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

Background: A discoid lateral meniscus (DLM) is a congenital anomaly of the knee in which the lateral meniscus has an “O” shape and contains irregular, abnormal collagenous tissue. A DLM can cause mechanical symptoms and pain. Treatment of a symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached at the capsule. Reports in the literature recommend a residual width of 6 to 8 mm. Purpose/Hypothesis: The purpose of this research was to determine the width of the lateral meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6 to 8 mm will be sufficient to approximate normal anatomy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We made direct measurements of the radial width of the lateral meniscus from the outer rim at the popliteal hiatus to the inner edge in 19 specimens (age, 2-120 months.) We measured one 4-year-old specimen with a bilateral complete DLM. We also measured 39 digital images of specimens (age, 1-132 months) using ImageJ. Finally, we made direct arthroscopic measurements of 8 skeletally mature specimens. Results: The average width of specimens Conclusion: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6 to 8 mm is insufficient for children ≥8 years old. A width of at least a full centimeter approximates the normal for 8-year-olds and at least 15 mm for adolescents.

Background: Pediatric athletes commonly sustain inversion-type ankle fractures.1,2 Approximately 1% will form post-traumatic subfibular ossicles (SO), especially after tip avulsion fractures.3,4 Athletes with SOs can have pain and recurrent sprains.5,6,7 Here we show the utility of magnetic resonance imaging (MRI) in clinical decision-making for athletes with ankle symptoms and the presence of a SO. Our hypothesis is that MRI can predict which athletes have a stable SO and will respond to non-operative management, and which athletes have an unstable SO and will need surgery. Methods: We performed an IRB approved retrospective cohort study. Children were eligible from our practices if (1) they had radiographic evidence of a SO, (2) they had symptoms of pain and recurrent sprains, and (3) they had undergone MRI during their clinical evaluation. We identified 19 eligible children (20 ankles;) eight girls and eleven boys, ages 5–19 years. Nine involved the left ankle; 11 the right ankle. Most frequent sport was soccer (12/16) followed by basketball (3/14.) From the radiograph we determined ossicle size and location. MRI images were considered positive if fluid-sensitive sequences showed a high-intensity signal between the SO and the fibular epiphysis. Main outcome was treatment (non-surgical or surgical) relative to the MRI findings. Results: Size shape and location: Size and shape were variable. Width ranged from 2 – 10.4 mm and length from 4 – 13.5 mm. Concerning location all were in the distal 1/3 pf the epiphysis. Six were anterior and 14 were anterior-inferior to the fibular tip. MRI findings: Sixteen of the 20 ankles (80%) had positive MRI findings (figure 1), and 4 had negative findings (figure 2). The ATFL attached directly to the fragment in 11 of the 16 MRI positive ankles. Clinical decision making: All athletes with negative MRI findings responded to non-operatively management. Ten of the 16 ankles with positive MRIs have had surgery. Eight had excision of the ossicle and two had internal fixation based on the size of the ossicle. Surgical findings confirmed attachment of the ATFL to the fragment (figure 3.) Six athletes with positive MRIs continue to be under observation. Conclusions The results support our hypothesis that MRI has predictive value in clinical decision-making for symptomatic athletes with a SO. When fluid-sensitive MRI sequences show high signal intensity between the ossicle and the fibular epiphysis, and when the ATFL attaches to the ossicle, the athlete has a poor prognosis for non-operative management. [Figure: see text][Figure: see text] References: Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin. 2015;20(4):705-719. Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care 2005;32(1):133-161. Han SH, Choi WJ, Kim S, Kim S-J, Lee JW. Ossicles associate with chronic pain around the malleoli of the ankle. 2008;90-B:1049-1054. Gamble JG, Sugi M, Tileston KR, Chan CM, Livingston KS. The natural history of type VII all-epiphyseal fractures of the lateral malleolus. Orthop J Sports Med. 2019; 7(3) (suppl 1) DOI 10.1177/2325967119S00116. Pill SG, Hatch M, Linton JM, Davidson RS. JBJS 2013;95: e115(1-6). Han SH, Choi WJ, Kim S, Kim SJ, Lee JW. Ossicles associated with chronic pain around the malleoli of the ankle. J Bone Joint Surg Br. 2008;90(8):1049-1054. Danielsson LG. Avulsion fracture of the lateral malleolus in children. Injury 12:165-167

Background: Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm.1,2 Purpose/Hypothesis: The primary purpose of this research is to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis is that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM. Methods: We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 120 months.) We measured one four-year-old specimen with bilateral complete DLM. We also measured 39 digital images of specimens (ages 1 month to 132 months) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens. Results: Figure 2 shows the relationship of meniscus width as a function age. The average width of specimens Conclusions: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient. References: Kocher MS, Logan CA, Kramer DE. Discoid lateral meniscus in children: diagnosis, management, and outcomes. J Am Acad Orthop Surg 2017;25:736-743. Hayashi LK, Yamaga H, Ida K, Miura T. Arthroscopic meniscectomy for discoid lateral meniscus in children. J Bone Joint Surg. 1988;70-A: 1495-1500. [Figure: see text][Figure: see text]

Purpose To study the degree of surface congruency between the talar dome and humeral head, to determine the size of graft harvestable from the talar dome, and to determine if there are surrogate markers that correspond to a higher degree of surface congruency. Methods Computer models of 7 nonmatched humeral heads and 7 talar domes were generated by digital segmentation of magnetic resonance (MR) images. Modeled defect regions of each humeral head were then aligned with medial and lateral surfaces of each talar dome using software to maximally limit surface mismatch. Modeled defect sizes ranging from 24 × 10 mm to 30 × 10 mm were tested. Congruence match of Results The average surface match between randomly selected talar domes to humeral head surfaces was 87.2% when 1 mm was selected as the maximal acceptable congruence difference. Congruence match was not affected by graft size or laterality of talar dome as source of graft. Matching radius of curvature of talar dome to humeral head and height of donor to recipient correlated with improved congruence match. Under best match conditions, a maximal congruence match of 95.2% was achieved. Conclusions The present study indicates that the talar dome can be a potential source of osteochondral allograft for Hill-Sachs lesions with a maximal defect size of 30 × 10 mm for a single graft. Larger graft sizes resulted in decreased success of actual graft harvest as a result of dimensional constraints of the talar dome. Additional studies are required to determine the biomechanical compatibility of this graft. Clinical Relevance The talar dome has a high degree of surface congruency in comparison with the humeral head though the maximal graft size harvestable limits its clinical applicability.

Objectives: Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can degenerate and cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm. The primary purpose of this research was to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM. Methods: We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 11 years.) We measured one four-year-old specimen with bilateral complete DLM (Figure 2.) We also measured 39 digital images of specimens (ages 1-month to 12-years) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens. Results: Figure 3 shows the relationship of meniscus width as a function age. The average width of specimens Conclusions: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient.

Cartilage injuries pose a challenging problem for the surgeon. This is especially true in the skeletally immature patient. Given the skeletal size of a juvenile patient, a seemingly small cartilage injury may represent a proportionally large area, respectively. An algorithmic approach to management of cartilage injuries in this population is helpful when determining treatment strategies to address cartilage injuries. Characterization of the lesion dimensions, cartilage health, and status of subchondral bone is quantified through the use of magnetic resonance imaging sequences. As several options exist for treating cartilage injuries, the comfort and training of the surgeon, along with a shared decision-making with the patient and family must be employed to optimize the most favorable outcome for the patient.

This review will focus on the evaluation and management of patellar instability in the developing patient. A large number of surgical techniques have been described to prevent recurrent patellofemoral instability in the pediatric population, including both proximal and distal realignment procedures. The wide variety of treatment options highlights the lack of agreement as to the best surgical approach. However, when a comprehensive exam and workup are paired with a surgical plan to address each of the identified abnormalities, outcomes are predictably good. Patellar instability is a common knee disorder in the skeletally immature patient that presents a unique set of challenges. Rates of re-dislocation in pediatric and adolescent patients are higher than in their adult counterparts. Careful consideration of the physeal and apophyseal anatomy is essential in these patients. While the majority of primary patellar instability events can be treated conservatively, multiple events often require surgical intervention.

Minocycline is a semisynthetic second-generation tetracycline derivative that is widely used as a broad-spectrum antibiotic and anti-inflammatory agent1. Long-term treatment with tetracycline and its related derivatives causes discoloration and hyperpigmentation of the skin, bone, teeth, sclerae, thyroid, and oral mucosa2-11. Minocycline shares the same basic ringed structure found in other tetracyclines, with the exception of a dimethylamino group substitution at C7 and a functional group absence at C6. These differences in chemical structure result in more lipophilic properties than in other members of the tetracycline family12. Whereas tetracycline is known to cause discoloration in bone by oxidation-induced color change after binding irreversibly to hydroxyapatite, which is later deposited at the mineralization front on unmineralized mature osteoid, minocycline poorly chelates calcium and is thought to cause bone discoloration by a less well-understood mechanism13. Findings, including minocycline’s ability to discolor fully formed mature teeth as well as the presence of iron with trace amounts of calcium in minocycline-induced dark pigment, give credence to this idea14-16. Because of its lipophilic nature, minocycline is believed to achieve extensive tissue penetration, and in vitro protein-binding studies have also shown minocycline to bind collagen6,17. Once deposited, it is believed that minocycline is either degraded or lysosomally oxidized from its naturally yellow crystalline appearance to a black deposit3,18. Gross examination often reveals a bluish-gray or black discoloration of the bone and surrounding soft tissue, although these findings can be mutually exclusive1. The incidence of minocycline-induced discoloration of bone is unknown since it is more commonly found as an incidental finding during routine surgical procedures. However, staining of adult dentition has been reported to occur in 3% to 6% of patients on long-term minocycline …

Study Design: The review of multicenter national pediatric scoliosis database. Objective: The purpose of this study was to compare the radiographic outcomes of patients who underwent scoliosis surgery utilizing different rod diameter constructs by the posterior approach. Background: Little attention has specifically been focused on the effect of rod diameter on correction of spinal deformity after posterior spinal instrumentation and fusion in children with adolescent idiopathic scoliosis (AIS). Methods: The review of national database comprised of 1125 patients, of which 352 patients had a minimum follow-up of 2 years. Of these, 163 patients received 5.5 mm and 189 patients received 6.35 mm diameter rods for posterior spinal instrumentation. Results: The 6.35 mm rods were used more often for patients who were male, taller, heavier, with larger coronal curves, and more flexible curves. Larger diameter rods were also more likely to be stainless steel, implanted with an increased number of implants per level, and an increased number of pedicle screws used on the concavity of the curve. Univariate analysis of coronal curve showed a significant difference between 5.5 and 6.35 mm rods in correction (67.0% vs. 57.3%) at 2 years. Multivariate analysis revealed that the most significant factors affecting coronal curve correction at 2 years were rod diameter, the patient’s preoperative coronal major curve and flexibility, and the implant density. In the sagittal plane, preoperative sagittal curve and rod diameter are the predictors of sagittal correction at 2 years. Conclusions: The study did not support our hypothesis that larger rods would be associated with a greater correction of frontal and sagittal plane in patients with AIS. In addition to rod diameter, implant density and the inherent flexibility and deformity of the patient were found to be influential factors contributing for the correction and maintenance of coronal and sagittal curves in AIS.

BACKGROUND Ipsilateral femoral neck fractures occur in 1% to 9% of adult trauma patients with femoral shaft fractures making dedicated imaging important. This is not as clear in children. Our purpose is to establish the incidence of ipsilateral femoral neck fractures in children with femoral shaft fractures and to provide recommendations regarding diagnostic imaging protocols. METHODS A retrospective analysis of medical records was performed for pediatric patients (below 18 y) with femoral shaft fractures seen at our trauma center over a 10-year period. Mechanism of injury, associated injuries, procedures, and follow-up data were collected, and all radiographs reviewed. Exclusion criteria included peri-implant fractures or evidence of pathologic fracture. A similar retrospective analysis was performed in a cohort of adult patients. RESULTS Of 267 pediatric patients with femoral shaft fractures, 2 patients (0.7%) had ipsilateral femoral neck fractures. One femoral neck fracture was detected on initial plain radiographs and the other on a pelvic computed tomography (CT) scan. Both of these fractures resulted from high-energy trauma, which accounted for 92 (42%) of pediatric femoral shaft fractures. The cohort of 100 adults aged 18 to 89 years with femoral shaft fractures revealed 6 adult patients (6%) with ipsilateral femoral neck fractures, all from high-energy trauma. High-energy trauma accounted for 85% of the adult femoral shaft fractures, and was more common than in the pediatric population (P

Study Design This study determines the rate of change in the scoliosis surgery plan in cases presented in preoperative indications conference. Objectives To determine the effect of preoperative indications conference on the plan of surgery and to identify characteristics that increased the likelihood of change. Summary of Background Data Preoperative indications conferences are used as a teaching and planning tool. Levels of fusion, construct options, and necessity for osteotomies are often debated in the planning of scoliosis surgery. Methods Scoliosis surgeries were presented at preoperative indications conference with four attending pediatric orthopedic surgeons present. The operative surgeon committed to a surgical plan before conference. A consensus-based plan was made without knowledge of the operative surgeon's preconference plan. Changes of plan were classified as major, minor, or no change. Results Of the 107 surgical plans, 50 were index surgeries, 13 were revisions, and 44 were scheduled growing rod lengthenings. There were two major changes, including a change to a growing construct from planned fusion, and a change in fusion levels in an adolescent idiopathic scoliosis (AIS) patient. There were 13 minor changes, which included changes in fusion levels (1 to 3; mean = 1.23) and the addition of an osteotomy. The rate of change was 28% for index surgeries and 7.69% for revisions. Of the 14 changes in the 50 index surgeries, there were 8 AIS, 3 cerebral palsy, 1 congenital scoliosis, 1 Ehlers-Danlos, and 1 patient with an undetermined neuromuscular condition. There was 1 change in 13 revision surgeries. There were no changes for growing rod lengthenings and no cancellations as a result of indications conference. Conclusions Although revision scoliosis surgery is complex, index AIS/JIS surgery was most subject to the influence of indications conference. This likely reflects controversy around choosing levels of fusion. Level of Evidence IV.

The purpose of this study was to examine the location of biceps tenotomy and the integrity of the superior labrum as they relate to superior glenohumeral joint stability in a cadaveric concavity-compression model.Eight cadaveric glenoid labrums were mounted individually onto a load cell with the corresponding humerus fixed to the loading arm in the hanging-arm position. All surrounding soft tissue was removed except the labrum and proximal stump of the long head of the biceps (LHB) tendon, simulating a biceps tenotomy. A compressive load of 22 N was applied across the glenohumeral joint. The humerus was then translated superiorly until it subluxated over the glenoid labrum. The force resisting superior translation was characterized for each of 50 cycles. Each specimen was tested under the following conditions: (1) with a 4 cm biceps stump after tenotomy, (2) with a 0 cm biceps stump, (3) after full detachment of the superior labrum, and (4) after repair of the labrum.Biceps tenotomy performed at the biceps-labral junction resulted in an average decrease in force required to superiorly subluxate the humeral head by 8.6% (P = .01) when compared with leaving 4 cm of biceps stump. Resection of the entire superior labrum resulted in a future decrease to 15.2% (P.001) from baseline. Repair of the labrum resulted in restoration of stability with a mean of 101.1% (P = .82) and was not statistically different from baseline. The kinematics of the glenohumeral joint was affected by labral repair, with an earlier upslope on the force-to-displacement curve and alteration in the total energy required to cause subluxation of the humeral head noted.In this study, location of the biceps tenotomy and integrity of the superior labrum affected glenohumeral stability during axial loading in the hanging-arm position. Repair of the labrum restored stability for superior subluxation but also changed the kinematics of the subluxation event.Preservation of superior labrum after biceps tenotomy provides increased resistive force to superior translation in a unidirectional biomechanical model.

Four normal variants of meniscomeniscal ligaments have been previously reported in the anatomy, arthroscopy, and radiology literature. The anterior and posterior transverse meniscal ligaments are the 2 most commonly observed, with a reported frequency of 58% and 1% to 4%, respectively. The last 2 variants include the medial and lateral oblique meniscomeniscal ligaments and account for a combined frequency of 1% to 4%. This article describes 2 patients with unilateral meniscomeniscal ligaments observed on magnetic resonance imaging. One patient had a unilateral lateral meniscomeniscal ligament extending from the anterior horn of the lateral meniscus to the posterior horn of the lateral meniscus and underwent conservative management. The second patient had a unilateral medial meniscomeniscal ligament with a concomitant medial meniscus tear and underwent arthroscopic intervention. The ligament was stable intraoperatively and, therefore, was not resected. Both patients had resolution of their symptoms. These 2 variants are additions to the previously described 4 normal intermeniscal ligament variants. The functions of the 2 new variants described in this article are poorly understood but are thought to involve meniscal stability. Accurate descriptions of normal variants can lead to the proper management of anomalous rare structures and prevent false imaging interpretations because these structures can closely mimic a double posterior cruciate ligament sign. Furthermore, an understanding of the various normal variants of intermeniscal ligaments can prevent unnecessary surgery that could result in further iatrogenic meniscus injury.