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The purpose of this study was to identify the incidence of venous thromboembolism (VTE) and characterize the demographics, comorbidities, and risk factors for patients with cerebral palsy (CP) having orthopaedic surgery.All patients diagnosed with CP who underwent an orthopaedic surgical procedure at one institution between 2008 and 2017 were identified. Diagnosis codes and associated patient events were recovered from the electronic medical record. Each VTE event was reviewed to ascertain an actual VTE episode related to a surgical event.The review included 2583 orthopaedic surgical events in 1371 patients. Of the initial 88 cases identified, 28 cases had a deep thrombosis documented. Six cases of VTE occurred within 3 months following the surgical event. Three of these cases had thigh thrombosis, and 2 patients had upper arm thrombosis, and 1 patient had a superior vena cava thrombosis. On further workup, 5 of these 6 patients were identified as having a congenital hypercoagulable condition.VTE is a relatively rare occurrence after orthopaedic surgery in pediatric patients with CP, but when it occurs, a full hematologic workup for a congenital hypercoagulable condition is indicated. Based on the low incidence of thigh thrombosis, routine pharmacological or intermittent mechanical calf compression is not recommended. A careful clinical and family history should be performed to identify patients with possible genetic hypercoagulable conditions who would merit prophylaxis.Level IV.

Pediatric injuries in performance sports represent a significant healthcare burden and account for over 50,000 annual Emergency Department (ED) visits in the United States. The objective of this study was to characterize and compare pediatric injury presentation across the most common performance sports.The National Electronic Injury Surveillance System (NEISS) database was retrospectively analyzed for pediatric injuries (3-18 years) related to gymnastics, dance, or cheerleading from 2015-2019. Cases were categorized as children (˂11 years) or adolescent (≥11 years). Injuries were categorized as orthopedic (fractures, dislocations, sprain, strains), non-orthopedic (contusion, internal injury, laceration), concussion, or other/unknown. Case narratives were used to categorize mechanism of injury as contact or non-contact. Appropriate sample NEISS weights estimation was applied for statistical analysis and Confidence Intervals (CI).A total of 393,110 injuries were observed over the five-year study period, with a mean of 78,622 annual injuries. Gymnastics, dance, and cheerleading accounted for 136,422 injuries, 96,416 injuries, and 160,272 injuries, respectively. Most cases were adolescent (71%; 95% CI: 68-74%) and occurred in a sports-related setting (65%, 95% CI: 57-72%). Gymnastics had the highest proportion of injuries among children (50%) as compared to dancers (25%) or cheerleaders (12%) (p 0.01). Non-contact injuries most affected the lower extremity (43-68%) and resulted in an orthopedic diagnosis (63-71%), and contact injuries had a higher proportion of injuries affecting the head, neck, and face (29-51%) and non-orthopedic diagnoses (29-38%). Gymnastics had the most upper extremity non-contact injuries (42%) and dance the most lower extremity non-contact injuries (68%) (p 0.01). Cheerleading had the highest incidence of overall concussions (8%), contact injuries (47%), and concussions due to contact injury (15%).Pediatric gymnasts, cheerleaders, and dancers have important similarities and differences in injury pattern which may lead to the development of sport-specific injury prevention programs for pediatric performance athletes.

Single-center retrospective chart review with minimum 2-year follow up.To determine incidence of pulmonary hypertension in adolescent idiopathic scoliosis patients and to determine the effect of scoliosis surgery on pulmonary hypertension.Spinal deformity in adolescent idiopathic scoliosis can increase right atrial and ventricular pressures secondary to restrictive lung disease. Pulmonary hypertension leading to cor pulmonale is the most feared outcome, however mild pulmonary hypertension in adolescent idiopathic scoliosis (AIS) patients has been reported. No study has previously examined changes in the improvement of right heart function following scoliosis surgery.Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), pulmonary function tests (PFTs), arterial blood gas (ABG), and patient demographics reviewed. Right ventricular systolic pressure (RVSP) estimated using Bernoulli equation (4[TRV]2) and right atrial pressure. RVSP ≥36 mmHg is a surrogate marker for pulmonary hypertension. All echocardiograms were read by board certified Pediatric Cardiologists. Logistic regression used to assess for differences in TRV between groups.Mean preoperative RVSP was significantly elevated in AIS patients (26.9 ± 0.49; P 0.001) compared with controls (17.25 + 0.88). Only 47 (21%) Group 1 patients had elevated preoperative TRV (≥2.8 m/s) versus none in Group 2 (P 0.001). Additionally, logistic regression showed AIS patients have odds ratio of 3.29 for elevated TRV (P = 0.007)-an indirect measure of pulmonary hypertension. In all Group 3 patients, the cardiac function normalized postoperatively (mean TRV = 2.09 + 0.23; P 0.001). No association found between Cobb angle, aortic root parameters, or pulmonary function tests.This study found 13.9% of patients with adolescent idiopathic scoliosis had elevated TRV while controls had no TRV abnormalities. Additionally, RVSP measurements demonstrated mild pulmonary hypertension in AIS patients. These abnormal values normalized postoperatively, indicating the benefits of scoliosis surgery on cardiac function in adolescent idiopathic scoliosis.Level of Evidence: 3.

Background: Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. Hypothesis: Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. Study Design: Case series. Level of Evidence: Level 4. Methods: Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. Results: A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. Conclusion: Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. Clinical Relevance: Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Casts are commonly used for fracture management and postoperative immobilization in pediatric patients. However, cast immobilization is not without complications (eg, thermal injuries, pressure sores, infection, and neurovascular injury) and may be associated with additional costs and increased loss of school/work days for cast removal or other complications. The disadvantages of traditional casting can be minimized by alternative management strategies: waterproof casts to facilitate bathing and swimming; a Pavlik harness in infants, a single-leg spica cast, or flexible intramedullary nails to avoid complications with double-leg spica casts for femur fractures; and braces or splints to manage buckle and minimally displaced distal radius fractures, toddler's fractures, and stable foot/ankle fractures.

Background: Meniscus repair has demonstrated favorable outcomes when performed with ACL reconstruction (ACLR). However, literature comparing meniscal tear patterns, treatments, and outcomes among pediatric patients remains limited. Purpose: The aim of this study is to evaluate the impact of surgical technique on patient outcomes, in primary pediatric ACLR with associated meniscal pathology. We secondarily examined patient factors and tear characteristics on these outcomes. Methods: This is a retrospective cohort study from 2014-2016 of pediatric ACL reconstruction patients who underwent concurrent surgical management of a meniscus tear. Predictors included patient demographics, injury mechanism, meniscal tear characteristics and surgical treatments. Clinical outcomes including return to sport (RTS), meniscus or ACL graft re-tear, and return to surgery were assessed via patient cross-sectional survey. Criteria for RTS were based on standardized postoperative rehabilitation protocols. Univariate and multivariate analyses were used to examine the relationship between studied predictors with the likelihood of RTS and other outcomes. Results: Inclusion criteria were met by 123 patients with an average follow-up time of 2.5 ± 0.7 years. RTS was achieved by 80.8% of patients while 17.1% of patients had a subsequent knee surgery within the studied timeframe. Univariate analysis of factors associated with successful RTS are shown in Table 1. While patients failing to RTS were shown to have delayed surgical intervention in univariate testing, multivariate analysis identified that patients who underwent meniscectomy were less likely to RTS than those who underwent meniscal repair (OR=2.690, 95% CI 1.044-6.930, p=0.040). Patients with an initial contact mechanism of injury were also demonstrated to be more likely to return to the OR for any reason (OR=13.443, CI 1.736-104.108, p=0.013) in multivariate modeling. Conclusion: In one of the few large cohorts of pediatric ACL reconstructions with concomitant meniscus surgery, this study adds to our understanding of a potentially modifiable factor (meniscus repair) in the surgical treatment of ACL injury with concaminant meniscus tear. Although no differences were seen in rates of meniscus or graft re-tear when comparing treatments, patients who underwent meniscal repair were more likely to return to sport than patients treated with meniscectomy. While these findings may reflect the quality of the torn meniscal tissue and severity of injury, it further emphasizes the importance of meniscal preservation not just for long term joint quality, but also for short term function in active pediatric patients. [Table: see text]

Background:Differences in postoperative recovery after anterior cruciate ligament reconstruction (ACLR) between men and women have been demonstrated in the adult population. Sex-based differences have been incompletely investigated in adolescents, which represent the subpopulation most affected by ACL injury.Purpose/Hypothesis:The purpose of this study was to compare the 6-month postoperative functional recovery after ACLR between adolescent boys and girls. It was hypothesized that significant differences in postoperative strength, dynamic balance, and functional hop test performance would be seen between the sexes.Study Design:Cohort study; Level of evidence, 3.Methods:Included in this study were athletes aged 12 to 19 years with closed or closing growth plates who underwent ACLR with hamstring autograft between May 2014 and May 2018 at a single institution. All athletes had undergone strength and functional testing between 5 and 8 months postoperatively. Exclusion criteria were previous knee surgery (contralateral or ipsilateral knee), concomitant injury/surgery other than meniscal tear/repair, allograft supplementation, and incomplete medical records. The limb symmetry index (LSI) for strength (measured with handheld dynamometer), as well as dynamic Y-balance and functional hop test performance, was compared between groups. To account for differences in physical characteristics between the sexes, 1-way between-group multivariate analysis of covariance was used to analyze the data.Results:Overall, 543 patients (211 boys, 332 girls) were included. There was no significant difference in age, body mass index, incidence of concomitant meniscal pathology, use of regional anesthesia, or time to functional testing between cohorts. Female athletes demonstrated a statistically significantly greater deficit in quadriceps strength LSI compared with male athletes (boys, +3.4%; girls, –2.3%; P = .011). Both male and female athletes demonstrated 33% hamstring strength deficits, with no statistically significant sex-based differences in dynamic balance or functional hop testing.Conclusion:Female athletes demonstrated greater quadriceps strength deficits than male athletes at 6 months after ACLR with hamstring autograft. Severe hamstring strength deficits persisted in both male and female patients at this time point. The correlation of such deficits to risk of ACL retear warrants continued study in the adolescent population and may support a delay in return to sports, which has been suggested in the more recent literature.

Diaphyseal long bone cortical tissue from 30 patients with lethal perinatal Sillence II and progressively deforming Sillence III osteogenesis imperfecta (OI) has been studied at multiple levels of structural resolution. Interpretation in the context of woven to lamellar bone formation by mesenchymal osteoblasts (MOBLs) and surface osteoblasts (SOBLs) respectively demonstrates lamellar on woven bone synthesis as an obligate self-assembly mechanism and bone synthesis following the normal developmental pattern but showing variable delay in maturation caused by structurally abnormal or insufficient amounts of collagen matrix. The more severe the variant of OI is, the greater the persistence of woven bone and the more immature the structural pattern; the pattern shifts to a structurally stronger lamellar arrangement once a threshold accumulation for an adequate scaffold of woven bone has been reached. Woven bone alone characterizes lethal perinatal variants; variable amounts of woven and lamellar bone occur in progressively deforming variants; and lamellar bone increasingly forms rudimentary and then partially compacted osteons not reaching full compaction. At differing levels of microscopic resolution: lamellar bone is characterized by short, obliquely oriented lamellae with a mosaic appearance in progressively deforming forms; polarization defines tissue conformations and localizes initiation of lamellar formation; ultrastructure of bone forming cells shows markedly dilated rough endoplasmic reticulum (RER) and prominent Golgi bodies with disorganized cisternae and swollen dispersed tubules and vesicles, structural indications of storage disorder/stress responses and mitochondrial swelling in cells with massively dilated RER indicating apoptosis; ultrastructural matrix assessments in woven bone show randomly oriented individual fibrils but also short pericellular bundles of parallel oriented fibrils positioned obliquely and oriented randomly to one another and in lamellar bone show unidirectional fibrils that deviate at slight angles to adjacent bundles and obliquely oriented fibril groups consistent with twisted plywood fibril organization. Histomorphometric indices, designed specifically to document woven and lamellar conformations in normal and OI bone, establish ratios for: i) cell area/total area X 100 indicating the percentage of an area occupied by cells (cellularity index) and ii) total area/number of cells (pericellular matrix domains). Woven bone is more cellular than lamellar bone and OI bone is more cellular than normal bone, but these findings occur in a highly specific fashion with values (high to low) encompassing OI woven, normal woven, OI lamellar and normal lamellar conformations. Conversely, for the total area/number of cells ratio, pericellular matrix accumulations in OI woven are smallest and normal lamellar largest. Since genotype-phenotype correlation is not definitive, interposing histologic/structural analysis allowing for a genotype-histopathologic-phenotype correlation will greatly enhance understanding and clinical management of OI., Highlights • Mosaic appearance of lamellar bone composed of short lamellae at oblique angles • Histomorphometry establishes new cellularity indices for woven and lamellar bone. • Golgi bodies by TEM show irregular dispersed cisternae and swollen tubulo-vesicles. • Changes in matrix conformation along woven to lamellar continuum reflect OI severity.

Background: Reports detailing the rates of radiographic healing after treatment of talar osteochondritis dissecans (TOCD) remain scarce. There is also a paucity of data characterizing treatment outcomes and the risk factors associated with poor outcomes in children with TOCD. Purpose: To identify factors associated with healing, assess treatment outcomes, and develop a clinically useful nomogram for predicting healing of TOCD in children. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of all patients ≤18 years of age with TOCD from a single pediatric institution over a 12-year period. Surgical treatment was left to the discretion of the treating surgeon based on standard treatment techniques. Medical records and radiographs were reviewed for patient and clinical data, lesion characteristics, and skeletal maturity. Radiographic healing was evaluated at the 1-year follow-up, and patients with complete versus incomplete healing were compared using multivariable logistic regression models to examine the predictive value of the variables. Results: The authors analyzed 92 lesions in 74 patients (mean age, 13.1 ± 2.7 years [range, 7.1-18.0 years]; 61% female). Of these, 58 (63%) lesions were treated surgically (drilling, debridement, microfracture, bone grafting, or loose body removal), and the rest were treated nonoperatively. Complete radiographic healing was seen in 43 (47%) lesions. In bivariate analysis, patients with complete healing were younger ( P = .006), were skeletally immature ( P = .013), and had a lower body mass index (BMI; P < .001) versus those with incomplete healing. In a multivariate regression model, the factors that correlated significantly with the rate of complete healing were age at diagnosis, BMI, and initial surgical treatment. The lesion dimensions were not significantly associated with the likelihood of healing. A nomogram was developed using the independent variables that correlated significantly with the likelihood of complete radiographic healing. Conclusion: Complete radiographic healing of TOCD lesions was more likely in younger patients with a lower BMI. The effect of initial surgical treatment on potential healing rate was greater in older patients with a higher BMI.

MINI: The objective of this study was to evaluate the accuracy and reliability of pedicle screw placement using O-Arm at dosages below the manufactured recommended dose. O-Arm at reduced dose showed a 90% accuracy when compared with computed tomography; however, about 30% medial breaches were misclassified.Cadaveric study.The objective was to evaluate O-Arm's ability at low-dose (LD) settings to assess intraoperative screw placement.Accurate placement of pedicle screws is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intraoperative imaging of patient's anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structures. We hypothesize using LD or ultra-low doses (ULDs) to obtain intraoperative images allow for accurate assessment of screw placement, both minimizing radiation exposure and preventing screw misplacement.Eight cadavers were instrumented with pedicle screws bilaterally from T1 to S1. Screws were randomly placed using O-arm navigation into three positions: contained within the bone, OUT-anterior/lateral, and OUT-medial. O-arm images were obtained at three dosage settings: LD (kVp120/mAs125-lowest manufacturer recommended), very-low dose (VLD) (kVp120/mAs63), and ULD (kVp120/mAs39). Computed tomography (CT) scan was performed using institution's LD protocol (kVp100/mAs50) and gross dissection to identify screw positions.LD, VLD, ULD, and CT for identifying "IN" screws relative to gross dissection had, a mean (standard deviation) sensitivity of 84.2% (±5.7), specificity of 76.1% (±9.3), and accuracy of 79.9% (±3.1) from all three observers. Across the three observers, the interobserver agreement was 0.67 (0.61-0.72) for LD, 0.74 (0.69-0.79) for VLD, 0.61 (0.56-0.66) for ULD, and 0.79 (0.74-0.84) for CT. Effective doses of radiation (mSV) for LD O-arm scan was 2.16, VLD 1.08, ULD 0.68, and our LD CT protocol was 1.05.Accuracy of pedicle screw placement is similar for O-arm at all doses and CT compared to gross dissection. Interobserver reliability was substantial for VLD and CT. Approximately 30% of medial screw breaches are, however, misclassified. ULD and VLDs can be used for intraoperative navigation and evaluation purposes within these limitations.N/A.

BACKGROUND CONTEXT Non-ambulatory NMS patients are typically fused to the pelvis to augment fixation, prevent loss of correction and improve seating balance. However, pelvic fixation extends the length of surgery, increases EBL and may increase pain. PURPOSE This study aims to evaluate the radiographic outcomes after PSF with all pedicle screws in NMS fixated (FP) and not fixated at the pelvis (NFP). STUDY DESIGN/SETTING Retrospective and Prospective Review. PATIENT SAMPLE Ambulatory and non-ambulatory neuromuscular patients undergoing spinal deformity correction at one institution. OUTCOME MEASURES Preoperative and postoperative radiographic parameters and intraoperative clinical measures (estimated blood loss, operative time). METHODS Radiographic measurements, OR parameters and demographics were recorded for neuromuscular surgeries between 2006-2016. Patients were divided into NFP and FP. Median values and Wilcoxon rank sum tests were used. Subanalysis was performed for patients with preoperative PO 20°. RESULTS There were 91 patients; 63 were non-ambulatory. Between NFP (n=54) and FP (n=37), preop Cobb (p=0.215), PO (p=0.158), and decompensation (p=0.247) were similar. Both had similar final Cobb (p=0.146) and PO (p=0.162), but NFP had significant coronal imbalance (35.8 vs 14.6, p 20, patients had similar preop PO (p=0.545) and decompensation (p=0.075). NFP had higher final PO (p=0.123) and significantly higher decompensation (135.4 vs 25.2, p=0.008). The change in PO (p=0.298) and decompensation (p=0.616) from postop to final was similar. CONCLUSIONS NFP with preop PO>20 had significant coronal imbalance and PO at final follow-up. Change in PO and coronal balance over time was similar between the two groups in less severe PO. PF achieves better coronal and PO correction. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Purpose Displaced supracondylar humerus fractures are treated with open or closed reduction and percutaneous pinning. In 2012, our management of patients with a displaced fracture changed from closed reduction in the emergency department (ED) to in situ splinting prior to closed reduction and pinning in the operating room (OR). The purpose of this study was to investigate if outcomes or complications differ between these two management methods. Methods Patients less than ten years old with a Gartland type II or III supracondylar humerus fracture between 2008 and 2016 were included. Cases of polytrauma were excluded. Radiographic outcomes were assessed at follow-up. The Fisher's exact test was used for categorical variables and the Wilcoxon rank sums tests for continuous variables. Results In all, 157 patients were included, 89 with reduction in the ED and 68 without. There was no significant difference between the groups related to demographic factors or fracture characteristics. Patients managed without reduction in the ED had a lower average delay from ED to OR compared with those treated with reduction (16 hours versus 22 hours, p < 0.005) and a shorter hospital length of stay (34 hours versus 40 hours, p < 0.005). Conclusion No difference in complications or outcomes was found between patients with Type II or III supracondylar fractures treated initially with or without closed reduction in the ED. Patients treated without ED reduction were taken to the OR sooner and remained in the hospital for a shorter period of time. Splinting in situ reduces anaesthesia exposure without increasing postoperative complications or suboptimal outcomes. Level of Evidence Level III, retrospective comparative study

Immunochromatographic assays are used by crime laboratories to conduct simple and quick analyses of bodily fluids. These streamlined tests are ideal for decreasing the sexual assault kit backlog in the United States. A large-scale analysis of the frequency of positive results of amylase and prostate specific antigen (PSA) endogenously found in the vaginal cavity was conducted using the SERATEC PSA Semiquant and Amylase tests. Vaginal swabs were self-collected by participants after 7-10 days of no oral contact or male ejaculation. In this study of 50 participants, 98% were negative for PSA and 92% were negative for amylase. Positive results were confirmed to contain no exogenous DNA by male-specific quantitation, short tandem repeat (STR) typing, and Y-STR typing. These results can be used by crime laboratories to help guide interpretation of immunochromatographic test results from vaginal swabs and aid in decision-making in downstream DNA testing.

Background: Pain control following ACL Reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Significant efforts have been made to reduce unnecessary opioid prescribing in this vulnerable population, but few have sought to define current practices. Purpose: The purpose of this study is to describe trends in postoperative pain management and assess factors that may mitigate overutilization of opioid medications. Methods: This is a retrospective review of a series of pediatric patients (Results: This study included 687 patients with a mean age of 15.1±1.9 years. The majority underwent ACL reconstruction using hamstring autograft (92.0%) at our main hospital (54.9%). Postoperatively, discharge medication prescribing was performed most frequently (38.1%) by advanced practitioners (NP/PA). While there was no change in the proportion of patients prescribed opioids (>95% of patients) over the 5 year period, the mean number of doses dispensed decreased annually (Fig. 1). This was accompanied by an increase in the annual percentage of patients prescribed oral NSAIDs and acetaminophen during that period. Preoperative opioid consent was obtained in 31.9% of the cohort and these patients received significantly fewer doses of prescribed opioids (25.0 vs. 34.6 doses, pConclusion: Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications. Continued efforts should be made to identify measures to limit overreliance on these medications and to mitigate issues related to misuse, overdose and addiction. [Figure: see text] Annual proportion of patients prescribed ibuprofen, acetaminophen and opioid medication postoperatively and the annual mean number of opioid doses prescribed. [Table: see text] Univariate and multivariate negative binomial regression analysis of factors associated with prescription of a greater number of postoperative doses of opioid medication. CI = Confidence Interval.

Background: The subject of sex-based differences in postoperative recovery after anterior cruciate ligament reconstruction (ACLR) between males and females has been incompletely investigated, with no published comparative analyses specifically in adolescent sub-populations, which represent those most affected by ACL injury. Purpose/Hypothesis: To compare the 6-month postoperative functional recovery following ACLR between adolescent males and females. We hypothesized that significant differences in postoperative strength, dynamic balance, and functional hop test performance would be seen between the sexes. Methods: All adolescent athletes with closed or closing growth plates who underwent ACLR at a single institution between May 2014 and May 2018 and who underwent functional return-to-sport (RTS) testing between 5-8 months post-operatively were considered for inclusion in this IRB-approved study. To control for potential graft-based rehabilitation differences or donor site morbidity as confounders, only primary ACLRs performed with hamstring autograft were included. Exclusions were previous knee surgery (contralateral or ipsilateral knee), concomitant injury other than meniscus tear, allograft supplementation, and incomplete medical records. Limb Symmetry Indexes (LSI) for strength (quadriceps, hamstrings, hip abductors, hip extensors), dynamic Y-balance (anterior, posterolateral and posteromedial distance), and functional hopping (single hop, triple hop, and cross-over hop for distance, and 6-meter timed hop) were compared between groups. To account for differences in physical characteristics between the sexes, one-way between group multivariate analysis of covariance (MANCOVA) was used, with p = 0.05. Results: Amongst 543 subjects (211 male, 332 female), there was no significant difference in age, BMI, incidence of concomitant meniscal pathology, use of regional anesthesia blocks, or time to functional testing between cohorts. However, height and weight differences were incorporated in the MANCOVA model. Females demonstrated a statistically significant greater deficit in quadriceps strength LSI compared to males (Table 1). Both males and females demonstrated 33% hamstring strength deficits, with no statistically significant sex-based differences in dynamic balance or functional hop testing, though single leg hop deficits were less severe in males, which trended towards significance (-4% vs. -8%, p=0.062). Conclusion: Females demonstrated greater quadriceps strength deficits than males at 6 months post-ACLR with hamstring autograft, which may translate into greater functional hop testing deficits. Severe hamstring strength deficits persist in both males and females at this time point, underscoring the potential importance of mitigating risk of ACL re-tear by delaying return to play until a later time point with more normalized, symmetric, performance-based metrics. Table 1. Strength, balance, and functional hop testing deficits in quadriceps, hamstrings, hip abductors, and hip extensors Groups Males(N = 211) Females(N = 332) P-values Quadriceps Strength: Uninvolved limb 4.57±1.2 (4.40, 4.73) 4.27±1.0 (4.16, 4.39) ACLR limb 4.61±1.2 (4.44, 4.78) 4.11±1.1 (4.00, 4.23) Deficits (LSI%) +3.4 (+0.5, +6.3) -2.3 (-5.0, +0.4) 0.011 Hamstrings Strength: Uninvolved limb 2.31±0.7 (2.21, 2.41) 2.17±0.6 (2.10, 2.24) ACLR limb 1.48±0.6 (1.40, 1.57) 1.40±0.6 (1.33, 1.46) Deficits (LSI%) -33.0 (-38.0,-28.0) -33.2 (-37.9, -28.6) 0.943 Hip abductor Strength: Uninvolved limb 1.90±0.6 (1.81, 2.00) 1.85±0.7 (1.76, 1.93) ACLR limb 1.94±0.6 (1.86, 2.03) 1.92±0.8 (1.83, 2.01) Deficits (LSI%) +3.8 (-0.8, +8.4) +6.2 (+1.9, +10.5) 0.490 Hip extensor Strength: Uninvolved limb 3.36±1.2 (3.19, 3.53) 3.25±1.0 (3.14, 3.36) ACLR limb 3.41±1.3 (3.23, 3.59) 3.27±1.1 (3.15, 3.38) Deficits (LSI%) +4.2 (-1.5, +9.9) +2.2 (-3.1, +7.5) 0.637 Anterior Reach: Uninvolved limb 61.9±7.8 (60.8, 63.0) 59.5±6.5 (58.8, 60.2) ACLR limb 60.3±7.5 (59.3, 61.3) 57.9±6.3 (57.2, 58.6) Deficits -0.7 (-3.1, +1.6) -0.9 (-3.1, +1.2) 0.905 Posteromedial Reach: Uninvolved limb 101.6±11.2 (100.1, 103.1) 94.2±8.8 (93.2, 95.2) ACLR limb 101.2±11.5 (99.6, 102.7) 92.9±10.6 (91.8, 94.1) Deficits +0.5 (-0.1, +0.2) +0.1 (-1.3, +1.5) 0.718 Posterolateral Reach: Uninvolved limb 96.5±11.3 (95.0, 98.0) 91.1±8.7 (90.1, 92.0) ACLR limb 96.3±11.4 (94.7, 97.8) 90.3±9.4 (89.3, 91.3) Deficits +0.8 (-1.1, +2.7) -0.5 (-2.3, +1.2) 0.334 Composite Score: Uninvolved limb 95.5±8.7 (94.2, 96.9) 96.6±7.3 (95.6, 97.5) ACLR limb 94.8±8.8 (93.4, 96.1) 95.6±8.0 (94.5, 96.6) Deficits +0.3 (-0.9, +1.4) -0.6 (-1.7, +0.5) 0.319 Single Hop: Uninvolved limb 1.29±0.27 (1.25, 1.34) 1.07±0.21 (1.04, 1.10) ACLR limb 1.22±0.28 (1.18, 1.27) 0.97±0.23 (0.94, 1.00) Deficits -4.0 (-6.9, -1.0) -8.1 (-10.9, -6.9) 0.062 Triple Hops: Uninvolved limb 4.40±0.77 (4.27, 4.53) 3.55±0.58 (3.47, 3.63) ACLR limb 3.13±1.21 (2.92, 3.33) 2.84±0.68 (2.75, 2.94) Deficits -27.0 (-32.9, -21.1) -20.0 (-25.5, -14.5) 0.117 Cross-over Hops: Uninvolved limb 3.82±0.84 (3.68, 3.97) 3.04±0.60 (2.95, 3.13) ACLR limb 3.62±0.80 (3.48, 3.76) 2.85±0.61 (2.75, 2.94) Deficits -4.5 (-7.0, -2.0) -5.8 (-8.1, -3.5) 0.501 6 meter Timed Hop: Uninvolved limb 2.12±0.47 (2.04, 2.20) 2.45±0.44 (2.39, 2.51) ACLR limb 2.21±0.49 (2.12, 2.29) 2.57±0.50 (2.50, 2.64) Deficits -1.7 (-3.9, +0.4) -3.6 (-5.7, -1.6) 0.244 Values are mean ± standard deviation with 95% confidence interval. * p < 0.05. Strength was measured in newton/kg. LSI = Limb Symmetry Index Dynamic balance reach was measured in centimeters. Single, triple, and crossover hop distance was measured in meters. 6 meter timed hop was measured in seconds.

Background: Quadriceps tendon autograft represents an increasingly popular graft option for ACL reconstruction (ACLR). However, there is a paucity of literature regarding the early post-operative effects of this graft technique on functional recovery, particularly in adolescents. Purpose/Hypothesis: To quantify post-operative strength, dynamic balance, and functional hop test performance in adolescents 6 months following ACLR with a quadriceps tendon autograft (ACLR-Q) and compare to an adolescent control group who underwent ACLR with hamstring autograft (ACLR-HS). Methods: Patients 12-19 years-old who underwent primary ACLR-Q from 2017-2019 by a single surgeon at a pediatric tertiary care hospital and performed return to sports (RTS) assessments between 5-9 months post-operatively were included. Exclusion criteria were prior ipsilateral or contralateral ACLR and concomitant procedures other than meniscal repair or meniscectomy. RTS tests included manual muscle testing of strength (hamstring, quadriceps, hip abductor), dynamic-Y-balance, and functional hop tests (single-hop, triple-hop, crossover, 6-meter timed hop). Limb Symmetry Index (LSI) was calculated for all measures and each was compared with an ACLR-HS control group using T-tests. One-way between-group multivariate analysis of covariance (MANCOVA) was utilized to control for any baseline differences. Results: There were no significant differences in age, BMI, sex, or rates of meniscal procedures between cohorts (Table 1). The small difference in time of RTS testing was controlled by MANCOVA model. ACLR-Q patients demonstrated a significantly smaller hamstring strength deficit (-3.6%) than the ACLR-HS group (-35.8%, p

Purpose The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. Methods A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the products was created. Results Trampoline-related fractures rose 14% yearly from 1991 to 1999, reached a plateau from 1999 to 2003, corresponding with a 1999 AAP statement. Injury rates dropped 4.3% from 2006 to 2010 after 2005 and 2006 statements, and reached another plateau thereafter, as 2010 and 2012 statements were published. ATV-related fractures rose 14% yearly between 1997 and 2002, then dropped 15% from 2007 to 2010 following yearly AAP or AAOS statements from 2004 to 2007. From 2010 to 2014, the injury rate held constant during which time 2010, 2013, and 2014 statements were published. Lawnmower injury rates did not fall despite statements in 1998 and 2001 and a poster campaign in 2001. A 25% drop from 2007 to 2008 coincided with an AAOS statement in 2008. Fracture rates further dropped 31% from 2009 to 2011 and 21% from 2012 to 2014, amidst 2012 and 2014 statements. For ATV-related and lawnmower-related injuries, more male individuals were affected than female individuals, and for ATVs alone, injury rates increased with age. Conclusions Although AAOS/AAP statements did not universally coincide with dropping fracture rates, statements often were associated with substantial decreases in following years. This is likely because injury prevention messages are dispersed from providers to the public over time and outcomes depend on highly variable patient behaviors. Level of evidence Level V-systematic review of descriptive data.

Purpose: Supracondylar humerus fractures are among the most common surgically treated pediatric fractures. Displaced supracondylar fractures are generally treated with open or closed reduction and percutaneous pinning. Multiple attempts at reduction may increase the risk of neuropraxia, elbow stiffness, myositis ossificans, and anesthetic complication. Previously, patients presenting to our institution with a displaced fracture underwent a closed reduction in the emergency department (ED) prior to repeat closed reduction and pinning in the operating room (OR). Currently, patients …

Purpose: There is a paucity of data describing the long-term function and quality of life of the approximately 10,000 children who sustain firearm injuries to the extremity annually. Many complications, such as physeal arrest and limb-length discrepancy, take months or years to manifest. The purpose of this study is to characterize clinical features and long-term outcomes of pediatric firearm extremity injuries. Methods: A retrospective review of the trauma registry at an urban Level 1 trauma center was performed, identifying 32 …

BACKGROUND CONTEXT Spinal deformity in asolescent idiopathic scoliosis (AIS) can increase right atrial and ventricular pressures secondary to restrictive lung disease. Pulmonary hypertension leading to cor pulmonale is the most feared outcome. However, mild pulmonary hypertension in AIS patients has been reported in the past. No study has examined these changes including the improvement of right heart function following scoliosis surgery. PURPOSE To determine if scoliosis repair resolves cardiac function abnormalities. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 363 patients: 184 AIS patients undergoing PSF, 179 healthty age-matched controls. OUTCOME MEASURES Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), PFTs, ABG, and patient demographics reviewed. Right ventricular systolic pressure (RVSP) was estimated using Bernoulli's equation (4[TRV]2) and right atrial pressure. METHODS Retrospective chart review. Group 1: 184 AIS patients, 10-22 years of age, undergoing PSF from 2009-2013 at a single institution. Group 2 control patients: 179 healthy, age-matched adolescents. Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), PFTs, ABG, and patient demographics reviewed. Right ventricular systolic pressure (RVSP) was estimated using Bernoulli's equation (4[TRV]2) and right atrial pressure. RVSP ≥25 mmHg is a surrogate marker for pulmonary hypertension. All echocardiograms were read by board certified pediatric cardiologists. Group 3: 39 AIS patients from Group 1 with elevated preoperative TRV underwent corrective PSF. Logistic regression was used to assess for differences in TRV between groups. RESULTS Mean preop RVSP was significantly elevated in AIS patients (25.7 vs 17.3; p CONCLUSIONS This study found that 21% of patients with AIS had elevated TRV while age-matched controls had no TRV abnormalities. Additionally, RVSP measurements demonstrated mild pulmonary hypertension in AIS patients. These abnormal values normalized postop, indicating the benefits of scoliosis surgery on cardiac function in AIS. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Forty years ago, Michael J. Hindelang delineated some ways in which public opinion surveys have explored issues related to crime and criminal justice, and pointed out how trends over time could be of interest, and differences in responses among demographic subgroups could be revealing. In this article, we update some of the trends Hindelang alluded to, and revisit some of the response differences he enumerated. In particular, we add support to Hindelang’s hypothesis that the opinions of non-White respondents can reflect consistent awareness of bias in the operation of the system (such as in the application of the death penalty and with respect to interceptions of citizens by police). Age differences in opinions concerning deviant behavior also show attitudinal consistency, particularly in the permissive stance of the youngest age group and the relatively extreme conservatism of “50+” respondents. Finally, with respect to the prospect of victimization, there is a consistent and substantial disparity in the perspectives of men and women. Demographic differences of this kind retain their salience where overall public opinion evolves (as it does with respect to the legalization of marijuana) and where there is negligible change over time (as there is with regard to the death penalty). However, new differences can emerge along the way, as they have in recent polarization along political and ideological lines.

Shoulder dislocation is relatively uncommon in the younger pediatric population. Because of the relative strength of the surrounding soft tissue structures of the shoulder compared with the proximal humeral physis, subluxation or dislocation resulting from a traumatic event or application of force is rare and instead a proximal humeral physeal injury occurs. Case presentation - We present a 5-year-old male who presented to the office with post-traumatic left shoulder pain for about 1 week. Radiographs of the left shoulder indicated inferior subluxation of the humeral head. He was ultimately diagnosed and treated for a septic shoulder. Septic arthritis of the glenohumeral joint accounts for about 3% of all septic arthritis cases. About half of the pediatric patients with a septic arthritis will present with a concomitant osteomyelitis about the joint involved. Widening of the glenohumeral joint and subluxation clinically as well as radiographically have been described in cases of large joint effusions because of an increase in intra-articular fluid in adults. This inferior subluxation is often noted without a frank dislocation. The case described in this report is unique in that this is the first to describe a pediatric septic shoulder presenting as a shoulder subluxation. Given the rarity of pediatric shoulder dislocations and subluxations, the pediatric orthopaedist and pediatrician should maintain a suspicion for a septic joint. Level of evidence Level V.

BACKGROUND CONTEXT Minimizing the fusion levels in PSF for AIS is important. Previous studies have shown good results utilizing touched vertebra (TV) as the lowest instrumented vertebra (LIV). TV is the vertebra ‘touched; by central sacral vertical line on standing AP XRs (TVS). In our experience, we find that TV moves proximally on supine or prone XRs. Thus utilizing TV on prone XRs (TVP) in LIV decision making may allow even shorter fusion. PURPOSE To determine if using TVP to determine LIV saves fusion levels with good correction and coronal balance. STUDY DESIGN/SETTING Ambispective cohort study. PATIENT SAMPLE A total of 260: 132 nonoperative scoliosis patients, 128 who underwent pedicle screw fixation. OUTCOME MEASURES Cobb, coronal balance, disc wedging, LIV tilt, levels saved, decompensation. METHODS There were three groups. Group I: patients where TVP was used to determine LIV. Group II: patients where TVS was used to determine LIV. Group III: nonoperative AIS (Risser 4/5, Cobb RESULTS The control group had 100 patients with a median Cobb angle of 20°, age of 15.3years, coronal balance 1.2 cm (0.5–1.8), disc wedging of 4° (3–6), and LIV tilt of 9° (6–11.5). In group I (n=83), median pre-op Cobb was 53.75° (47.55°–61.9°), kyphosis was 32.2° (25.3°–38.9°), and coronal balance was 1.6 cm (1.0–3.0 cm). Post op median Cobb was 12.9° (7.0°–19.7°), kyphosis was 37° (24.6°–39.7°) and coronal balance was 1.4 cm (0.3–2.45 cm). Compared to controls, group I patients had similar coronal balance (0.9vs. 1.2, p=.18), but significantly lower disc wedging (1.2° vs. 4, p>.001), and LIV tilt (4.3° vs. 9 p CONCLUSIONS In AIS, using TVP to determine LIV allows shorter fusion saving than TVS. Despite shorter fusion, coronal balance and correction is maintained, at final follow up with no adding on. LIV tilt and disc wedging is also within ‘acceptable’ levels determined on controls.

Purpose: Accurate placement of pedicle screw is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intra-operative imaging of patient’s anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structure. We hypothesize using low or ultra-low doses to obtain …

MINI: The objective of this study was to determine the safety limits of anterior/anterolateral pedicle screw breaches. Through clinical and cadaveric study, it appears that less than 4 mm of breach has a significantly lower likelihood of impingement on vital structures (P

By 1990 prison populations in the United States had risen 135 percent since 1980, and most states were facing record budget deficits and cuts. After well over a dozen years of renewed interest in prison industry programs and slow but steady growth in inmate employment, most prisons still suffered from vast unemployment of inmates. This article proposes a policy of prisoner full employment, presents a number of models, and discusses the implications of dramatically increasing prisoner employment. It asserts that prisons can be made more productive without significant threats to the civilian labor force and that these centers of productivity can yield economic, institutional, and individual benefits.

Methamphetamine (MA) is a highly addictive psychostimulant that, used in excess, may be neurotoxic. Although the mechanisms that underlie its addictive potential are not completely understood, in animal models matrix metalloproteinase (MMP) inhibitors can reduce behavioral correlates of addiction. In addition, evidence from genome-wide association studies suggests that polymorphisms in synaptic cell-adhesion molecules (CAMs), known MMP substrates, are linked to addictive potential in humans. In the present study, we examined the ability of MA to stimulate cleavage of intercellular adhesion molecule-5 (ICAM-5), a synaptic CAM expressed on dendritic spines in the telencephalon. Previous studies have shown that shedding of ICAM-5 is associated with maturation of dendritic spines, and that MMP-dependent shedding occurs with long term potentiation. Herein, we show that MA stimulates ectodomain cleavage of ICAM-5 in vitro, and that this is abrogated by a broad spectrum MMP inhibitor. We also show that an acute dose of MA, administered in vivo, is associated with cleavage of ICAM-5 in murine hippocampus and striatum. This occurs within 6 h and is accompanied by an increase in MMP-9 protein. In related experiments, we examined the potential consequences of ICAM-5 shedding. We demonstrate that the ICAM-5 ectodomain can interact with β(1) integrins, and that it can stimulate β(1) integrin-dependent phosphorylation of cofilin, an event that has previously been linked to MMP-dependent spine maturation. Together these data support an emerging appreciation of MMPs as effectors of synaptic plasticity and suggest a mechanism by which MA may influence the same.

Adenovirus E1A has long been known to activate/repress cellular and viral transcription. The transcriptional activity of nuclear extracts was depleted after chromatography on immobilized E1A protein columns that specifically retained the transcription factor (TF) IID. Stronger direct interactions between E1A and human TFIID than between E1A and yeast TFIID suggest that the unique sequences of the human protein may be involved. We have demonstrated that this interaction occurs directly between bacterially produced E1A and bacterially produced human TFIID in a protein blot assay. We propose that E1A protein may transduce regulatory signals from upstream activators to basal elements of the transcriptional machinery by contacting TFIID.

• The vitreoretinal relationships of 312 eyes with diabetic retinopathy were analyzed statistically, based on the results of biomicroscopic observation and photography of the vitreous. Vitreous detachment usually occurs outside the temporal vascular arcades, and the macula subsequently becomes involved in the midstage of the proliferative process. The incidence of no vitreous detachment and complete vitreous detachment are significantly lower in proliferative retinopathy as compared with nonproliferative retinopathy. The incidence of partial vitreous detachment is significantly higher in proliferative than in nonproliferative retinopathy. The relatively high incidence of proliferation with no vitreous detachment indicates that vitreous detachment is not the sole triggering factor in the development of proliferative changes. However, partial vitreous detachment was shown, retrospectively, to stimulate a rapid exacerbation of the proliferative process as compared with eyes having no vitreous detachment or complete vitreous detachment.