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BACKGROUND Physeal instability has been shown to be associated with a higher risk of avascular necrosis (AVN) in patients with slipped capital femoral epiphysis (SCFE). The purpose of this study was to identify additional preoperative factors associated with AVN in patients with unstable SCFE. METHODS Basic demographic information, chronicity of symptoms, and estimated duration of nonambulatory status were noted. Preoperative radiographs were used to measure the Southwick slip angle, slip severity by Wilson criteria, and epiphyseal translation. Translation was measured by 3 distinct radiographic parameters in the position demonstrating maximal displacement. Postoperative radiographs at the time of most recent follow-up were assessed for the presence of AVN. Translation measurements were tested for inter-rater reliability. Patients who developed AVN were compared with those that did not by Fisher exact test and Wilcoxon tests. Logistic regression assessed the effect of translation on the odds of developing AVN. Receiver operating characteristic curve was plotted to assess any threshold effect. RESULTS Fifty-one patients (55 hips) out of 310 patients (16%) treated for SCFE were considered unstable. Seventeen hips' unstable SCFE (31%) showed radiographic evidence of AVN. Slip severity by Wilson grade (P=0.009) and epiphyseal translation by all measurements (P< 0.05) were statistically significantly greater among patients who developed AVN. Superior translation had the best inter-rater reliability (intraclass correlation coefficient=0.84). Average superior translation in hips that developed AVN was 17.2 mm compared with 12.9 mm in those that did not (P

BACKGROUND Supracondylar humerus (SCH) fractures are the most common surgically treated elbow injuries in children. There have been debates regarding if an early postoperative follow-up before pin removal is necessary to decrease the complications related to surgical fixation. To date, studies examining this topic have included smaller sample sizes, limiting the generalizability of their findings. METHODS A retrospective chart review of outcomes after operative management of Gartland type II and III SCH fractures at a single level 1 pediatric trauma center between 2005 and 2015 was performed. Patient demographics, fracture characteristics, pin number and configuration, timing of initial follow-up, change in treatment plan after initial follow-up, time to pin removal, initial and final fracture radiographic parameters, and complications were observed via chart review. RESULTS A total of 1518 SCH fractures underwent operative fixation: 755 Gartland type II and 765 type III. Of the 1518 SCH fractures identified, 1370 met inclusion criteria and were included for analysis. Of these, 1196 patients returned for initial follow-up within 1 to 2 weeks of surgery, and 174 patients had their initial follow-up 3 to 4 weeks postoperatively. There were 8 incidences where initial early follow-up resulted in a change of management; however, change in management was limited to cast alteration in 7 of these cases. CONCLUSIONS Closed reduction and percutaneous pin fixation of otherwise uncomplicated closed SCH fractures have good outcomes and a very low complication rate at a level 1 pediatric trauma center. Early postoperative follow-up before the pin removal visit provides minimal utility in decreasing complications and may be safely omitted as long as the initial fracture fixation is deemed to be stable. LEVEL OF EVIDENCE Level III.

Prospective, observational cohort study.To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery.Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated.The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups.The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p.0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05).This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery.Level 2, prospective comparative study.

BACKGROUND Pediatric and adolescent athletes are a large demographic undergoing anterior cruciate ligament reconstruction (ACL-R). Postoperative rehabilitation is critical, requiring patients to complete home exercise programs (HEPs). To address obstacles to HEP adherence, we developed an interactive health technology, interACTION (iA), to monitor knee-specific rehabilitation. iA is a web-based platform that incorporates wearable motion sensors and a mobile app that provides feedback and allows remote monitoring. The Wheel of Sukr is a gamification mechanism that includes numerous behavioral elements. OBJECTIVE This study aims to use a user-centered design process to incorporate behavioral change strategies derived from self-management theory into iA using the Wheel of Sukr, with the aim of influencing patient behavior. METHODS In total, 10 athletes aged 10-18 years with a history of ACL-R were included in this study. Patients were between 4 weeks and 1 year post–ACL-R. Participants underwent a 60-minute triphasic interview. Phase 1 focused on elements of gaming that led to high participation and information regarding surgery and recovery. In phase 2, participants were asked to think aloud and rank cards representing the components of the Wheel of Sukr in order of interest. In phase 3, the patients reviewed the current version of iA. Interviews were recorded, transcribed, and checked for accuracy. Qualitative content analysis segmented the data and tagged meaningful codes until descriptive redundancy was achieved; next, 2 coders independently coded the data set. These elements were categorized according to the Wheel of Sukr framework. The mean age of participants was 12.8 (SD 1.32) years, and 70% (7/10) were female. Most participants (7/10, 70%) reported attending sessions twice weekly. All patients were prescribed home exercises. Self-reported HEP compliance was 75%-100% in 40% (4/10), 50%-75% in 40% (4/10), and 25%-50% of prescribed exercises in 20% (2/10) of the participants. RESULTS The participants responded positively to an app that could track home exercises. Desirable features included exercise demonstrations, motivational components, and convenience. The participants listed sports specificity, competition, notifications, reminders, rewards, and social aspects of gameplay as features to incorporate. In the Wheel of Sukr card sort exercise, motivation was ranked first; self-management, second; and growth, esteem, and fun tied for the third position. The recommended gameplay components closely followed the themes from the Wheel of Sukr card sort activity. CONCLUSIONS The participants believe iA is a helpful addition to recovery and want the app to include exercise movement tracking and encouragement. Despite the small number of participants, thematic saturation was reached, suggesting the sample was sufficient to obtain a representative range of perspectives. Future work will implement motivation; self-management; and growth, confidence, and fun in the iA user experience. Young athlete ACL-R patients will complete typical clinical scenarios using increasingly developed prototypes of the gamified iA in a controlled setting. CLINICALTRIAL