What Are the Psychosocial Effects of Pavlik Harness Treatment? A Prospective Study on Perceived Impact on Families and Maternal-Infant Bonding.

BACKGROUND: The Pavlik harness (PH) is the most common treatment for infants with developmental dysplasia of the hip. Although success rates are high when used appropriately, brace treatment may impact family function and parental bonding. The purpose of this study was to prospectively determine how PH treatment affected these psychosocial variables. METHODS: This is a prospective, single-surgeon study at a tertiary-care, urban, academic children's hospital between November 2022 and March 2023. All patients newly treated with a Pavlik were eligible. Caregivers were administered the Postpartum Bonding Questionnaire and the Revised Impact on Family Scale (rIOFS) at the baseline visit and 2- and 6 weeks following treatment initiation. Demographic and treatment-specific information was collected through surveys and retrospective chart review. Descriptive statistics and bivariate analysis were used. RESULTS: A total of 55 caregiver-child dyads were included in the final analysis. Most patients were female (89%) and/or first-born (73%). Forty (73%) hips were diagnosed as having stable dysplasia. rIOFS scores steadily improved from baseline, through 2- and 6 weeks posttreatment initiation. Six-week rIOFS scores were significantly lower than both baseline ( P= 0.002) and 2 weeks ( P =0.018). Average parental bonding scores also improved steadily throughout treatment and did not surpass the threshold of clinical concern at any time. Neither full-time harness use (24 h/d vs. 23 h/d based upon clinical stability) nor age at treatment initiation had a statistically significant effect on parental bonding or family functioning (all P >0.05). Additional demographic variables such as birth order, parental history of anxiety/depression, and relative socioeconomic disadvantage also had no significant effect on psychosocial outcomes. CONCLUSION: PH treatment did not significantly impact maternal-fetal bonding or family dynamics. Relative to other pediatric diseases, PH treatment has an impact on family life greater than that of single-leg spica, but less than that of school-age children with chronic medical illnesses. As PH treatment is a widely used treatment for infantile developmental dysplasia of the hip, this study provides information that clinicians may use to more accurately counsel families and assuage parental concerns. LEVELS OF EVIDENCE: Level IV-prospective uncontrolled cohort study.

Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents?

BACKGROUND: Research has indicated that lower socioeconomic status is associated with delays in the treatment of anterior cruciate ligament (ACL) injuries; however, there is a paucity of literature evaluating its association with patient-reported outcomes (PROs). Using the Area Deprivation Index (ADI), a validated proxy for socioeconomic status, the study aimed to determine how relative socioeconomic disadvantage is related to PROs after primary ACL reconstruction (ACLR) in pediatric patients. METHODS: This retrospective cohort study included all patients 18 years old or above who underwent primary ACLR at an academic institution between 2018 and 2021. Exclusion criteria included multiligament injury, congenital ACL absence, and absent outcomes data. The minimum follow-up was 6 months. A Patient-reported Outcomes Measurement Information System (PROMIS) 50 Pediatric self-report questionnaire was completed at postoperative visits, and domain scores for pain, physical function/mobility, fatigue, anxiety, depression, and peer relationships were generated. The National ADI percentile was calculated using the patients' addresses. Patients were divided into quartiles (low, moderate, moderate-severe, and severe ADI), and comparative analyses were performed to determine the relationship between ADI and PROMIS. RESULTS: A total of 413 patients were identified, including 49% (n=207), 33% (n=139), 11% (n=48), and 7% (n=30) from the low, moderate, moderate-severe, and severe deprivation areas, respectively. As compared with those in the low-deprivation quartile, patients in the severe deprivation quartile had delayed time to the first clinic visit (11 vs. 16.5 d, P=0.044) and surgery (51 vs. 80 d, P=0.004). There were no differences in the number of additional procedures required at index surgery. All quartiles had progressive improvements in physical function/mobility and pain scores throughout recovery, but at 9 months, there was significantly more pain in the severe deprivation cohort, despite no difference in self-reported physical function and mobility. Those with severe socioeconomic disadvantage had worse psychosocial outcomes, including significantly increased depression, fatigue, and anxiety and decreased peer relationship scores. CONCLUSIONS: Although there were no differences in preoperative PROMIS scores, pediatric patients living in areas with higher levels of socioeconomic deprivation/disadvantage had worse psychosocial PROs after ACLR. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

A Prospective, Multicenter Study of Developmental Dysplasia of the Hip: What Can Patients Expect After Open Reduction?

BACKGROUND: Although there are several predominantly single-center case series in the literature, relatively little prospectively collected data exist regarding the outcomes of open hip reduction (OR) for infantile developmental dysplasia of the hip (DDH). The purpose of this prospective, multi-center study was to determine the outcomes after OR in a diverse patient population. METHODS: The prospectively collected database of an international multicenter study group was queried for all patients treated with OR for DDH. Minimum follow-up was 1 year. Proximal femoral growth disturbance (PFGD) was defined by consensus review using Salter's criteria. Persistent acetabular dysplasia was defined as an acetabular index >90th percentile for age. Statistical analyses were performed to compare preoperative and operative characteristics that predicted re-dislocation, PFGD, and residual acetabular dysplasia. RESULTS: A cohort of 232 hips (195 patients) was identified; median age at OR was 19 months (interquartile range 13 to 28) and median follow-up length was 21 months (interquartile range 16 to 32). Re-dislocation occurred in 7% of hips (n=16/228). The majority (81%; n=13/16) occurred in the first year after initial OR. Excluding patients with repeat dislocation, 94.5% of hips were IHDI 1 at most recent follow-up. On the basis of strict radiographic review, some degree of PFGD was present in 44% of hips (n=101/230) at most recent follow-up. Seventy-eight hips (55%) demonstrated residual dysplasia compared with established normative data. Hips that had a pelvic osteotomy at index surgery had about half the rate of residual dysplasia (39%; n=32/82) versus those without a pelvic osteotomy with at least 2 years follow-up (78%; n=46/59). CONCLUSIONS: In the largest prospective, multicenter study to date, OR for infantile DDH was associated with a 7% risk of re-dislocation, 44% risk of PFGD, and 55% risk of residual acetabular dysplasia at short term follow-up. The incidence of these adverse outcomes is higher than previous reports. Patients treated with concomitant pelvic osteotomy had lower rates of residual dysplasia. These prospectively collected, multicenter data provide better generalizable information to improve family education and appropriately set expectations. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Anterior vertebral body tethering for adolescent idiopathic scoliosis associated with less early post-operative pain and shorter recovery compared with fusion.

PURPOSE: While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery. METHODS: In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping. RESULTS: The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation (p = 0.004, and 0.030), decreased PROMIS pain behavior at all time points (p = 0.024, 0.049, and 0.001), decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points (p = 0.036, 0.038, and 0.018), and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep (p = 0.024, 0.049, and 0.001). CONCLUSION: In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF. LEVEL OF EVIDENCE: IV.

Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear.

BACKGROUND: Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear. METHODS: This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear. RESULTS: A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%). CONCLUSION: This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit. LEVEL OF EVIDENCE: II.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing. AIM: To assess whether NSAID exposure is a risk factor for fracture nonunion in children. METHODS: We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence. RESULTS: A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects. CONCLUSION: This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review.

The most common causative organism of pediatric osteomyelitis is Staphylococcus aureus, although, more recently, organisms such as Kingella kingae and methicillin-resistant S. aureus have been increasing in prevalence. Magnetic resonance imaging is the best diagnostic imaging modality for pediatric osteomyelitis given its high sensitivity and specificity. Most cases of early osteomyelitis without a drainable abscess can be adequately treated with a short course of intravenous antibiotics followed by at least 3 weeks of oral antibiotics. Surgical management of pediatric osteomyelitis is usually indicated in the presence of an abscess and/or failed treatment with antibiotic therapy. Clinical examination, fever, and C-reactive protein testing should be used to guide the conversion to oral antibiotics, the total antibiotic regimen duration, and the need for an additional debridement surgical procedure.

Idiopathic stroke after syndromic and neuromuscular scoliosis surgery: a case report and literature review.

Children with syndromic and neuromuscular scoliosis undergoing corrective surgery experience higher complication rates than those with idiopathic scoliosis. A rare but devastating complication is stroke, which occurs in 0.57% of operations for neuromuscular scoliosis but accounts for 7.6% of deaths. Comorbidities associated with non-idiopathic scoliosis that increase risk of stroke include hypercoagulability, cardiac dysfunction, and contractures, which interfere with positioning and risk vascular compromise. Syndromic and neuromuscular diseases may predispose patients to intraoperative dural tears, either primarily (e.g., dural ectasia) or secondarily, in particular due to severity of deformity. We present the case of a perioperative, idiopathic stroke in a 15-year-old boy with scoliosis in the setting of neurofibromatosis type I, reviewing possible causes as well as strategies for preoperative assessment and postoperative monitoring.

Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort.

BACKGROUND: Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR. METHODS: Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed. RESULTS: A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia. CONCLUSIONS: Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip. LEVEL OF EVIDENCE: Level II-prospective observational cohort.

The Diagnostic Utility and Clinical Implications of Wrist MRI in the Pediatric Population.

BACKGROUND: Unexplained wrist pain is a common presentation in children. To our knowledge, no studies have explored the clinical utility of magnetic resonance imaging (MRI) in the diagnostic workup of pediatric patients. METHODS: We retrospectively reviewed 307 consecutive wrist MRIs ordered at a tertiary-care pediatric hospital. Demographic data and the indication for imaging were recorded and grouped into admitting categories. The final impression of each MRI was scored with regard to potential impact on future treatment (0 = normal, 1 = minimal, 2 = moderate, 3 = high). Patients who went on to wrist surgery within 1 year were noted. RESULTS: In our cohort, 27% of all studies were normal, including 34% of those with pain. Although pain was the most common category, MRI was most useful in the delineation of a mass/cyst, evaluating for infection and evaluating arthropathy. Compared with all other categories, patients with pain were 3.6 times more likely to have a normal study and 4.6 times more likely to have a clinical score less than or equal to 1. Given an admitting diagnosis of pain, females were 1.7 times more likely to present for an MRI and 2.4 times more likely to have a normal MRI. The Spearman correlation revealed no linear relationship between age and MRI outcome. In all, 13% of patients went on to have surgery within 1 year of MRI. CONCLUSIONS: At our pediatric institution, the majority of wrist MRIs were ordered for wrist pain. Given our data, wrist MRI is not an ideal screening tool in children, particularly in those with wrist pain, and should only be used to exclude or confirm a specific diagnosis.

Pavlik Harness Disease Revisited: Does Prolonged Treatment of a Dislocated Hip in a Harness Adversely Affect the α Angle?

BACKGROUND: Current dogma contends that prolonged treatment of a dislocated hip in Pavlik harness beyond 3 weeks will cause "Pavlik harness disease." To our knowledge, however, no previous studies have documented objective morphologic changes to the acetabulum from continued treatment of a persistently dislocated hip. METHODS: We retrospectively reviewed a consecutive series of infants with developmental dysplasia of the hip, below 6 months old, who failed Pavlik treatment from a single, tertiary-care pediatric hospital and a multicenter, international study group. Inclusion criteria were dislocated hips confirmed by ultrasound (both initially and at Pavlik termination) and a minimum of 2 ultrasounds during harness treatment at least 3 weeks apart. As a global measure of acetabular morphology, α angle (AA) was compared between initial and final ultrasound. The final means of obtaining successful hip reduction was recorded from the medical records. RESULTS: Forty-nine hips in 38 patients were identified. Median age at Pavlik initiation was 4 weeks (range, 0 to 18 wk); median time in harness was 6 weeks (range, 3 to 14 wk). Surprisingly, a mean of 4 degrees improvement in AA (95% CI, 2-6 degrees; P=0.001) was observed between first and final ultrasound. We found no difference in AA change between those in harness 3 to 5 weeks and those with prolonged wear >5 weeks (P=0.817). There was no significant association between change in AA and time in harness (P=0.545), age at Pavlik initiation (P=0.199), clinical reducibility of the hip (P=0.202), or initial percent femoral head coverage (P=0.956). Following harness failure, 22/49 hips (45%) were successfully treated with rigid abduction bracing, 16 (33%) by closed reduction/spica casting, and 10 (20%) by open reduction; 1 hip (2%) spontaneously reduced and required no further treatment. CONCLUSIONS: On the basis of the lengths of harness treatment in our series, most hips did not exhibit negative changes in the acetabular AA in response to prolonged treatment of a dislocated hip in harness. Furthermore, 80% of hips failing Pavlik treatment were successfully reduced through closed means, indicating that subsequent treatment was not compromised. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Osteochondritis Dissecans Lesions in Family Members: Does a Positive Family History Impact Phenotypic Potency?

BACKGROUND: Although repetitive microtrauma and athletic overuse patterns are most commonly associated with osteochondritis dissecans (OCD), recent studies have identified a potential genetic predisposition for OCD. Several case series have documented family pedigrees that support autosomal-dominant inheritance, but the families in these studies were all selected as a result of unique histories that may not accurately represent OCD inheritance patterns at large. Because there has been little investigation beyond these case reports, we aimed to describe a broader, more representative pattern of OCD inheritance applicable to all affected patients. QUESTIONS/PURPOSES: (1) What proportion of patients treated for OCD of the knee have one or more immediate and/or extended family members with a history of OCD lesions? (2) Do patients with more phenotypically potent lesions, which we defined as patients with bilateral OCD lesions or patients who have undergone multiple procedures for OCD, have a higher frequency of affected relatives than those with less potent lesions? METHODS: This retrospective study queried patient databases, diagnosis codes (International Classification of Diseases, 9th Revision), and surgical logs at a regional, tertiary care children's hospital to identify all patients treated over a 10-year period (March 2004-March 2014) by the senior author for OCD of the knee. All patients aged 0-18 years at the time of diagnosis were included. At our institution, patients with intact lesions are treated with a trial of conservative therapy; conversely, patients with a break in the articular cartilage and/or loose fragments of bone/cartilage are treated surgically. There were no OCD-specific contraindications to surgery. This search identified 543 patients. After patient identification, a questionnaire was designed that asked for the number, age, and gender of all immediate family members and the history of OCD lesions in any family member (immediate or extended). For all positive family members, patients were further queried regarding relevant clinical details to affirm a history of OCD. Patients were contacted by mailed questionnaires and phone calls for survey completion. All 543 patients received the survey, of which 103 (19%) responded to it and were included here. Responders were approximately 1 year younger than nonresponders; there was no difference in gender distribution. A retrospective chart review was then conducted to collect demographic information, phenotypic disease severity, and treatment details. Of the 103 included patients, 20 patients (19%) with unilateral lesions were managed nonoperatively ("conservative" group), 50 patients (49%) had unilateral lesions advanced to surgery ("unilateral" group), 21 patients (20%) had bilateral lesions managed either conservatively or surgically ("bilateral" group), and 12 patients (12%) underwent multiple procedures for the same lesion ("multiple" group). Of those included, 75 patients (73%) were treated surgically. With the numbers available, there were no baseline differences among the groups in terms of gender, lesion laterality, lesion location, or number of secondary procedures at the time of the initial surgical intervention. RESULTS: In total, 14 of 103 (14%) patients treated for OCD in this study had an immediate and/or extended family member with a history of OCD lesions. This included four of 20 (20%) patients in the conservative group, five of 50 (10%) in the unilateral group, four of 21 (19%) in the bilateral group, and one of 12 (8%) in the multiple group. With the numbers available, we did not identify a higher proportion of immediate and/or extended family members with a positive history of OCD in those patients with phenotypically potent lesions (bilateral and multiple) as compared with those with patients phenotypically less potent lesions (conservative and unilateral; five of 33 [15%] versus nine of 70 [13%]; odds ratio, 1.2; 95% confidence interval, 0.4-3.9; p = 0.751). CONCLUSIONS: In this broad, heterogeneous cohort of pediatric patients with OCD, the proportion of patients with a positive family history of OCD was 14%, which appeared to be much higher than the reported prevalence of OCD in the general population according to prior research. Therefore, our data provide preliminary support for a familial inheritance pattern for OCD, suggesting that further clinical, biologic, and genomic investigation might help to improve our understanding of who is at highest risk for OCD and what moderating factors might influence their disease severity and risk of progression. Furthermore, our data suggest that expanded patient education and screening regarding inheritance patterns might enhance identification of potential familial disease burden and improve access to timely and appropriate treatment. LEVEL OF EVIDENCE: Level IV, prognostic study.

A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion.

STUDY DESIGN: Retrospective comparative cohort. OBJECTIVES: To determine if a standardized multimodal analgesic and rehabilitation protocol (rapid recovery pathway [RRP]) in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) could improve pain control, reduce opioid-related complications, and expedite early mobilization. BACKGROUND: Several reports have described postoperative recovery pathways for AIS patients undergoing PSF that shorten length of stay (LOS) without reporting the impact such pathways might have on patients' pain or quality of recovery. METHODS: We compared two high-volume surgeons' patients managed on our conventional pathway (CP) or our RRP. The CP analgesia consisted of intraoperative methadone and postoperative patient-controlled analgesia (PCA) until tolerating oral analgesics, with adjunctive diazepam. Analgesia on the RRP includes intraoperative methadone and postoperative PCA; patients also receive preoperative gabapentin and acetaminophen, intraoperative intravenous acetaminophen, and postoperative diazepam, gabapentin, acetaminophen, and ketorolac. Ambulation and full diet are permitted beginning postoperative day 1. The primary outcome was mean daily pain scores. Secondary outcomes were LOS, time to pathway milestone completions, and frequency of opioid-related side effects requiring treatment. RESULTS: There were 58 patients in the RRP group and 80 patients in the CP group. Patients on RRP had improved mean daily pain scores on postoperative days 0 (p = .027), 1 (p < .001) and 2 (p = .004). RRP patients were discharged home 31% earlier, discontinued from PCA 34% earlier and had their urinary catheters removed 26% earlier. Total opioid consumption decreased on postoperative day 0 (p < .001), but not postoperative day 1 (p = .773) or 2 (p = .343). Fewer patients on the RRP required medication for opioid-induced pruritus (p = .001), but there was no difference in the frequency of odansetron administration (p = .566). There were no differences in 30-day rates of readmission (p = .407). CONCLUSION: Implementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

BACKGROUND: Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. METHODS: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. RESULTS: Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. CONCLUSION: We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.

Compartment syndrome in infants and toddlers.

PURPOSE: To study the cause, diagnosis, treatment and outcome of acute compartment syndrome in infants and toddlers aged <3 years. METHODS: Fifteen patients aged <3 years with acute compartment syndrome were identified from two large pediatric trauma centers over a fifteen-year period. All children underwent fasciotomy. The mechanism of injury, time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded. RESULTS: Nine (60 %) of fifteen patients developed compartment syndrome secondary to trauma, four (4/15, 27 %) due to infection, and two (2/15, 13 %) due to intravenous infiltration. The average time from injury or hospital admission to fasciotomy was 31.8 h (range 2.9-136.3 h). In general, the functional outcome was excellent at the latest follow-up with thirteen (13/15, 87 %) patients having an excellent outcome. No cases of Volkmann's ischemia were noted at the time of fasciotomy, even when performed as late as 5 days after injury. CONCLUSIONS: Compared to the general pediatric population, the diagnosis of compartment syndrome in infants and toddlers may be further delayed, i.e., >24 h after injury. Despite delays in diagnosis and time to treatment, the present study shows that outcomes in infants and toddlers remain favorable even when fasciotomy is performed 48-72 h after injury. LEVEL OF EVIDENCE: Case series, level IV.

Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis.

BACKGROUND: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population. METHODS: We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate. RESULTS: We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway. CONCLUSIONS: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center.

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.

Sport-Specific Yearly Risk and Incidence of Anterior Cruciate Ligament Tears in High School Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played. PURPOSE: To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools. STUDY DESIGN: Meta-analysis. METHODS: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears. RESULTS: The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys' football had the highest number of ACL injuries at 273, girls' soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%). CONCLUSION: There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling.

Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?

BACKGROUND: Gadolinium-enhanced perfusion MRI (pMRI) after closed reduction/spica casting for developmental dysplasia of the hip (DDH) has been suggested as a potential means to identify and avoid avascular necrosis (AVN). To date, however, no study has evaluated the effectiveness of pMRI in clinical practice or compared it with other approaches (such as postreduction CT scan) to show a difference in the proportion of AVN. QUESTIONS/PURPOSES: (1) Can a pMRI-based protocol be used immediately post closed reduction to minimize the risk that AVN would develop? (2) What are the overall hip-related outcomes after closed reduction/spica casting using this protocol? (3) Do any patient-specific factors at the time of closed reduction predict future AVN? METHODS: This was a retrospective cohort study at a large tertiary care children's hospital. Between 2009 and 2013 we treated 43 patients with closed reduction/spica casting for DDH, of whom 33 (77%) received a postreduction pMRI. All patients were indicated for pMRI per treating surgeon preference. A convenience sample totaling 25 hips in 22 patients treated with pMRI was then established using the following exclusion criteria: DDH of neuromuscular/syndromic origin, failed initial closed reduction, less than 1 year of clinical and radiographic followup, and subsequent open reduction. Next, the 40 patients treated with closed reduction between 2004 and 2009 were screened until the chronologically most recent 25 hips (after applying the previously mentioned exclusion criteria) were identified in 21 of the first 34 patients (62%) screened. Although termed the CT group, specific postreduction imaging was not a defined inclusion criterion in this group with the majority (21 of 25 [84%]) receiving postreduction CT and the remainder (four of 25 [16%]) receiving only postreduction radiographs. All hips with globally decreased femoral head perfusion on postreduction pMRI were treated with immediate cast removal followed by repeat closed reduction or open reduction, as per surgeon preference, with two of 33 (6%) requiring such further interventions. Salter criteria were then used to determine the proportion of AVN on radiographs at 1-year and final followup. Secondary outcomes including residual dysplasia and the need for further corrective surgery were ascertained through radiographic and retrospective chart review. RESULTS: At 1-year followup there was no difference in the proportion of AVN in the historical CT group as compared with the pMRI group (six of 25 [24%] versus one of 25 [4%]; odds ratio [OR], 7.6; 95% confidence interval [CI], 0.8-363; p = 0.098). However, by final followup there was a statistically higher proportion of AVN in the CT group (seven of 25 [28%] versus one of 25 [4%]; OR, 9.3; 95% CI, 1.0-438; p = 0.049). No patient with normal perfusion on postreduction pMRI went on to develop AVN. In those pMRI patients in whom a successful reduction was initially obtained, two of 25 (8%) went on to require further corrective surgery and one of 25 (4%) had a redislocation event. With the numbers available, no patient-specific factors at the time of closed reduction were predictive of future AVN, including the patient's age/weight, the presence of an ossific nucleus, history of previous bracing treatment, or the abduction angle in spica cast. CONCLUSIONS: A pMRI-based protocol immediately after closed reduction/spica casting may decrease the risk of AVN by helping the surgeon to evaluate femoral head vascularity. Although preliminary in nature, this study could serve to guide further investigation into the potential role of pMRI for the treatment of patients who require closed reduction/spica casting for DDH. LEVEL OF EVIDENCE: Level III, therapeutic study.