Journal of the Pediatric Orthopaedic Society of North America <p><em><strong>JPOSNA</strong></em><strong>®</strong> (the <strong>Journal of the <a href="">Pediatric Orthopaedic Society of North America</a>)</strong> is an open access journal focusing on pediatric orthopaedic conditions, treatment, and technology.</p> <p><a href=""><img src="" alt="Technology Supplement" width="100%" /></a></p> POSNA en-US Journal of the Pediatric Orthopaedic Society of North America 2768-2765 Pediatric Ankle Syndesmosis Injuries <p>Ankle syndesmosis injuries occur in 1% of pediatric ankle trauma. In the younger populations, an open physis has been thought to be a protective factor against syndesmotic injury and therefore favoring more Salter-Harris type injuries. Clinical methods used to diagnose syndesmotic injuries may not be effective in the pediatric population. Radiographic findings are mostly based on the study of adolescent and adult populations. Therefore, syndesmotic injuries may be overlooked in the younger pediatric patient with ankle trauma and open physes. Here we present a review of the literature of ankle syndesmotic injuries and a case report of such an injury that was initially missed in the younger pediatric patient. Further research is needed to characterize the ankle syndesmosis in the younger pediatric patient, how this may change with time and growth, clinical exam findings that may accurately diagnose a syndesmotic injury, and radiographic findings concerning for syndesmotic injury in this population.</p> Ara Alexanian Kerry Loveland Jill Christine Friebele Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-553 Efficacy of a Photograph-Based Triage System Initiated During the COVID-19 Pandemic to Identify and Streamline Pediatric Foot and Ankle Referrals <p><strong><span lang="EN-US">Background: </span></strong><span lang="EN-US">The COVID-19 pandemic required hospitals to reduce in-person visits. Although most pediatric foot and ankle conditions do not require urgent consultation, clubfoot (CF) relies on early identification and treatment. To avoid unnecessary hospital visits for infants, we developed a triage system using standardized clinical photographs of the child’s feet taken by the parents for clinician review. This study assesses the efficacy of this triage system based on accuracy of the triage diagnosis (TDx) and time from referral to initial consultation (IC). </span></p> <p><strong><span lang="EN-US">Methods: </span></strong><span lang="EN-US">This is a retrospective cohort review of patients referred to a tertiary care pediatric institution for a foot and ankle condition from 03/16/20 to 09/15/20 (onset of COVID-19), and from the same period in 2019 (prior to use of the triage system). Patients were identified by referring diagnosis (RDx). Patients were excluded if they missed their initial visit or the RDx was not clear. Chart review was performed to collect demographic data, clinical photographs, RDx, TDx, IC diagnosis, and time to IC. Diagnosis accuracy (DA) scores were assigned: 0 when RDx or TDx did not match diagnosis at IC, 0.5 if the diagnosis was partly correct, and 1 when diagnoses aligned. </span></p> <p><strong><span lang="EN-US">Results: </span></strong><span lang="EN-US">Of the 118 patients included, 62 were referred for CF and 56 for other foot and ankle conditions (FA). In 2020, 23/27 CF and 11/12 FA patients sent photographs. The average time to IC for FA patients was similar in both years (142 days in 2019 vs 183 days in 2020, p= 0.24), while the average time to IC for CF decreased from 66 days in 2019 to 31 days in 2020 (p=0.08). Accuracy for TDx in 2020 was high for CF (0.98) and FA (0.92) patients (p=0.49). </span></p> <p><strong><span lang="EN-US">Conclusion: </span></strong><span lang="EN-US">Triage diagnosis was accurate and time from referral to consultation decreased for clubfoot patients from 2019 to 2020 supporting that this novel photo-based triage system for pediatric foot and ankle referrals is effective in identifying urgent consults and ensuring timely assessment. </span></p> Luandrya Egea Martins Barbara Harvey Marwah Sadat Maryse Bouchard Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-492 Avoiding Subluxation of the Calcaneocuboid Joint During Calcaneal Lengthening Osteotomy <p>The calcaneal lengthening osteotomy (CLO) is a frequently utilized procedure for the surgical correction of pes planovalgus in the pediatric population. Subluxation of the calcaneocuboid (CC) joint is a well-described and common complication of this operation. In this case report, we propose that intraoperative technique plays a key role in the development of this complication. We recommend pinning the joint with the foot in its natural “deformed” planovalgus position and provide a technical tip to maintain anatomic alignment of the joint.</p> Anthony M. Padgett Roshan Jacob Ashish Shah Michael J. Conklin Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-567 Pitfalls of Calcaneal Lengthening Osteotomies <p>I would like to compliment the authors on highlighting the importance of technique when performing the calcaneal lengthening osteotomy. Management Principle #2 in my book states “A less-than-ideal surgical or nonsurgical outcome can be due to a poor technique, a poor technician, or both.”<sup>1 </sup>This principle certainly applies to clubfoot management by some pediatric orthopaedic surgeons who report unusually and unexpectedly high rates of surgery despite proclaiming utilization of the Ponseti technique. The Ponseti technique is exacting with excellent reported outcomes by all who implement it without modification. If the Ponseti method were being utilized exactly as he so clearly described it, clubfoot surgery would rarely, if ever, be performed.</p> <p>Like the Ponseti clubfoot technique, flatfoot reconstruction surgery based on the calcaneal lengthening osteotomy has many components. Success is based on attention to all reported details.1-4 One of those details is the prevention of subluxation at the calcaneo-cuboid (CC) joint during distraction of the calcaneal fragments. As the authors of this article point out, I described preventing subluxation at the CC joint when distracting the calcaneal fragments in my first description of the modified Evans procedure in 1995 and in all my subsequent published descriptions.1-4 My recommendation was to simulate weight-bearing by fully everting the subtalar joint before advancing the pin retrograde across the CC joint. My reasoning was that 1) the CC joint is not subluxated in normal weight-bearing, 2) CC joint subluxation is often seen on lateral non-weight-bearing x-rays of the foot, 3) if the anterior calcaneal fragment subluxates dorsally (cuboid subluxates plantarward), it cannot follow the rest of the acetabulum pedis into inversion down and around the talar head; deformity correction is then limited.</p> <p>To my knowledge, CC joint subluxation was not a recognized issue until I brought it to light while developing my modification of Evans’ lateral column lengthening.2,5In the first 3 years of my clinical practice, I saw several children who had significant subluxation at the CC joint after having undergone Evans lateral column lengthening at other centers; nothing had been done to stabilize the CC joint. These children had gross subluxation at that joint, resulting in pain at that location and a large bony prominence along the lateral column of the foot, the anterior end of the calcaneus. While the feet were reasonably well-shaped compared to preoperative x-rays and lateral column lengthening was probably the best procedure for correcting hindfoot valgus in these cases, I felt that soft tissue and bony management of the primary and associated deformities required further elucidation.</p> <p>Evans’ description of the operation was terse and lacked detail. This was his entire surgical technique description: “An incision is made over the lateral surface of the calcaneus parallel with, and just above, the peroneal tendons, avoiding the sural nerve lest it be involved in the scar. The anterior half of the bone is exposed and the calcaneo-cuboid joint is identified. The anterior end of the calcaneus is then divided through its narrow part in front of the peroneal tubercle by an osteotome, the line of division being parallel with and about 1.5 cm behind the calcaneo-cuboid joint. The cut surfaces of the calcaneus are then prised apart by means of a spreader, and a graft of cortical bone taken from the tibia is inserted between the blades of the spreader to maintain separation of the two pieces of the calcaneus.”5 Few surgeons outside of Cardiff, Wales (Evans’ hometown) performed, or continued to perform, the operation following his report in 1975. I learned that some surgeons attempted it, but, because of poor technique description that resulted in poor outcomes, had abandoned it.</p> <p>As I began performing calcaneal lengthenings, I observed many areas for improvement, including prevention of CC joint subluxation. I advised lengthening the lateral soft tissues that inhibit lateral column lengthening, plicating the redundant medial soft tissues, correcting structural forefoot supination deformity that is often present in flatfoot deformities, and lengthening contracted heel cords that are usually the source of pain in otherwise asymptomatic flexible flatfeet.</p> <p>For years after my technique was published in JBJS,2 I received e-mails or other types of communication from orthopaedic surgeons reporting subluxation at the CC joint. In all cases, the joint had not been pinned as I recommended. More recently, there have been reports on CC joint subluxation despite pinning. Note that if two solid objects with flat adjacent surfaces are pinned centrally, they cannot shift on one another. That’s basic carpentry. They may rotate, but two solid, flat-surface objects do not have the soft tissue constraints, nor the undulating surfaces found at and around the CC joint that tend to prevent or limit rotation in the foot. So, if a “pinned” CC joint subluxates, it was either not pinned centrally, or it rotated (but it can’t rotate more than a few degrees because of the soft tissue and bone shape constraints), or the pin cut through one or both bones. The authors of this <em>JPOSNA</em><em>®</em> article reiterate that, perhaps, the most likely reason for CC joint subluxation is that the joint was pinned in a subluxated position. Their “thumbs up” technique seems quite sound as a method to supplement holding the hindfoot fully everted to ensure CC joint congruity at the time of joint pining.</p> <p>The other and perhaps larger issue is whether mild subluxation matters. In 1983, Phillips reported an average 13-year follow-up on a series of Evans’ patients, the longest reported follow-up for any flatfoot reconstruction surgery.6 He found a small percentage of patients with painful CC joint subluxation, but he did not correlate the degree of subluxation with pain. Since Evans did not try to prevent subluxation with pinning, it’s reasonable to assume that most CC joints subluxated and it didn’t seem to matter in most. Also note, for those who have been concerned about the CLO being intraarticular in the subtalar joint, Phillips did not report any cases of subtalar joint pain. In fact, there are no reports in the literature of subtalar joint arthritis following CLO.</p> <p>One of the nice things about having spent my entire 37-year career in one place is that I have had the opportunity to see my good and not-so-good surgical results. The sad news is that rarely have any of my nearly 600 CLO’s followed up after 2 years, despite my requests to do so. I have assumed that they do not return because they are doing well. I also assumed that at least some of those who were not doing well due to pain in the CC or subtalar joint would return to see me. Note that I pinned all CC joints, and I cannot recall any of the approximately 600 returning due to CC or subtalar joint pain during the 35 years that I’ve been performing my modification of the Evans procedure. On the other hand, I have seen several cases of painful gross CC joint subluxation in patients who were operated upon elsewhere and who did not have congruous joint stabilization.</p> <p>The message seems to be that mild CC joint subluxation with CLO’s probably occurs often and is well-tolerated long-term, but severe CC joint subluxation is not well-tolerated. Perhaps ongoing clinical research will be able to differentiate “mild” from “severe” and establish a threshold for acceptable CC joint subluxation with flatfoot reconstruction based on the CLO. Meanwhile, evert the hindfoot and push upwards on the cuboid when pinning the CC joint as Padgett et al. so nicely illustrate. And, as I recommended in my 1995 article, add a second pin if “subluxation” of a congruously pinned CC joint is noted intraoperatively following distraction of the calcaneal fragments. This phenomenon probably represents rotation that a second pin would prevent. Of course, remove the graft and realign the CC joint with hindfoot eversion and upward pressure on the cuboid before adding the second pin.</p> Vincent S. Mosca Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-593 Use of Hyperselective Neurectomy in the Management of the Pediatric Spastic Upper Extremity <p>In children, upper extremity spasticity is a complex clinical finding with functional deficits and social implications that can be substantial. It can create significant challenges and cause distress in both the patients and their caregivers. Unfortunately, spasticity is incurable, and available treatment options are imperfect. Historically, surgical treatments for this condition were predominantly bone and soft tissue-based procedures. More recently, there is a growing body of evidence to support nerve-based procedures to decrease the degree of spasticity within select muscle groups, while maintaining volitional control. The term “hyperselective neurectomy” (HSN) has been used to describe a procedure where a specific, partial neurectomy is performed on peripheral nerve branches in close proximity to the level of the motor endplates. The result is less dysfunctional spasticity while maintaining selective native innervation to allow for continued volitional function. In this review, we discuss the role of HSN in the treatment of the spastic pediatric upper extremity. Additionally, we describe our groups’ early clinical experience with this procedure and how we have implemented it into our established practice of single-event multilevel surgery (SEMLS). HSN techniques may be applicable to the lower extremity cerebral palsy surgeons doing similar SEMLS.</p> Alexander H. Hysong Samuel L. Posey Michael Geary Daniel R. Lewis Bryan J. Loeffler R. Glenn Gaston Peter M. Waters Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-588 Radial Head Stress Fracture Nonunion in Adolescent Overhead Athletes: A Case Series <p><strong>Background: </strong>While osteochondritis dissecans of the humeral capitellum is well-described in adolescent overhead athletes, lateral compartment overload may also present with isolated radial head involvement. The primary goals of this study are to present a case series of radial head stress fracture nonunions in adolescent athletes and to provide guidelines regarding surgical indications and treatment. We hypothesize that surgical reduction and fixation of symptomatic lesions is safe, effective, and preserves the stability and articular congruity of the radiocapitellar joint.</p> <p><strong>Methods: </strong>We retrospectively reviewed the clinical and radiographic records of nine patients presenting to a pediatric tertiary care center for radial head stress fracture nonunion from January 2008 to December 2016. Patient characteristics, presenting signs and symptoms, clinical and radiographic features, postoperative elbow motion, and radiographic healing were assessed. </p> <p><strong>Results: </strong>Nine patients (five female; mean age 12.0 years at time of injury) were treated for symptomatic radial head stress fracture nonunion. All patients reported persistent elbow pain with activities of daily living (ADLs) and athletics. Seven patients had limited elbow range of motion. Radiographically, the nonunion fragments comprised 20-45% of the radial head articular surface, and five patients had concomitant radial head subluxation. Five patients underwent open reduction internal fixation, one patient underwent microfracture and debridement, and one patient underwent intraarticular corrective osteotomy. All operative patients had improved or complete resolution of pain with ADLs. Additionally, all operative patients either significantly increased or regained full elbow range of motion. Progressive or complete radiographic healing was seen at a median of 14 weeks postoperatively.</p> <p><strong>Conclusions: </strong>In this case series, skeletally immature athletes with radial head stress fracture nonunions experienced pain relief, maintained or improved motion, and radiographic bony union following surgical intervention. Radiocapitellar joint stability and congruity were preserved or restored.</p> Arin E. Kim Evan W. Beatty Donald S. Bae Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-440 A Universal C-arm Language Improves OR Morale <p><strong>Background:</strong> Miscommunication while using intraoperative fluoroscopy C-arm can increase frustration, time, and radiation exposure. There have been no studies to date that have examined a standardized C-arm language during live cases, nor its durability over time. We aimed to design a directive language for use at a single institution and compare pre- and post-implementation surgeon and radiology technologist satisfaction and sense of operative efficiency.</p> <p><strong>Methods:</strong> All surgeons regularly using intraoperative fluoroscopy and all radiology technicians were surveyed regarding their experience and satisfaction regarding C-arm usage. Respondents provided their preferred terminology for each C-arm motion; the most frequent responses for each movement were used to create a universal language. Users were educated on the language via email and OR/C-arm signage for 1 month. Participants’ recall of the terminology and satisfaction with the use of the C-arm was evaluated at 1- and 3-months post-intervention.</p> <p><strong>Results:</strong> 57 people responded to the initial survey—30 radiology technicians and 27 surgical attendings. Initially, surgeons indicated significantly greater need to correct C-arm movement and repeat fluoroscopy and more case delays due to miscommunication than radiology technicians. At 3 months, surgeons reported significant improvements in how often the C-arm movement had to be corrected due to miscommunication (p=0.007), frustration due to C-arm miscommunication (p=0.002), and frequency of operative delays due to C-arm miscommunication (p=0.03). At 1 month, participants were able to recall the standardized language terms 76.9% of the time (surgical attendings: 74.4%, radiology technicians: 79.2%). This decreased slightly to 72.2% at 3 months (surgical attendings: 66.7%, radiology technicians: 77.6%).</p> <p><strong>Conclusions:</strong> Training in a universal C-arm language significantly improved surgeon but not radiology technician experience using C-arm intraoperatively, with decreased frustration and perceived improvements in efficiency. There was good retention of the language terms at 3 months.</p> Ena Nielsen Jennifer M. Bauer Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-536 Pediatric Orthopaedic Surgery Research Quality: A Decade of Change at POSNA Annual Meetings from 2011-2020 <p><strong>Background</strong>: The Pediatric Orthopaedic Society of North America (POSNA) is a leading organization focused on disseminating research and promoting high-quality pediatric orthopaedic care. The purpose of our study was to understand how research quality in pediatric orthopaedic surgery has evolved over time by evaluating trends in clinical evidence and study design in podium presentations given at POSNA annual meetings from 2011-2020. </p> <p><strong>Methods</strong>: Podium presentation abstracts for all POSNA meetings from 2011-2020 were independently reviewed for number of study patients, single-center versus multicenter, randomized vs. non-randomized design, and abstract focus/topic. The level of evidence (LOE) assigned in the abstract program was also recorded. Chi-squared and Mann-Whitney U tests were used to compare differences in abstract characteristics between 2011-2015 and 2016-2020. Linear regressions were performed to analyze changes in level of evidence and the proportion of multicenter studies over time.</p> <p><strong>Results</strong>: A total of 1589 podium presentations were reviewed including 679 from 2011-2015 and 910 from 2016-2020, representing a 34% increase in the total number of presentations. The median number of patients per abstract was higher in 2016-2020 compared to 2011-2015 (81.5 vs. 49, p&lt;0.001). An increased proportion of presentations from 2016-2020 were multicenter (14.1% vs. 9.7%, p=0.009), with spine abstracts having the highest proportion of multicenter collaboration (23.9%, p=0.002). More studies from 2011-2015 focused on spine (19.5% vs. 14.9%, p=0.018). Overall, 4.9% of the presentations were categorized as Level 1 evidence, 18.5% level 2, 41.8% level 3, and 34.8% level 4. Between 2011-2020, the proportion of LOE 3 studies increased (p=0.039) and the proportion of LOE 4 studies approached a significant decrease (p=0.060). There was no change in the proportion of level 1 and 2 studies (p=0.416)<strong>.</strong></p> <p><strong>Conclusions</strong>: POSNA podium presentations have increased in number over the past decade, in large part due to the development of subspecialty day programs. This appears to have resulted in greater diversity in the academic program, with a lower proportion of spine abstracts over time. The LOE of POSNA presentations has increased with a higher proportion of level 3 and a lower proportion of level 4 evidence studies. More recent abstracts have evaluated higher numbers of patients and more commonly utilized multicenter study designs, suggesting improved collaboration.</p> Mitchell Johnson Hillary Mulvey Andrew Parambath Jason Anari Apurva Shah Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-499 Pediatric Musculoskeletal Infection Roundtable: Tips and Tricks for Streamlining Care for Common Scenarios <p>Musculoskeletal infections originate from pathogens introduced into the tissues via direct inoculation, through hematogenous spread, or via contiguous extension from adjacent areas of infection. In pediatric patients, these infections are a common cause of morbidity, with the possibility of long-term functional impairment. Prompt diagnosis and treatment are important to prevent irreversible damage to the bones and joint space, to decrease length of hospital stay, and to minimize treatment morbidity. While pediatric orthopaedic surgeons may definitively manage these cases, multidisciplinary collaboration provides the best outcomes for patients.</p> <p>Cases of severe musculoskeletal infection should be managed urgently or emergently. However, management decisions often vary between physicians and institutions, including when to perform imaging, whether to use sedation or contrast with MRIs, and whether to take these cases during daytime operating room block hours or overnight. Increasing data about bacteria, the immune response, and antibiotic susceptibility have influenced and standardized many hospital practice guidelines. However, interinstitutional variation in care pathways still exists and may be attributed to differences in endemic bacteria. Standardization of treatment algorithms and protocols improves patient outcomes, but they must be modified for regional bacterial prevalence and antibiograms. This manuscript addresses the management of common pediatric musculoskeletal infections through a case-based, roundtable approach with national experts. </p> Candice S. Legister Todd J. Blumberg Lawson Copley Jonathan Schoenecker Julia Sanders Daniel Miller Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-570 JPOSNA Quiz - Preventing SSI: What Do We Know, What Don’t We Know? <p>Surgical site infections (SSIs) are a devastating and resource-intensive complication of surgical intervention. The most recent, comprehensive data available suggests that the risk of surgical site infection in all orthopaedic procedures is approximately 1%.<sup>1</sup> In pediatric orthopaedic spine fusion procedures, SSI rates range from 1% in idiopathic scoliosis up to 19% in patients with myelomeningocele.<sup>2</sup> Financial costs associated with surgical treatment of SSIs in spine fusion patients are estimated to be from $66,000 up to $1 million.<sup>3</sup> Implant-heavy surgeries significantly increase the risk of a SSI, and accordingly, the surgeon aims to be extremely vigilant with these higher-risk situations. The majority of orthopaedic implants are made of materials that are avascular in nature and are therefore susceptible to infection and the formation of biofilms making eradication of the infection significantly more difficult.<sup>4</sup> The purpose of this quiz is to probe our knowledge of the history of antisepsis, the evolution of infection prevention, and current best practices applicable in pediatric orthopaedic surgery. How many of our actions are truly dogma and how many are evidenced based practice? What elements are historical and what elements are best practices? </p> Ryan P. Farmer Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-565 Pediatric Spine SSI: Res Ipsa Loquitur <p>We have made significant progress in minimizing the rate of surgical site infection (SSI) after pediatric spine surgery in the last 15 years. SSI are now uncommon in patients with adolescent idiopathic scoliosis, although still problematic in our patients with neuromuscular scoliosis with significant co-morbidities.<sup>1</sup> A spike in SSI at my institution in 2008 led us to think critically about how we could do better for these patients. Our exploration revealed no “smoking gun” (these spikes are almost always multifactorial, related to breaks in systems that allow errors to propagate through the “Swiss cheese”), and thus, we began a series of investigations.</p> <p>Working with my friends at Children’s Hospital of Los Angeles and Children’s Hospital of Philadelphia, we quickly learned that gram-negative infections were accounting for a significant percentage of these infections—not only in our New York experience but much more broadly.<sup>2</sup> Seeking to understand if there was a “best practice” for SSI prophylaxis, we performed a survey of POSNA members and discovered significant variability in practice patterns.<sup>3</sup> Unexplained clinical variability usually means that at least some patients are receiving suboptimal care. We then formally examined the evidence in this space and, not surprisingly, found a lack of high-quality evidence to guide practice in this area.<sup>4</sup> We became aware of the reality that significant practice variability and paltry evidence supported the current “best practices.”</p> <p>In order to gain consensus, we convened a group of experts and developed guidelines for best practices (BPG). The resulting BPG was published in <em>JPO </em>in 2013<sup>5</sup> and was the first of many such guidelines led by the Project for Safety in Spine Surgery ( The following year, our group experienced no SSI, leading us to reflect if infections should be a “never event.” Ten years later, rates of SSI remain much lower at our institution but also nationally as reflected in multiple papers using varying sources of data.<sup>6</sup> Most recently, Sponseller et al. (with the Harms Study Group as part of the Project for Safety in Spine Surgery, 2022 Spine Surgery Safety Month) updated these guidelines reflecting some new evidence and also some new thinking (See Best Practice Guidelines - SSI Prevention &amp; Treatment in High-risk Pediatric Surgery).</p> <p>In this <em>JPOSNA</em>® edition, Dr. Ryan Farmer shares a thoughtfully prepared quiz, and Dr. Ken Noonan provided me with an opportunity to reflect on where we have come from in the past and how we are doing now. The questions provided in this quiz point out some important issues and realities regarding our current understanding of what constitutes best practices for prophylaxis for the prevention of SSI. But while rates of SSI certainly seem lower than in the past, it is not exactly clear why this is. As supported by both the original and updated spine BPG, we have in many cases “thrown the kitchen sink” at the problem. For many reasons, we seem to pay more attention to SSI which may itself have a positive effect via the Hawthorne effect. Unfortunately, we actually do not have that much more high-quality evidence than we had 15 years ago. It should therefore be of no surprise that some of the “answers” in this quiz (which in some cases make intuitive sense) are not supported by consensus guidelines created by many of the “experts” in the aforementioned BPGs.</p> <p>SSI in pediatric spine is rare and often occurs as a result of a combination of complex interactive host, system, and clinical factors. Efforts to examine a single issue (e.g., comparative efficacy of CHG) are extremely limited by the biases which are essentially unavoidable in the design and conduct of this research. These methodological challenges to high-quality research in this area have led to some confusing findings resulting in mixed messaging about what the data is trying to tell us. When evidence is strong, it should always trump “expert opinion.” Unfortunately, the current evidence has not sufficiently improved upon knowledge present a decade ago when we were first confronted with this issue. Obviously, we need to be doing better in developing stronger evidence. Perhaps though, “res ipsa loquitur” (the thing speaks for itself). While rates of infection after spine surgery have certainly decreased, we can and should do better. We now have accurate models that allow us to identify higher-risk patients.<sup>7 </sup>And many of the proposed interventions have essentially no downside risk. To me, my obligation to the patient trumps my obligation to evidence. Until convinced otherwise, why not continue to change your gloves every 2 hours, place antibiotics in the wounds, keep temperature up, limit OR traffic, use topical skin disinfectant preoperatively, etc.?” As William Cowper said more than 200 years ago, “Absence of proof is not proof of absence.”</p> Michael G. Vitale Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-529 Management of Malunions and Nonunions Following Elbow Trauma <p style="font-weight: 400;">Fractures in children are common in pediatric orthopaedic practice with the majority having positive outcomes with standard treatment. However, complications can develop and clinicians should be aware of common sequelae of pediatric elbow trauma and understand their prevention and treatment. The focus of this article is to provide an overview of common sequelae following pediatric elbow trauma including malunions of supracondylar humerus fractures and nonunion of lateral condyle, radial neck, and medial epicondyle fractures.</p> K. Aaron Shaw Justin M. Hire The Trauma, Prevention, and Disaster Response Committee Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-566 Do Forearm Fracture Characteristics and Outcomes Differ Between Obese and Non-Obese Children? <p><strong>Background:</strong> Nearly one-third of children and adolescents are overweight or obese in the United States. This study aimed to explore the difference in injury characteristics and treatment outcomes between forearm fractures in children based upon weight status.</p> <p><strong>Methods:</strong> Four hundred and sixty-eight skeletally immature children sustaining forearm fractures between 2017-2019 were retrospectively reviewed. Demographics, injury characteristics, treatment methods, and complications were reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight (UN) versus overweight and obese (OO).</p> <p><strong>Results:</strong> The median age at injury was 10 years. The distribution of BMI categories was 4.1% underweight, 56.2% normal weight, 16.2% overweight and 23.5% obese. OO individuals were less likely to have angulated (&gt;10 degrees) fractures in any plane (34% vs. 45%) and less likely to require closed reduction (27% vs. 37%) compared to their UN peers. Those with an acceptable cast index (less than 0.8), regardless of weight, trended towards lower rates of loss of reduction compared to those with poor cast index (17% vs. 29%). No statistically significant differences were found in rates of open fracture, low energy mechanism, operative treatment, loss of reduction, or complications between OO and UN children.</p> <p><strong>Conclusions:</strong> Overweight and obese children sustain forearm fractures that are less angulated and require closed reduction at a lower rate. There are no differences in rates of open fracture, low energy mechanism, operative treatment, loss of reduction, or complications between overweight and normal-weight children treated for forearm fractures.</p> Madeline Lyons Patrick Cole McGregor Aaron Hoyt Amy Wozniak Teresa Cappello Felicity G. Fishman Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-437 Postop Spinal Fusion Pain and the Continued Neglect of Biopsychosocial Lens in Pediatric Orthopaedics <p>The recent <em>JPOSNA</em>® article by Younis et al.<sup>1</sup> represents a troubling, antiquated lens on chronic pain following posterior spinal fusion (PSF) that perpetuates confusion about its etiology and undermines optimal evaluation, prevention, and management. Importantly, chronic pain does not occur in a physical vacuum – it is impossible to understand how chronic pain develops after surgery using a narrow focus on tissue, inflammatory processes, or mechanical complications alone.</p> <p>Instead, a biopsychosocial perspective is needed to more clearly understand the development/persistence of chronic pain and prevent acute pain from transitioning to chronic following surgery.<sup>2</sup> In brief, a biopsychosocial conceptualization considers the combined and multi-directional contributions between biological (e.g., genetics, hormone abnormalities, comorbid disease, inflammatory response, nociception variation), psychological (e.g., premorbid psychiatric history, expectations, pain beliefs, maladaptive coping skills, thought patterns and perceptions, mood), and socioenvironmental components (e.g., extent of social support, socioeconomic factors, culture, health literacy, relationship with medical providers, interpersonal relationships). For example, pain catastrophizing (i.e., magnifying the threat of pain) and depressive symptoms can occasion persistent pain and undermine the course of recovery following musculoskeletal surgery.<sup>3</sup> Persistent pain can lead to a sense of helplessness, social withdrawal, and worsening mood, which further perpetuates movement avoidance behaviors, deterioration of musculoskeletal tissue, and deconditioning.<sup>4</sup> The biopsychosocial perspective is far from a novel concept across the extant literature. Bevers and colleagues highlighted that it has been “the most heuristic approach to chronic pain assessment, prevention, and treatment” since the 1970s.<sup>5</sup> There is a wealth of knowledge in orthopaedic, rheumatologic, and neuro-mediated processes of pain, and greater attention needs to be paid to synthesizing these contributors.<sup>4</sup> Psychological processes and socioenvironmental influences on pain have been well-documented for years,<sup>2,3,6,7</sup> and even highlighted in recent articles from this very journal!<sup>8</sup></p> <p>Given the “biopsychosocial model of pain dominates the scientific community’s understanding of chronic pain”<sup>6</sup> and provides important opportunities for optimizing treatment, we were disappointed to see only vague and over-simplified allusions to psychological and socioenvironmental pain contributors in the Younis et al. paper.<sup>1</sup> We encourage the <em>JPOSNA</em>® readership at large to more deliberately consider these influences and related opportunities to enhance pain care for patients undergoing PSF, particularly given literature demonstrating comprehensive pain interventions are both cost-effective and yield better outcomes relative to traditional management.<sup>9</sup> Pediatric health psychologists, as inherent experts on biopsychosocial care, are arguably some of the best-positioned specialists for integration into multidisciplinary management, whether in the form of routine preoperative behavioral health workup/clearance for PSF patients or as PRN postop care. While many medical specialties have routinely taken a multidisciplinary care approach for some time,<sup>10</sup> it remains more the exception than the rule in pediatric orthopaedics – even in the face of literature repeatedly demonstrating prevalent behavioral health and psychosocial problems in context of AIS management/surgical intervention and related risk of postoperative complications like elevated acute pain, chronic pain, impairments in health-related quality of life, greater hospitalization length of stay and cost.<sup>2,11-16</sup> Pediatric orthopaedics will do a great disservice to patients and families should we continue burying our heads in the sand, knowing there are critical opportunities to mitigate problems and address modifiable factors through the biopsychosocial lens.</p> Nicholas D. Young Chasity T. Brimeyer Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-583 Spine <p>Pediatric spine surgeons coding their cases benefit from a more limited number of typical procedures compared to other subspecialties. However, each surgery involves several CPT codes and their details can be confusing. Many of us adopt the coding of our training mentors, but different hospital billing teams may understand operative dictations differently, new procedures may have been introduced since then, and as in a game of telephone, some misinterpretation may occur as coding wisdom is passed down. We aim to address the coding of some of the most common pediatric spine procedures to help new surgeons while also covering some details that even the most experienced will gain new insight into. As always, these are meant as examples and ultimately, your coding should reflect what you did in the operation.</p> Jennifer M. Bauer Sarah Wiskerchen Ryan D. Muchow Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-603 Spanish Language Resources for Patients with Developmental Dysplasia of the Hip <p><strong>Background:</strong> In the United States, the majority of patient educational material is written in English, thereby limiting the available resources for the growing Spanish-speaking population. Developmental dysplasia of the hip (DDH) commonly affects Hispanic patients and patient education is integral to the successful management of this condition. This study aims to analyze the readability and availability of Spanish and English patient education on DDH provided by the top 50 pediatric orthopedic hospitals and the major professional societies. </p> <p><span style="font-weight: bolder; font-size: 0.875rem;">Methods: </span><span style="font-size: 0.875rem;">We performed a cross-sectional analysis by determining the proportion of top 50 pediatric orthopedic hospitals and major professional societies providing English and Spanish resources. We also assessed the readability of the information provided via three measures of readability. Descriptive, univariate, and multivariate analyses were performed.</span></p> <p><strong>Results:</strong> Of the top 50 hospitals ranked by US News, 84% (42/50) provided English language patient education on DDH. In contrast, only 36% (18/50) of the hospitals provided a Spanish language patient education. All of the major orthopedic professional societies provided English resources, but only 2 out of 3 professional societies provided Spanish resources. There were no significant differences in the rates of Spanish language resources and their readability scores between states that had greater or less than 20% Spanish-speaking population (p &gt; 0.05). However, English language materials consistently ranked higher in grade level (9th grade vs 7-8th grade, p&lt;0.01) and readability measures (11.70 vs 10.18, p&lt;0.01) than Spanish materials on DDH. </p> <p><strong>Conclusion:</strong> The availability of Spanish patient education resources is limited, despite the growing Spanish-speaking population in the United States. In states with more than 20% of patients that are Spanish speaking, there was no significant increase in the available Spanish language resources, indicating a discordance between educational materials and patient populations. The readability of written materials continues to be above the recommended level for patient education.</p> Laura Mendoza Siobhan Mitchell Ishaan Swarup Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-472 The Etiology and Management of Slipped Capital Femoral Epiphysis <p><strong>Purpose: </strong>The purpose of this review is to discuss the insights into slipped capital femoral epiphysis (SCFE) gained during the last decade, including a proposed rotational pathomechanism, the importance of epiphyseal morphology, subclinical endocrinopathies and atypical SCFE, and updates to current management practices.</p> <p><strong>Pathophysiology: </strong>Growing literature has highlighted the importance of the epiphyseal tubercle as a ‘keystone’ stabilizer of the proximal femoral epiphysis. Both anatomic and clinical studies recently demonstrated that the epiphysis rotates around the epiphyseal tubercle during SCFE. Clinical endocrinopathies contribute to the pathogenesis of SCFE, though recently the effects of subclinical endocrine derangements such as hyperinsulinism and leptin abnormalities have been demonstrated to play a role in SCFE.</p> <p><strong>Diagnosis: </strong>The standard diagnostic tools for SCFE remain the antero-posterior pelvis and frog-leg lateral radiograph. The importance of imaging bilateral hips is well known, due to the increased incidence of contralateral slip development in SCFE patients. Additionally, due to increased knowledge of atypical SCFE, patients with positive age-weight or age-height testing are also recommended to undergo further endocrine workup due to the high likelihood of atypical SCFE in these patients.</p> <p><strong>Management: </strong>In-situ pinning remains the gold standard treatment of SCFE. Use of two-screws is mainly reserved for unstable or severe slips, while one-screw fixation remains the standard for mild-moderate slips. Contralateral prophylactic pinning is typically considered in those patients at high risk for contralateral slip, including those with endocrine risk factors, skeletal immaturity via modified oxford bone age, or aberrant radiographic parameters such as posterior epiphyseal tilt or posterior sloping angle. Novel techniques including intraoperative epiphyseal perfusion monitoring have provided insight into reducing complications such as avascular necrosis and have shown the benefit of intracapsular hematoma decompression for unstable SCFE. Open surgical management via the modified Dunn procedure should be cautiously considered, as high rates of osteonecrosis have been reported due to the vulnerable blood supply of the proximal femoral head.</p> Shamrez Haider David A. Podeszwa William Z. Morris Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-589 Use of 3D Imaging in Planning Varus Derotation Osteotomy in Neuromuscular Hip Subluxation <p>Proximal femur varus derotation osteotomy (VDRO) is the primary component of hip reconstruction surgery for the management of hip subluxation/dislocation in patients with neuromuscular dysplasia. Understanding the pathophysiology and abnormal proximal femur geometry is crucial to performing a successful surgery and dosing the surgical correction accurately. Children with neuromuscular hip dysplasia experience increased coxa valga, femoral anteversion and variable degrees of acetabular dysplasia. Understanding the relationship between these three anatomic aberrations can be difficult with standard two-dimension plain radiography. In this paper, we will review our novel three-dimensional imaging protocol to assess the pathologic anatomy of the proximal femur and acetabulum in children undergoing neuromuscular hip reconstruction. Understanding the anatomic relationship between the neck shaft angle, anteversion and acetabular dysplasia aids in the planning and execution of effective VDRO and hip reconstruction surgery.</p> Blake Montgomery Delma Jarrett Donna Agahigian Colyn Watkins Benjamin Shore Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-562 A Multidisciplinary Perioperative Care Coordination Pathway for Hip and Spine Reconstruction in Non-ambulatory Patients with Cerebral Palsy <p>Many non-ambulatory children with cerebral palsy (CP) who are indicated for hip reconstruction and/or spine surgery are medically complex and thus high-risk surgical candidates. A well-coordinated, multidisciplinary team approach to the care of these youth is essential to reduce the risk of perioperative complications. This review offers an evidence-based overview covering interventions that have been shown to improve safety and outcomes after hip and spine surgery in non-ambulatory CP. Specifically, this review will focus on the team approach to perioperative care coordination with the goals of optimizing medical and nutritional status, reducing postoperative complications, and improving patient and family satisfaction. Further, this review will highlight the associated care pathway utilized at Nemours Children’s Health-Delaware, in addition to highlighting key measures that may be adopted by other institutions to help foster organizational cultures that prioritize family-centered care. </p> Arianna Trionfo Margaret Salzbrenner Jason J. Howard M. Wade Shrader Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-585 Multidisciplinary Approach to Optimize the Health of Children with Medical Complexity Undergoing Orthopaedic Surgery <p><strong>Background:</strong> The study objective was to determine whether a multidisciplinary<u>,</u> comprehensive preoperative assessment and co-management structure improved the perioperative course in children with medical complexity (CMC) undergoing orthopaedic surgery. Data was collected from three phases, standard of care, partial optimization review process, and full optimization review process. By the last phase, patients were seen for a pre-surgical optimization review by the pediatric nurse practitioner (PNP), followed by coordination with the pediatric complex care team and the patient’s sub-specialty providers. Gaps in the patient’s care that would limit clearance for surgery, as identified during the optimization review, were addressed and then comprehensive care plans were created preoperatively. Patients were treated postoperatively with a co-management framework between the pediatric medical management teams and orthopaedic services<strong>. </strong></p> <p><strong>Results</strong>: There were 90 children who met inclusion criteria for retrospective chart review. Cerebral palsy was the leading primary diagnosis (n=62). Posterior spinal fusion (n=37) and hip containment (n=37) procedures were the most frequent procedures. Twenty nine children underwent formal review with a statistically significant increase in review completion between phase 2 and phase 3 (p=0.001). A statistically significant number of patients who underwent review were found to have gaps in care (n=21; p= &lt;0.00001). Additionally, patients reviewed were 1.92 times more likely to receive anticipatory guidance than patients who did not have review (p= &lt; 0.00001). Length of stay for children undergoing review was relatively stable at 3.18 days compared to 3.51 days for those who did not undergo review. There was a decreased time to resumption of enteral feeds by 51.3% (p=0.007743). Most notably, there was elimination of rapid responses and transfers to higher level of care in patients that underwent health optimization. Among phases there was a 42.8% reduction in post-operative complications. This reduction however did not correlate directly with those who received health optimization review versus those that did not (p=0.954068).</p> <p><strong>Conclusion:</strong> A preoperative optimization program and co-management model improves the CMC’s surgical readiness and postoperative outcomes.</p> Sheila L. Mason Megyn R. Sebesta Sybil Snow John Frino Bettina Gyr Savithri Nageswaran Jeanna R. Auriemma Cara Haberman Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-490 The Hidden Cost of Growth-Friendly Treatment for Early Onset Scoliosis <p style="font-weight: 400;">Surgical treatment of early-onset scoliosis (EOS) presents unique challenges because of the long period of treatment and multiple surgical interventions. Current surgical techniques are successful in terms of deformity correction, but by looking at a wider perspective, one can see that there is much more to EOS than the radiographic deformity.</p> <p style="font-weight: 400;">Growth-friendly treatment with growing rods have the potential to allow sufficient pulmonary development to prevent cardiopulmonary disease. Recent evidence suggests that improvements in pulmonary functions are somehow lower than expected, and repetitive procedures can result in a stiff thoracic cage.</p> <p style="font-weight: 400;">Surgical stress is well-known to affect the psychosocial status of a child, and EOS treatment with repetitive surgeries can be overwhelming. Recent studies show significant deteriorations in the child and parents’ psychosocial status not only during the treatment period but even after the surgical treatment is over.</p> <p style="font-weight: 400;">Metal ion release is another important issue to consider. Serum levels, especially for titanium, may remain elevated longer than expected. Radiation exposure of patients with EOS is also higher than the general population, and even with the new imaging techniques reducing ionizing radiation exposure, there could still be long-term effects that are yet unclear.</p> <p style="font-weight: 400;">The summary of literature we provided in this comprehensive review aims to emphasize that EOS is not solely a musculoskeletal disorder, but more of a systemic one. Surgical treatment may bring lifelong impacts on the patient’s health, some being iatrogenic and others more of a disease-related nature. The non-spine outcomes of EOS treatment should not be overlooked.</p> Riza Mert Cetik Muharrem Yazici Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-577 Surgical Techniques for Adolescent Lumbar Spondylolisthesis <p>Lumbar spondylolisthesis in adolescents is a common cause of back pain. Low-grade spondylolisthesis usually responds to non-surgical treatment. High-grade spondylolisthesis often requires surgery for relief of symptoms. The primary goals in surgical treatment of adolescent lumbar spondylolisthesis (L5-S1) are relief of back and radicular pain, relief of any motor weakness from nerve compression, and achieving a stable spinal fusion. Optimal surgical strategy is debated with questions regarding need for reduction of deformity, choice of spinal instrumentation, use of interbody fusion, and choice of bone graft. This overview will review commonly used surgical techniques with a focus on pearls and pitfalls of each. Recommended post-operative care and management of common complications will conclude this review. </p> Diana G. Douleh Graham Albert Sumeet Garg Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-545 Impact of the COVID-19 Pandemic on Health-related Quality of Life in Children with Early Onset Scoliosis <p><strong>Background: </strong>Throughout the COVID-19 pandemic, decreases in health-related quality of life (HRQoL) have been observed in adults and children, with isolation, economic disruption, school closures, and health-related anxiety likely contributing. In this study, we evaluated the impact of COVID-19 on self-reported HRQoL of EOS patients and their caregivers using the Early Onset Scoliosis Questionnaire-24 (EOSQ-24).</p> <p><strong>Methods: </strong>Patients with EOS and their caregivers enrolled in the Pediatric Spine Study Group (PSSG) registry with EOSQ scores from the year before the COVID-19 pandemic and the first year during COVID-19 were included. Two years of before-COVID-19 baseline EOSQ scores were recorded for each patient. We recorded patient medical demographics, scoliosis etiology, and comorbidities.</p> <p><strong>Results: </strong>618 patients met inclusion criteria (255 male, 363 female). All EOSQ subscores increased significantly from pre-COVID to early-COVID (p &lt; 0.001, p &lt; 0.05, respectively), though the mean difference was well below the proposed EOSQ-24 MCID. There was no evidence of change in Combined HRQoL or impact- and satisfaction-related scores between early COVID to late COVID (p &gt; 0.37). When stratified by etiology, there was no evidence of decrease in the HRQoL combined score or other subscores in any subgroup between pre-COVID and during COVID.</p> <p><strong>Conclusions: </strong>Overall, there was no evidence of negative impact on HRQoL by the COVID-19 pandemic for children with EOS or their caregivers. In the future, protective factors contributing to the resilience of this population may be explored further.</p> Jennifer A. Kunes Divya Raman Hiroko Matsumoto Afrain Boby Sumeet Garg Joshua Pahys Benjamin Roye Michael G. Vitale Pediatric Spine Study Group Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-533 Editor's Note Ken Noonan Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-607 Message from the President <p>Fall is upon us, leaves are turning, kids are back at school, and football season is in full swing. It is a good time to reflect on the past year as well as look forward to the upcoming holidays and the year ahead. As we prepare to publish <em>JPOSNA®</em> Volume 4, Number 4, we here are doing the same thing.</p> <p>Over the past year, <em>JPOSNA®</em> has continued to develop and grow into one of the leading journals in Pediatric Orthopaedics, due in part to our unique ability to publish not only original research but also things that traditional journals are unable to such as surgical technique/tip videos, expert panel discussions, coding tips, and interesting commentary. This edition continues that mission with a wide range of topics, formats, and articles from a diverse group of authors. This year, we have expanded our reach and published our first supplement: <em>Advances in Pediatric Orthopaedic Education and Technical Training</em>, edited by Elizabeth Hubbard, MD. It is the flexibility afforded to us by owning our own journal that allows us to produce incredibly valuable and relevant work like this that could not be published in a traditional orthopaedic journal.</p> <p>Soon our second supplement, edited by Julie Samora, MD, PhD, highlighting the 2022 Annual Meeting Pre-Course on Diversity, Equity, and Inclusion will be published as well. Even more exciting is that only two short years ago, the publishing industry looked at <em>JPOSNA®</em> as an “unproven startup concept,” and now we are viewed as a unique, interesting, and successful journal. It has quickly become the home for the best and latest information in Pediatric Orthopaedics worldwide. We are continuing to explore opportunities that can further expand the reach and value of <em>JPOSNA®</em> while staying true to its mission, including pursuing a path to PubMed listing which is underway.</p> <p>As an organization, POSNA is doing the same thing, and this past year has been exceptional. We have not only survived the COVID-19 pandemic but thrived and come out as a better, stronger, and more resilient organization. Interest in IPOS® 2022 and the Annual Meeting in Nashville in 2023 is strong and shows us the value of face-to-face interaction, both personally and professionally. The opportunity at this time is to be able to critically assess and leave behind things that no longer worked for us, leaving us more time and energy for those things that do. There are many initiatives underway to streamline and improve our committee structure and the CAP process, our meeting structure/footprint, educational platforms, our operational budget and organizational structure, and industry relations to name a few.</p> <p>One topic that deserves special attention is technology, as it impacts almost everything we do as an organization and as a journal, and this will become even more important in the future. We have seen a rapid expansion in the use of technology in educational webinars, podcasts, and meetings. We have tremendous value in our digital content in POSNAcademy, OrthoKids, POSNA Study Guide as well as <em>JPOSNA®</em>. Our ability to own, control, and use this content to further our educational mission allows us tremendous flexibility and adaptability. For this reason, we have asked a working group, led by Bryan Tompkins, MD, Todd Milbrandt, MD, and Jaysson Brooks, MD, to put together a Ten Year Technology Timeline to help us assess where POSNA is in regard to technology and what our needs might be over the next decade. To assist us, we are in the process of identifying a consultant to assess our current organizational technology structure, identify our strengths and weaknesses, and help us position ourselves in an optimal way in the future.</p> <p>This is truly an exciting time for <em>JPOSNA®</em> and POSNA as we move into 2023 and beyond. With all these advances, it is also important to remember that at the heart of all these successes are our people. This is your journal, your organization, and your professional “home.” Thank you to all of you who volunteer your time, energy, and support to further our mission. One person who needs a special mention is Lisa DuShane, our Managing Editor, who joined the editorial staff in 2021. Her energy, passion, and many years of experience as well as her calm nature even around stressful deadlines make us truly better as a journal and as an organization.</p> <p>As the year comes to an end, we hope that you will consider POSNA in your charitable giving through POSNA Direct, if you haven’t done so already. We are a volunteer organization, and in these uncertain economic times, your financial support will allow our amazing work to improve the musculoskeletal care of children to continue and grow.</p> <p>On a personal note, I would like to thank all of you for the tremendous amount of energy, passion, and work that you all do. It is an honor and a privilege to lead this organization. I hope you have a wonderful holiday season with your family, friends, and colleagues, and look forward to an even more incredible 2023.</p> Jeffrey R. Sawyer Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-608 Regional and Local Anesthesia in Pediatric Orthopaedic Surgery <p style="font-weight: 400;">Pediatric orthopaedic surgical procedures require a thoughtful multimodal approach to perioperative pain management that maximizes both patient comfort and safety. Local infiltrative anesthesia (LIA) has been commonly used with a variety of formulations and application methods. However, local anesthesia provides limited anatomic coverage over a relatively short length of time. In comparison, regional anesthesia can provide increased anatomic coverage over a longer duration by applying anesthetic medication directly around a targeted peripheral nerve or nerves. Peripheral nerve blocks (PNB) have become commonly used in pediatric and adolescent sports medicine procedures, especially for anterior cruciate ligament reconstructions (ACLR), but there is wide variation in how PNBs are performed with limited evidence in support of their overall benefits in children relative to potential complications, such as prolonged sensory or motor nerve paralysis. Even less is known about their use and indications for a variety of non-sports pediatric orthopaedic procedures. This article provides a review of the uses and indications of both local and regional anesthesia in pediatric orthopaedics with a discussion of the available evidence in the literature on safety and efficacy.</p> Zachary Stinson Yasmine S. Ghattas Allison Crepeau Bridget M. Oei Kelly VanderHave Samuel Gammerman Kevin Finkel Eapen Mathew Copyright (c) 2022 Journal of the Pediatric Orthopaedic Society of North America 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-579 Age as a Prognostic Factor in Arthroscopic Drilling of Juvenile Osteochondritis Dissecans of the Knee: A National Database Review <p><strong>Background:</strong> Juvenile Osteochondritis Dissecans (JOCD) is a common knee condition that can cause significant morbidity if the lesion does not heal. Arthroscopic drilling is a common surgical treatment for low-grade intact lesions, but its success rate and complications have not been well defined in a large series.</p> <p><strong>Purpose:</strong> This study seeks to determine the reoperation rate and the incidence of major complications following arthroscopic drilling of JOCD lesions of the knee.</p> <p><strong>Methods:</strong> A query of patients in the Pediatric Health Information System (PHIS) database from 2013 to 2018 was performed for the diagnosis and billing codes specific for arthroscopic drilling of an intact JOCD lesion. Subsequent surgical procedures on ipsilateral and contralateral knees were then analyzed for evidence of additional surgical procedures related to non-healing of the lesion.</p> <p><strong>Results:</strong> We identified 1027 patients, 6-17 years of age, who underwent arthroscopic drilling as their initial surgical treatment for a diagnosis of JOCD of the knee. Within 6 months of the original surgery, 27 patients (3%) had a secondary surgery on the ipsilateral knee and 27 patients (3%) had surgery on the contralateral knee. By 2 years, 84 patients (8%) had a secondary surgery on the ipsilateral knee and 38 patients (4%) had surgery on the contralateral knee. Patient age was a significant factor in both the frequency and invasiveness of secondary surgeries, with older patients requiring repeat procedures and more invasive procedures more frequently. Less than 1% of patients underwent another surgical procedure of the knee not specifically to treat the JOCD lesion.</p> <p><strong>Conclusions:</strong> The 2-year reoperation rate following drilling of an intact juvenile OCD lesion was 8%. Younger patients were less likely to undergo a subsequent procedure compared to older patients. In addition, if they did require a second procedure, younger patients were less likely to require a salvage-type cartilage procedure. The rate of complications requiring additional knee surgeries was less than 1%.</p> <p> </p> David Isaacs Soroush Baghdadi Alexander Lee Thaddeus Woodard Nishank N. Mehta Divya Talwar Silas Morsink J. Todd Lawrence Copyright (c) 2022 JPOSNA® 2022-11-01 2022-11-01 4 4 10.55275/JPOSNA-2022-503