BACKGROUND: Intraoperative methadone, a long-acting opioid, is increasingly used for postoperative analgesia, although the optimal methadone dosing strategy in children is still unknown. The use of a single large dose of intraoperative methadone is controversial due to inconsistent reductions in total opioid use in children and adverse effects. We recently demonstrated that small, repeated doses of methadone intraoperatively and postoperatively provided sustained analgesia and reduced opioid use without respiratory depression. The aim of this study was to characterize pharmacokinetics, efficacy, and safety of a multiple small-dose methadone strategy. METHODS: Adolescents undergoing posterior spinal fusion (PSF) for idiopathic scoliosis or pectus excavatum (PE) repair received methadone intraoperatively (0.1 mg/kg, maximum 5 mg) and postoperatively every 12 hours for 3–5 doses in a multimodal analgesic protocol. Blood samples were collected up to 72 hours postoperatively and analyzed for R-methadone and S-methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidene (EDDP) metabolites, and alpha-1 acid glycoprotein (AAG), the primary methadone-binding protein. Peak and trough concentrations of enantiomers, total methadone, and AAG levels were correlated with clinical outcomes including pain scores, postoperative nausea and vomiting (PONV), respiratory depression, and QT interval prolongation. RESULTS: The study population included 38 children (10.8–17.9 years): 25 PSF and 13 PE patients. Median total methadone peak plasma concentration was 24.7 (interquartile range [IQR], 19.2–40.8) ng/mL and the median trough was 4.09 (IQR, 2.74–6.4) ng/mL. AAG concentration almost doubled at 48 hours after surgery (median = 193.9, IQR = 86.3–279.5 µg/mL) from intraoperative levels (median = 87.4, IQR = 70.6–115.8 µg/mL; P < .001), and change of AAG from intraoperative period to 48 hours postoperatively correlated with R-EDDP (P < .001) levels, S-EDDP (P < .001) levels, and pain scores (P = .008). Median opioid usage was minimal, 0.66 (IQR, 0.59–0.75) mg/kg morphine equivalents/d. No respiratory depression (95% Wilson binomial confidence, 0–0.09) or clinically significant QT prolongation (median = 9, IQR = −10 to 28 milliseconds) occurred. PONV occurred in 12 patients and was correlated with morphine equivalent dose (P = .005). CONCLUSIONS: Novel multiple small perioperative methadone doses resulted in safe and lower blood methadone levels, <100 ng/mL, a threshold previously associated with respiratory depression. This methadone dosing in a multimodal regimen resulted in lower blood methadone analgesia concentrations than the historically described minimum analgesic concentrations of methadone from an era before multimodal postoperative analgesia without postoperative respiratory depression and prolonged corrected QT (QTc). Larger studies are needed to further study the safety and efficacy of this methadone dosing strategy.

* Careful scrutiny of radiographs is important in the assessment of pediatric elbow injuries. Disruption of the radiocapitellar line and an increased bow of the posterior ulnar border are sometimes subtle signs of a Monteggia injury.* An attempt at closed reduction up to 4 weeks after injury has been cited in the literature as successfully treating some missed injuries.* Operative reduction of chronic radial-head dislocation provides good to excellent range of motion and functional outcome in the setting of irreducible chronic radial-head dislocation.* Ulnar osteotomy and correction of the ulnar deformity component of the missed Monteggia injury are the key to indirect anatomic reduction of the radiocapitellar joint.* Supplemental procedures aimed at increasing the stability of the radiocapitellar joint (e.g., annular ligament reconstruction, radiocapitellar Kirschner wire fixation, radioulnar Kirschner wire fixation) should be directed by a thorough assessment of radiocapitellar stability following ulnar osteotomy and correction of the ulnar deformity.

BackgroundRecreational sports facilities with trampolines have become increasingly popular, and trampoline-related injuries incurred have been increasing. The goal of this study was to determine impact of recreational sports facilities on trampoline-associated injuries.MethodsAn epidemiological study was performed using data from the National Electronic Injury Surveillance System (NEISS). All patients in the NEISS database coded for trampoline injury were included. Statistical analyses were performed comparing home trampoline injuries (HTIs) and recreational sports facilities-related trampoline injuries (RSIs) for standard demographic variables using appropriated weighted statistical methods.ResultsThere were an estimated 1 376 659 emergency department (ED) visits for trampoline related injuries from 1998 to 2017; 125 811 were RSIs and 1 227 881 were HTIs. Between 2004 and 2017, the number of RSIs increased rapidly, while HTIs decreased. RSIs more often presented to large hospitals and HTIs to smaller ones. Strain/sprains were more associated with RSIs, whereas HTIs sustained more internal organ injuries. Lower extremity fractures occurred more frequently in RSIs and upper extremity fractures in HTIs. There was a greater percentage of RSIs in 15–34 years old age group (28.2% vs 13.6%). There were no differences by gender and race between HTIs and RSIs.ConclusionsThe rapid expansion in recreational sports facilities with trampolines coincided with increasing RSIs. RSIs differed from HTIs regarding changes over time, hospital size, diagnosis and injury location. Recreational sports facilities with trampolines pose a public health hazard.