Anterior knee pain (AKP) is a common presenting complaint for pediatricians and orthopaedic surgeons and is often seen in young athletes. AKP is multifactorial and has a broad differential diagnosis. The growth changes, biomechanics, and anatomy around the knee add to the complexity of diagnosis and treatment of AKP. Common causes of AKP include Osgood-Schlatter's disease, patellar tendinitis, and patellofemoral instability. In the diagnosis of AKP, it is important to rule out serious and morbid causes of pain, including infection and tumor. It is crucial to complete a detailed history and physical examination and obtain appropriate imaging studies. In general, the majority of patients will respond to nonoperative measures targeted to correct neuromuscular control and kinetic chain dysfunction.

Fluoroscopy poses an occupational hazard to orthopedic surgeons. The purpose of this study was to examine resident and faculty understanding of radiation safety and to determine whether or not a radiation safety intervention would improve radiation safety knowledge. An anonymous survey was developed to assess attitudes and knowledge regarding radiation safety and exposure. It was distributed to faculty and residents at an academic orthopedic program before and after a radiation safety lecture. Pre- and post-lecture survey results were compared. 19 residents and 22 faculty members completed the pre-lecture survey while 11 residents and 17 faculty members completed the post-lecture survey. Pre-lecture survey scores were 48.3% for residents and 49.5% for faculty; post-lecture survey scores were 52.7% and 46.1% respectively. Differences between pre and post-survey scores were not significant. This study revealed low baseline radiation safety knowledge scores for both orthopedic residents and faculty. As evidence by our results, a single radiation safety information lecture did not significantly impact radiation knowledge. Radiation safety training should have a formal role in orthopedic surgery academic curricula.

The most common corrective surgery for adolescent idiopathic scoliosis (AIS) is posterior instrumented spinal fusion, which is a relatively lengthy procedure. Longer procedures are known to have higher rates of negative outcomes and higher economic costs across the surgical specialties. The purpose of this study is to identify the factors that influence the length of this operation in AIS patients. This was an institutional review board-approved, retrospective cohort study. All primary posterior instrumented arthrodesis procedures in 2011-2013 performed by three surgeons on AIS patients at a tertiary care hospital were included. Age, race, sex, BMI, Cobb angle, curve flexibility, Lenke classification, number of levels fused, number of screws used, osteotomy use, intraoperative O-arm use, and length of surgery (time from incision to closure) were obtained from the electronic medical record. Multivariable linear regression analysis was used to determine independent predictors of length of surgery, and standardized regression coefficients were calculated to compare the relative magnitude of significant variables. A total of 95 procedures were included. The average length of surgery was 375 ± 72.7 min. The multivariable linear regression analysis contained the variables Cobb angle, number of screws used, osteotomy use, Lenke curve type, surgeon, patient age, and sex. The regression identified the number of screws used [β=4.72, P=0.003, 95% confidence interval (CI) 1.7-7.8], osteotomy use (β = 50.2, P = 0.004, 95% CI 16.2-84.1), Lenke type 3 curve (β = 77.9, P = 0.001, 95% CI 31.7-174), male sex (β=62.5, P=0.003, 95% CI 21.5-103), the Cobb angle (β=1.04, P=0.045, 95% CI 0.02-2.1), and the surgeon (β = 75.2, P < 0.0001, 95% CI 40-110) as independently associated with the length of surgery. The most significant factor associated with operative duration was the surgeon performing the case. We identified male sex, number of screws used, Lenke type 3 curves, osteotomy use, Cobb angle, and the surgeon variable as significantly associated with increased length of surgery in posterior arthrodesis of AIS patients.

We performed a retrospective chart review of 50 youths with Autism Spectrum Disorder (ASD), prescribed amitriptyline (AMI) for hyperactivity and impulsivity. Data was systematically extracted from 50 outpatient clinic charts, including AMI treatment duration, dose, trough levels and adverse events. Mean age was 9.4 years (4.6-17.9); 40 were males and 10 females. 30 % had failed atomoxetine and 40 % had failed ≥3 ADHD medications. Mean dose was 1.3 ± 0.6 mg/kg/day, mean trough level 114.1 ± 50.5 ng/ml, mean duration 3.4 years. Clinical Global Impressions Scale-Improvement (CGI-I) was ≤2 in 60 % of patients at the final visit, and in 82 % of patients for at least 50 % of follow-ups. Cautious use of low dose AMI shows promise for treatment-resistant youth with ASD accompanied by hyperactivity, impulsivity, aggression and self injury.

Background: Several fixation methods have been reported for the operative treatment of tibial eminence fractures. Previous biomechanical studies have demonstrated that suture fixation may be a stronger construct; however, the maturity status of these specimens was not scrutinized. Purpose: To examine if suture fixation remains a biomechanically superior fixation method to screw fixation in both skeletally mature and immature specimens. Study Design: Controlled laboratory study. Methods: Sixteen total matched porcine (Yorkshire) knees (8 skeletally immature knees and 8 skeletally mature knees) were procured, and a standardized tibial eminence fracture was created. In each age-matched group of knees, 4 knees underwent randomization to fixation with 2 screws while 4 knees were randomized to fixation using a dual-suture technique. Once fixation was complete, the specimens underwent cyclic loading (200 cycles) in the anteroposterior plane of the tibia and load-to-failure testing, both with the knee positioned at 30° of flexion. Relevant measurements were recorded, and data were analyzed. Results: Among mature specimens, load to failure was 1.9 times higher in the suture fixation group compared with the screw fixation group (1318.84 ± 305.55 vs 711.66 ± 279.95 N, respectively; P = .03). The load to failure was not significantly different between the groups in immature specimens (suture: 470.00 ± 161.91 N vs screw: 348.79 ± 102.46; P = .08). Conclusion: These findings suggest that suture fixation may represent a better construct choice for fixation of tibial eminence fractures in the skeletally mature population. However, in the skeletally immature population, fixation with screws or suture may be equivalent. Displacement after cyclic loading did not appear to differ by fixation method, nor did stiffness. Clinical Relevance: A stronger fixation construct may be beneficial and allow for earlier range of motion to help potentially decrease postoperative stiffness. Clinical studies are warranted to see if these results may be replicated in humans.

Case: Two patients presented with infections of their recent proximal humerus fracture sites. These immunocompromised patients were being treated nonoperatively for their proximal humerus fractures; however, both were taken to the operating room for surgical debridement. Conclusions: These 2 cases demonstrate the need for further investigation into infection of closed fracture sites. Attention should be paid to immunocompromised patients who present with proximal humerus fractures, especially displaced 2-part surgical neck fractures with anterior deltoid injury and subsequent hematoma formation. These patients may develop an infection with potential rapid progression to life-threatening septic shock.

Traumatic anterior shoulder dislocations are the most common dislocations of the shoulder, and the recurrence rate is high when they are treated nonoperatively in young patients (<30 years old). This has led to a trend toward early surgical stabilization. Originally open Bankart repair was considered the standard of care, with good clinical outcomes and a low recurrence rate. However, the majority of Bankart repairs are now performed with newer arthroscopic techniques because of their potential advantages and similar results. Both open and arthroscopic repairs have been shown to decrease the recurrence rate to 6% to 23%. Although arthroscopic Bankart repair is now more common, open repair should be considered for younger patients participating in contact sports or military activity, osseous Bankart lesions, revision cases, shoulder instability with "subcritical" (20% to 25%) glenoid bone loss, ligamentous laxity, or cases not considered repairable with arthroscopic techniques. Therefore, knowing how to perform an open Bankart repair is essential. The major steps of the procedure are (1) preoperative planning, (2) induction of anesthesia, (3) patient positioning and setup, (4) examination under anesthesia, (5) possible arthroscopic examination of the shoulder, (6) incision along the anterior axillary fold, (7) exposure using the deltopectoral interval, (8) clavipectoral fascia incision, (9) vertical tenotomy of the subscapularis tendon, (10) dissection of the capsule from the subscapularis, (11) assessment of the quality of the capsule, (12) "T" capsulotomy, (13) repair of the Bankart lesion, (14) anterior capsulorrhaphy, (15) subscapularis repair, (16) possible closure of the rotator interval, (17) wound closure, and (18) postoperative rehabilitation. Studies have shown that surgical stabilization after traumatic anterior shoulder instability decreases the recurrence rate, and open and arthroscopic techniques have similar clinical outcomes.

* Scapular winging is a rare condition that can lead to considerable functional impairment and cosmetic deformity but is frequently missed or misdiagnosed.* Scapular winging is of particular concern in the pediatric patient given its association with birth injuries, perinatal thoracic operations, inherited disorders, and potential malignancies.* Primary scapular winging may develop from nerve palsy, an osseous abnormality, or a soft-tissue defect.* Secondary scapular winging is typically due to glenohumeral dysfunction but can also be voluntary or habitual.