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**Background:** Approximately 60% of hospitalized children undergoing surgery experience at least 1 day of moderate-to-severe pain after surgery. Pain following spine surgery may affect opioid exposure, length of stay (LOS), and costs in hospitalized pediatric patients. This is a retrospective cohort analysis of pediatric patients undergoing inpatient primary spine surgery. **Objectives:** To examine the association of opioid-related and economic outcomes with postsurgical liposomal bupivacaine (LB) or non-LB analgesia in pediatric patients who received spine surgery. **Methods:** Premier Healthcare Database records (January 2015–September 2019) for patients aged 1–17 years undergoing inpatient primary spine surgery were retrospectively analyzed. Outcomes included in-hospital postsurgical opioid consumption (morphine milligram equivalents [MMEs]), opioid-related adverse events (ORAEs), LOS (days), and total hospital costs. A generalized linear model adjusting for baseline characteristics was used. **Results:** Among 10 189 pediatric patients, the LB cohort (n=373) consumed significantly fewer postsurgical opioids than the non-LB cohort (n=9816; adjusted MME ratio, 0.53 [95% confidence interval (CI), 0.45–0.61]; P

STUDY OBJECTIVE To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. DESIGN Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302). SETTING Operating room. PATIENTS Two separate age groups were evaluated (age group 1: patients 12 to

STUDY DESIGN Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. OBJECTIVE The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. SUMMARY OF BACKGROUND DATA AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. MATERIALS AND METHODS A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. RESULTS The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P

STUDY DESIGN Retrospective comparative cohort study. OBJECTIVE To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P

Clinical outcomes of children with bacterial septic arthritis, common in the pediatric age group, are often satisfactory with early recognition, prompt surgical drainage, and appropriate antibiotic therapy. However, the optimal duration and route of antibiotic administration for treatment of septic arthritis continues to be debated, as traditional treatment favored longer intravenous (IV) therapies yet oral regimens are increasingly available that are more cost effective, safe and produce satisfactory disease resolution.Records of 186 patients from two children's hospitals, one that was thought to convert from IV to oral antibiotic therapy considerably earlier than the other, treated between 1985 and 1995 for bacterial septic arthritis were reviewed. Patients with concurrent osteomyelitis were excluded.Patients at Hospital #1 were converted to oral antibiotics after 7.4+/-7.4 days of IV antibiotic therapy and at Hospital #2 after 18.6+/-13.6 (P0.001) days of IV therapy. Both groups received an average of four weeks of total antibiotic treatment. There was similar time to defervescence (2.4+/-3.2 d vs. 2.4+/-3.8 d, P0.05) and to normalization of erythrocyte sedimentation rate (35.7+/-19.7 d vs. 33.8+/-44.9 d, P0.05) in the patients converted to oral therapy early compared to those converted late. One case of mild avascular necrosis with no clinical disability developed in a patient from Hospital #2.We conclude that the clinical outcome in patients with septic arthritis converted to oral antibiotic therapy early in their treatment based on defined criteria was similar to those converted late.

Ganglion cysts originating from the sternoclavicular joint in children have not been previously reported. In this study, 5 children who presented with a small mass over the anterior aspect of the sternoclavicular joint were evaluated and treated. Only 1 patient was symptomatic. A ganglion cyst was suspected in each case and confirmed by magnetic resonance imaging in 3 patients and ultrasound in one patient. Excisional biopsy was performed in 3 patients and the diagnosis of a ganglion cyst confirmed histopathologically. No patient has had a recurrence. Observation of asymptomatic cystic lesions that arise in the sternoclavicular location is recommended.

Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The incidence of compartment syndrome in association with these fractures is controversial. The authors reviewed 978 consecutive children admitted to the hospital with upper extremity long bone fractures during a 13-year period. Forty-three children with ipsilateral fractures of the humerus and forearm were identified. Of 33 children with a supracondylar humerus fracture and ipsilateral forearm fracture, three children (7%) had compartment syndrome develop and required forearm fasciotomies. All three cases of compartment syndrome occurred among nine children with ipsilateral displaced extension supracondylar humerus and displaced forearm fractures; the incidence of compartment syndrome was 33% in this group. These findings suggest that children who sustain a displaced extension supracondylar humerus fracture and displaced forearm fracture are at significant risk for compartment syndrome. These children should be monitored closely during the perioperative period for signs and symptoms of increasing intracompartmental pressures in the forearm.

Hemihypertrophy is best defined as asymmetry between the right and left sides of the body to a greater degree than can be attributed to normal variation. This asymmetry often appears as a difference in the size or length of the extremities, but it may also involve the head, trunk, and internal organs. It is often extremely difficult to distinguish hemihypertrophy from normal variation. However, this distinction is very important because young children who have hemihypertrophy are at increased risk of malignant intra-abdominal tumors, such as Wilms tumor or hepatoblastoma9,21,22,24,27,29,31,47,60. The increased risk of neoplasia has led to the controversial recommendation of frequent abdominal ultrasound screening designed to detect the tumor at the earliest possible stage2,12,16,25. The orthopaedic literature regarding hemihypertrophy has focused primarily on the treatment of discrepancy between the lengths of the lower limbs and has only superficially acknowledged link between hemihypertrophy and cancer in children4,37,38,45. Even the most recent pediatric and pediatric orthopaedic textbooks mention this association only briefly if at all8,42,59. The objectives of the present review were to describe the clinical features of hemihypertrophy and its related syndromes, to focus on the relationship between hemihypertrophy and malignant tumors in children, and to discuss the controversy surrounding the frequent abdominal ultrasound screening that is recommended for this group of patients. Hemihypertrophy occurs when a limb or one side of the body enlarges asymmetrically compared with the contralateral limb or side beyond the limits of normal variation. This enlargement may affect only the soft tissues, but it ordinarily involves both the soft tissues and the underlying skeleton. Although …

Torticollis in children may result from a wide variety of pathologic processes. We retrospectively analyzed 288 patients seen in a tertiary care pediatric orthopedic facility for the evaluation of torticollis over a 10-year period to ascertain the frequency of nonmuscular causes of this condition. Fifty-three of these children (18.4% of the study population) had a nonmuscular etiology for their torticollis. Of these 53 patients, Klippel-Feil anomalies were present in 16 (30%), and an underlying neurologic disorder was present in 27 (51%). These neurologic conditions included ocular disorders in 12 (23%) patients, brachial plexus palsies in nine (17%) patients, and lesions involving the central nervous system in six (11%) patients. We conclude that nonmuscular causes of torticollis are collectively not rare. In a child without an identifiable muscular etiology for torticollis, Klippel-Feil anomalies or an underlying neurologic disorder is likely to be the cause of the deformity in the majority of patients.