort study.

Reliability of 2-Dimensional Video Analysis in Adolescent Runners.

Background: The literature on the reliability of qualitative and quantitative measures for running video analysis in the adolescent population is limited. Reliability of 2-dimensional (2D) video analysis has been reported in adult runners, but these findings may not apply to youth runners. Purpose: We sought to determine the intra-rater and inter-rater reliability of sagittal and frontal plane kinematics using 2D video analysis in healthy adolescent runners. Methods: High-definition (1080p) videos were recorded of 10 healthy runners between 14 and 18 years old running on a treadmill at self-selected speed with markers attached to the cervical spine, pelvis, and lower extremities. Kinematic variables in the sagittal and frontal planes were measured using Dartfish Motion Analysis Software by 3 raters (2 sports medicine physical therapists and a research assistant). Intra- and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs). Results: Of the 10 runners, 4 (40%) were male and the mean age was 16 ± 1.5 years. The intra-rater ICC for all kinematic variables ranged from 0.574 to 0.999 for the experienced physical therapist, and 0.367 to 0.973 for the inexperienced research assistant. The inter-rater ICC for all raters ranged from -0.01 to 0.941. Eleven kinematic variables showed substantial agreement and 4 showed almost perfect agreement. Step width and foot progression showed fair and poor agreement, respectively. Conclusions: Running analysis using 2D video can be performed reliably in adolescents on all kinematic variables except for step width and foot progression. Inexperienced raters can be properly trained in the video analysis of running kinematics to consistently assess the same runner.

Posterior Approach With Small Incision Is a Safe Alternative to Anterior Approach for Hamstring Autograft Harvest in Adolescents.

Background: There are potential drawbacks and complications associated with using the anterior approach to harvest the hamstring tendon as an autograft source for anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstruction. A posterior harvest technique has been described as an alternative to an anterior approach in skeletally mature patients. The 2 approaches have not been compared in adolescents. Purpose: We sought to compare the incision size and harvested tendon length produced by anterior and posterior hamstring harvest techniques in an adolescent population. Methods: After obtaining consent, we prospectively collected data on a consecutive series of 115 adolescents undergoing ACL or MPFL reconstruction, including the length of the incision and of the harvested hamstring tendon. Demographic information including age, sex, and body mass index (BMI) was collected at the time of surgery. Results: The mean age at the time of surgery was 14.3 ± 1.8 years (range: 9-21 years), and 43% (N = 50) of participants were male. Of the 115 hamstring autografts, 26 were harvested anteriorly and 89 were harvested posteriorly. Neither mean semitendinosus length nor mean gracilis length was significantly different when harvested anteriorly versus posteriorly. The posterior harvest group had a mean incision length that was significantly smaller than that of the anterior harvest group. No iatrogenic nerve injuries or neurovascular complications were observed in either group. Conclusion: A posterior incision for hamstring autograft harvest provided an alternative approach in adolescents, which resulted in a 20% smaller incision than an anterior approach. For procedures such as MPFL reconstruction that do not require concomitant anteromedial work, posterior hamstring harvest may be used to improve cosmesis while producing viable hamstring autograft tissue for surgical reconstruction.

Legacy Patient-reported Outcome Measures Can Be Reliably Translated to PROMIS Domains for Use in Adolescent Spinal Deformity.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to determine whether Patient-reported Outcomes Measurement Information System (PROMIS) Pediatric Domain scores can be accurately and reliably predicted from legacy patient-reported outcome measures (PROMs) for use in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Previous efforts have been made to develop translational models between PROMIS domains and legacy PROMs in adult spinal deformity, but translational models for pediatric and adolescent patients with spinal deformity have not yet been developed. METHODS: Scores were retrospectively collected on pediatric patients 8-17 years old who were diagnosed with spinal asymmetry or scoliosis for the following PROMs: Scoliosis Research Society-22r (SRS-22r), Trunk Appearance Perception Scale (TAPS), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and PROMIS Pediatric Domains: Pain Interference, Mobility, Physical Stress Experiences, Psychological Stress Experiences, and Physical Activity. Pearson correlations were calculated between legacy and PROMIS scores. In the derivation cohort, PROMIS domains were modeled from SRS-22r or HSS Pedi-FABS using linear regression. These equations were used to predict PROMIS scores in the test cohort to determine the reliability of the translation model. RESULTS: A total of 1171 patients (68% female) with a mean age of 13.4 ±â€Š2.3 years were included in the final analyses. PROMIS Pain Interference was dependent on SRS-22r domains Pain, Function, Mental Health, and Management Satisfaction, PROMIS Mobility was dependent on SRS-22r Pain, Function, Mental Health, and Self-Image, PROMIS Physical Stress Experiences and Psychological Stress Experiences were dependent on SRS-22r Pain, Mental Health, and Management Satisfaction, and PROMIS Physical Activity was dependent on HSS Pedi-FABS. (P < 0.05 for all). In the test cohort, all developed models for PROMIS domains demonstrated strong correlations between estimated and actual scores (r = 0.63-0.75). CONCLUSION: All of the evaluated PROMIS domains (Pain Interference, Mobility, Physical Stress Experiences, Psychological Stress Experiences, Physical Activity) were reliably translated directly from these legacy scores for pediatric and adolescent patients with spinal deformity.Level of Evidence: 3.

Age Is More Predictive of Safe Movement Patterns Than Are Physical Activity or Sports Specialization: A Prospective Motion Analysis Study of Young Athletes.

BACKGROUND: Movement quality and neuromuscular balance are noted predictors of acute injury. Early sports specialization and extremely high activity levels have been linked to elevated risk of injury. PURPOSE: To investigate for any relationships among quality of physical movement, quantity of physical activity, and degree of sports specialization in a healthy cohort of active children and adolescents. STUDY DESIGN: Cross-sectional study with prospectively collected data. METHODS: Healthy children between the ages of 10 and 18 years were recruited and completed the Hospital for Special Surgery Pediatric Functional Activity Brief Scale to assess quantity of physical activity and the Jayanthi scale to assess degree of sports specialization (high, score of 2 or 3; low, score of 0 or 1). Movement quality was assessed using motion analysis sensors during 5 repetitions of 4 different jumping and squatting motions, with a maximum score of 100 per participant. Independent-samples t tests were used to compare participants with high versus low specialization on physical activity and movement quality. A Spearman correlation was used to determine the relationship between quantity of physical activity and movement quality, and linear regression was used to assess for the effect of participant age on relevant covariables. RESULTS: Final analyses included 147 participants (72% male) with a mean ± SD age of 13.4 ± 2.2 years. Participants who were highly specialized displayed better movement quality than did participants with low sports specialization (27.6 ± 14.0 vs 19.8 ± 10.1; P < .01). Participants who were highly specialized had significantly higher activity levels (24.6 ± 5.9 vs 18.1 ± 6.9; P < .001). Movement quality was moderately correlated with physical activity level (r = 0.335; P < .001). Physical activity; hours of organized sports activity; hours of free, unorganized physical activity; and specialization level were not significant predictors of movement quality when controlling for age. Age alone predicted 24.2% of the variance in the overall movement quality score (R2 = 0.242; B = 3.0; P < .001). CONCLUSION: This study found that sports specialization and physical activity levels were not associated with movement quality when controlling for age, which was the most important variable predicting athletic movement quality. Although all participants displayed movement patterns that were associated with high risk for injury, overall movement quality improved with advancing chronological age. CLINICAL RELEVANCE: All young athletes should ensure that neuromuscular training accompanies sport-specific training to reduce risk of injury.

More than half of opioids prescribed to pediatric patients after ambulatory knee surgery are unused.

OBJECTIVE: To determine the number of opioid pills remaining after pediatric ambulatory knee surgery to provide insight into how many pills are actually used. DESIGN: Prospective observational cohort study. Participants who were expected to be prescribed 20 (Group 1) versus 40 (Group 2) opioid pills according to the institutional policy (based on the type of surgery) were studied. Patient's reported pain, medication use, and number of opioid pills remaining at post-operative days (PODs) 7 and 14. Participants were not randomly assigned to groups and no intervention was applied. SETTING: An urban tertiary care musculoskeletal institution. PARTICIPANTS: Sixty adolescents between the ages of 12 and 19 undergoing ambulatory knee surgery. INTERVENTIONS: Observational study, no experimental study intervention. MAIN OUTCOME MEASURE: The total number of opioid pills remaining. RESULTS: By POD7, more than 70 percent of patients had stopped taking their prescribed opioid medication mainly because their knee pain was tolerable either without the opioid or by using other medications. By POD14, the mean number of pills taken was 6.3 ± 5.3 for Group 1 and 18.4 ± 13.9 for Group 2. The mean number of unused opioids was 13.5 ± 7.2 for Group 1 and 17.9 ± 13.7 for Group 2. CONCLUSIONS: Even with prescribing practice guidelines in place, opioids may be overprescribed and could be given in a smaller quantity without affecting the quality of acute postoperative pain control in adolescents undergoing ambulatory knee surgery. However, one needs to consider that some patients may need a larger than average amount in order to be appropriately treated for their level of pain and thus prescription amounts-preferably after reevaluation-should be individualized.

Patients With Lower Limb Deformity Report Worse Quality of Life Than Control Subjects Regardless of Degree of Deformity.

INTRODUCTION: The purpose of this study was to determine how Limb Deformity Modified Scoliosis Research Society (LD-SRS) scores differ between patients with different types and degrees of limb deformity compared with control subjects. METHODS: Patients who were >17 years and scheduled for reconstructive surgery for limb lengthening or angular deformity with internal and/or external fixation and healthy control subjects were prospectively enrolled. Patients completed the LD-SRS preoperatively. Mechanical axis deviation (MAD) and leg length discrepancy (LLD) were recorded preoperatively. Participants were stratified into five groups based on their diagnosis. ANOVA was used to test for associations between LD-SRS scores and diagnosis as well as mechanical axis deviation. RESULTS: Patients with LLD, angular deformity, or combined LLD and angular deformity reported significantly worse scores than control subjects in LD-SRS Function/Activity, Pain, Self-Image/Appearance, and total score (P < 0.001 for all). Patients with short stature reported significantly worse LD-SRS Self-Image/Appearance (P < 0.001) and total score compared with control subjects (P = 0.015). There was a significant correlation between LLD and LD-SRS Self-Image/Appearance in the LLD and angular deformity group (r = -0.359, P = 0.043). DISCUSSION: Although LD-SRS scores were worse in patients with limb deformity compared to controls, LD-SRS scores were not related to the degree of deformity in most patients, indicating that patient self-perception may be a construct unrelated to objective radiographic or clinical findings.

Implant-Mediated Guided Growth for Coronal Plane Angular Deformity in the Pediatric Patient with Patellofemoral Instability.

Pediatric patellofemoral instability is a complex problem, for which there are several anatomic risk factors. Coronal plane malalignment (i.e., genu valgum) is one cause of patellofemoral instability, and treatment of genu valgum has been associated with improved patellofemoral stability. Coronal plane angular deformity correction, typically achieved by distal femoral osteotomy in the adult population, can be achieved with less invasive surgical techniques in pediatric patients using implant-mediated guided growth. By temporarily tethering one side of an open physis to generate differential growth in the coronal plane, valgus malalignment can be corrected. We present our technique for medial distal femoral implant-mediated guided growth using tension band plating for treatment of pediatric patellofemoral instability associated with genu valgum. This technique is minimally invasive, has a low complication rate, and in conjunction with conventional treatment can reduce the risk of recurrent instability.

Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort.

BACKGROUND: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. PURPOSE: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability. RESULTS: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements). CONCLUSION: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.

Discrimination Ability of Patient Reported Outcome Measurement Information System Pediatric Domains Compared With Scoliosis Research Society-22r and Legacy Patient Reported Outcome Measures in Juvenile and Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Comparative cohort study. OBJECTIVE: To compare patient reported outcome measures (PROMs) in children and adolescents with varying extent of spinal deformity. SUMMARY OF BACKGROUND DATA: Several PROMs have been proposed to help assess health-related quality-of-life (HRQoL) in pediatric spinal deformity surgery and research, but it is unclear which are sensitive to deformity severity. METHODS: Pediatric patients diagnosed with spinal asymmetry or juvenile/adolescent idiopathic scoliosis completed the patient-reported outcomes management information system (PROMIS) pediatric computer adaptive test bank (Domains: Mobility, Pain Interference, Physical Activity, Physical Stress Experiences, Psychological Stress Experiences), Scoliosis Research Society-22r (SRS-22r), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) activity scale, and Trunk Appearance Perception Scale. Patients were grouped as spinal asymmetry, mild deformity, and substantial deformity by major Cobb angle measuring less than 10°, between 10° and 40°, and greater than 40° respectively. One-way analysis of variance with a Tukey post-hoc correction was used to determine score differences between groups. RESULTS: Final analyses included 206 patients, of which 135 (66%) were female. The mean age was 13.0 ±â€Š2.2 years, and the mean major Cobb angle was 20.1 ±â€Š14.1° (range: 0-74.2°). Compared with both spinal asymmetry and mild deformity patients, patients with substantial deformity reported worse outcomes, including lower function, more pain, and decreased psychological health by legacy PROMs and PROMIS. PROMIS Physical Activity and Psychological Stress Experiences did not capture any significant differences between all groups. There were no significant differences in outcomes between the spinal asymmetry and mild deformity groups for all PROMs measured. CONCLUSION: Patients with substantial spinal deformity reported lower activity and function, more pain, and greater physical and psychological stress compared with patients without clinical spinal deformity by legacy PROMs and several PROMIS domains. As PROMIS Physical Activity and Psychological Stress Experiences did not capture these differences, these PROMs may measure different constructs than the legacy PROMs as they relate to spinal curvature and may be less relevant to measure HRQoL in this population.Level of Evidence 3.

Use Caution When Assessing Preoperative Leg-Length Discrepancy in Pediatric Patients With Anterior Cruciate Ligament Injuries.

BACKGROUND: Pre- and postoperative standing hip-to-ankle radiographs are critical for monitoring potential postoperative growth arrest and resultant deformities after pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine the prevalence of apparent preoperative leg-length discrepancies (LLDs) that resolve at the first postoperative radiographic examination in patients undergoing ACL reconstruction in order to understand what proportion of the noted preoperative deformities may have been inaccurate. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of prospectively collected preoperative and first postoperative full-length hip-to-ankle radiographs was performed in a cohort of skeletally immature patients who had an acute ACL injury and underwent subsequent surgical reconstruction. Leg length measurements for both the injured and the uninjured legs were obtained for comparison. RESULTS: A total of 112 patients (mean age, 12.7 ± 1.7 years) were included (79 boys and 33 girls). Leg-length measurement interrater reliability among 3 raters for 25 randomly chosen images was nearly perfect (intraclass correlation coefficient, 0.996; 95% CI, 0.994-0.998). At baseline, there was no apparent preoperative LLD (<5 mm) in 48% (n = 54) of participants, while 37% (n = 41) displayed a small apparent LLD (5 to <10 mm), 12% (n = 13) displayed a moderate apparent LLD (10 to <15 mm), and 4% (n = 4) displayed a large apparent LLD (≥15 mm). Of the patients with an apparent preoperative LLD, 66% (n = 38) of them tore their ACL on the leg measuring shorter. At first postoperative radiographs, 48% (n = 28) of patients with an apparent preoperative LLD showed resolution to no LLD: 46% (n = 19) of patients with a small apparent preoperative LLD, 54% (n = 7) of patients with a moderate apparent LLD, and 50% (n = 2) of patients with a large apparent LLD. CONCLUSION: A high percentage of patients (48%) with apparent preoperative LLDs showed resolution to no LLDs by their first postoperative imaging, indicating that preoperative hip-to-ankle radiographs display some false LLDs in patients with recent ACL tears who are unable to fully extend their injured leg and bear weight.

Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria.

BACKGROUND: Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated. PURPOSE: To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation. STUDY DESIGN: Economic and decision analysis. METHODS: A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation. RESULTS: The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%. CONCLUSION: The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up-as well as advanced testing goals upon which RTP is contingent-to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis. CLINICAL RELEVANCE: This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.

The Epidemiology of Back Pain in American Children and Adolescents.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To determine the prevalence of back pain in American children and adolescents, with a focus on anatomic region, duration, severity, and treatment patterns, and to investigate for any predictive variables. SUMMARY OF BACKGROUND DATA: No study has examined the prevalence of back pain in American children and adolescents in the last 15 years. Because the prevalence of back pain varies greatly by country and year of investigation, previous studies are not generalizable. METHODS: A United States epidemiologic cross-sectional survey-based investigation was performed in children and adolescents ages 10 and 18 years old, equally split by age and sex, and representing census-weighted distributions of state of residence, race/ethnicity, and health insurance status. Prevalence of back pain was evaluated and described. RESULTS: In total, 1236 (33.7%) participants reported experiencing back pain within the last year and 325 (8.9%) reported severe back pain within the last year. Prevalence of back pain increased with age and was significantly more common in females, P < 0.001 for both. Treatment for back pain was sought by 505 (40.9%) of the participants with pain, of which physical therapy was the most common. Invasive procedural treatment (e.g., injections, surgery) were rare and comprised only 61 (1.6%) of study participants. In addition, government insurance and lack of insurance coverage was associated with low treatment seeking behavior compared to private insurance users (P = 0.010 and P = 0.006, respectively). CONCLUSION: Despite how commonly it presents, the majority of young patients with back pain do not report procedural treatment such as injections or surgery. However, because many American children and adolescents seek treatment, future research on the etiology, treatment, and prevention of back pain in children and adolescents is essential to reducing a common and financially demanding problem. LEVEL OF EVIDENCE: 4.