JPOSNA® 2022-05-02T06:10:11-06:00 POSNA Staff Open Journal Systems <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> Message from the President 2022-05-01T17:33:49-06:00 Mininder S. Kocher <p>In this issue of <em>JPOSNA</em><em>®</em>, the History &amp; Archives Committee present an historical perspective: <em>POSNA: Where Are We Now?</em> Dr. Hugh Watts wrote an amazing <a href="">history of POSNA from 1971 to 1996</a>. Dr. Scott Rosenfeld and the History &amp; Archives Committee have worked hard to update this history.</p> <p>It is important for us as pediatric orthopaedic surgeons to know our past, present, and future.</p> <p><strong>PAST:</strong> Prior to 1969, the practice of orthopaedic surgery restricted to children alone was unusual. The Pediatric Orthopaedic Society (POS) was formed in 1971 by 12 surgeons: Drs. Bianco, Coleman, Curtis, Green, Griffin, Lovell, MacEwen, McKay, Ryder, Samilson, Stelling, and Tachdjian. In 1974, Drs. Hamlet Peterson of the Mayo Clinic and Henry Cowell of the duPont Institute believed that the young pediatric orthopaedists needed their own forum and formed the Pediatric Orthopaedic Study Group (POSG) and included Drs. Cowell and Peterson as well as Badger, Eilert, Gallien, Hensinger, Klassen, Lyne, and Simons. After trials, tribulations, and negotiation, the two groups (POS &amp; POSG) merged in 1984 to form POSNA. Dr. John Roberts, the first President of POSNA, chose a logo and a Latin motto: <em>Pueri Providentur Melius Coniunctis</em> (we unite to take better care of children). The logo was two bent trees with a single stake, representing the two societies coming together under a common collective leadership. Many of the senior members lived through this transition and through the formation of this new society, POSNA. They are members of our Hall of Fame and we should hear and appreciate their stories. Our history is one of collaboration in the best interest of the musculoskeletal care of children.</p> <p><strong>PRESENT:</strong>&nbsp; Over the last 2+ years, POSNA has struggled (like we all have personally and professionally) with COVID. The pandemic resulted in virtual board meetings, changing the 2020 Annual Meeting to virtual, cancelling 2020 IPOS®, changing the 2021 Annual Meeting to hybrid, and affected access to pediatric orthopaedic care, education, and advocacy. As such, POSNA has had to adjust meetings, finances, and procedures. Nevertheless, POSNA remains strong. Membership continues to grow, and the acceptance of new members this year is the largest in POSNA history. POSNA continues to deliver on its core competencies: education, research, and advocacy. Although finances have been altered by the impact of in-person meetings, POSNA has remained financially strong with an increase in net assets through membership, industry support, investments, hybrid meetings. We have successfully navigated the transition to independent management and new headquarters. We recently completed an effective strategic plan and we have examined best practices for corporate governance. We are blessed with talented and dedicated staff led by our Executive Director Teri Stech. POSNA has been able to implement a number of important initiatives including <em>JPOSNA</em><em>®</em>, diversity activities, and committee streamlining. POSNA is fueled by volunteers on the board, in committees, and in membership who care and support their professional home. &nbsp;&nbsp;</p> <p><strong>FUTURE:</strong> The future of POSNA is bright. The future includes increasing diversity efforts in pediatric orthopaedics. We will lead orthopaedics overall with increased membership and leadership of women and underrepresented minorities. We also will successfully navigate the “new normal” in education: in-person and virtual education. We will continue to advocate for the musculoskeletal care of children and we will lead the way with our QSVI efforts including the POSNA Safe Surgery Program (PSSP). We will continue to fund pediatric orthopaedic research and identify areas of key research importance. <em>JPOSNA</em><em>®</em> will include original scientific research and will become the preeminent scientific journal in pediatric orthopaedics. Most importantly, we will protect and nurture the secret sauce of POSNA: our culture, collaboration, friendship, and fun!</p> <p>Mininder S. Kocher, MD, MPH<br>President, POSNA</p> <p>&nbsp;</p> 2022-04-27T08:49:35-06:00 Copyright (c) 2022 JPOSNA® The Pediatric Orthopaedic Society of North America: Where Are We Now? 2022-05-02T06:10:11-06:00 Heather Kong Zachary Meyer Oussama Abousamra Sarah Nossov Scott Rosenfeld POSNA History & Archives Committee <p>The Pediatric Orthopaedic Society of North America (POSNA) is excited to celebrate 50 years of the subspecialty of pediatric orthopaedic surgery in North America.&nbsp; In 1996, Dr. Hugh Watts, POSNA historian from 1992-1999, wrote a very detailed and personal account of the first 25 years of the pediatric orthopaedic societies in North America (1971-1996).&nbsp; The current members of the History &amp; Archives Committee of POSNA have sought to expand on this historical account, with notable updates from the past 25 years (1996-2021).&nbsp; These highlights are certainly not comprehensive, but seek to touch on POSNA’s missional pillars of membership, education, research, patient care and advocacy.&nbsp;&nbsp;</p> 2022-04-28T08:53:36-06:00 Copyright (c) 2022 JPOSNA® POGO Travel Journal: Tenwek Hospital in Bomet, Kenya 2022-05-01T17:33:50-06:00 Amanda J. McCoy <p>This article shares the perspective and experience of an early career pediatric orthopaedic surgeon at a mission hospital in Kenya, where she spent nearly her first three years in practice.&nbsp; She shares the reasoning behind her decision to engage in full-time global orthopaedics work as well as some of the logistical aspects of planning for the transition to international practice.&nbsp; Trauma, osteomyelitis, and COVID-19 are focal points of sharing her experience.&nbsp; The role of historical social and political injustice and its contribution to local and global health inequity is explored, emphasizing the importance of simultaneously pursuing global and local health justice.</p> 2022-04-19T06:25:06-06:00 Copyright (c) 2022 JPOSNA® Coding Challenges in Common Pediatric and Adolescent Hip Preservation Procedures 2022-05-01T17:33:50-06:00 David D. Spence Sarah Wiskerchen Christopher A. Makarewich Alfred A. Mansour III Courtney M. Selberg Geovanny F. Oleas-Santillan Jonathan R. Schiller Grant D. Hogue POSNA QSVI Hip/Lower Extremity Committee <p>Pediatric and adolescent hip preservation is a rapidly evolving subspecialty that envelopes clinical and technical aspects of other subspecialties such as sports medicine and adult joint reconstruction. Despite many of the techniques having been established for several decades, numerous procedures performed in this field do not have corresponding CPT codes resulting in considerable variability in how different surgeons code for the same procedure. This article presents case scenarios for common hip pathologies treated surgically by pediatric orthopaedic surgeons. The intent is to clarify some discrepancies in coding for these procedures and aid the surgeon in proper billing. It is important to note that the following scenarios are hypothetical and therefore ultimate code selection should always reflect the procedure performed and reported within the operative documentation.</p> 2022-04-18T00:00:00-06:00 Copyright (c) 2022 JPOSNA® Estimating Skeletal Age in Children: A Comprehensive Anatomic Approach 2022-05-01T17:33:50-06:00 Evan W. Beatty Tasha L. McAbee Andrew T. Pennock Mininder S. Kocher Benton E. Heyworth <p>Skeletal maturity is a critical consideration for pediatric orthopedic surgeons, general pediatricians, endocrinologists, metabolic bone disease specialists, rheumatologists, and physiatrists in the development and modification of treatment plans for growing children. Arguably the most widely utilized method of determining skeletal age, the Greulich and Pyle method (GPM), unfortunately has many shortcomings. Between the method reflecting limited population metrics and its reliance on a voluminous hard-copy radiographic atlas, the GPM may not lend itself to widespread use or optimized learning in the modern era of orthopedics. In 2013, the Shorthand Bone Age (SBA) method suggested a simpler approach by demonstrating reliability when just a single feature for each skeletal age, depending on patient sex, was sufficient in providing an accurate bone age estimate reflective of the full GPM. In addition to the SBA, an expanding body of research has emerged over the past two decades, attempting to provide the orthopedic community with simpler yet effective tools to determine skeletal age. In this review, we compare and present the spectrum of current concepts encompassing validated bone age determination methods for each of six commonly imaged anatomic locations: hand/wrist, elbow, shoulder/proximal humerus, hip/pelvis, knee, foot/ankle. All methods are presented visually in table format, with detailed graphic design, quantitative approximations to generate relative consistency between systems, and age-based color-coding for ease of memorization and use. All images are derived from patients presenting to the study institution within the past three months, so as to harness modern image quality and populations while also adhering to the principles and age-based features inherent to each system’s different categories. The purpose of this review is multifaceted: to enable better incorporation of skeletal age considerations into daily practice by caregivers in many disciplines; to enhance awareness regarding the full array of tools that may spare young patients additional and unnecessary radiation; and to serve as a springboard for a mobile application to be utilized in any clinical setting by anyone with a mobile device.</p> 2022-04-21T08:50:10-06:00 Copyright (c) 2022 JPOSNA® #PediPodsOnline: Social Media Use in Pediatric Orthopaedic Surgery 2022-05-01T17:33:50-06:00 Philip Nowicki Craig Louer Jr. Corinna Franklin Carter Clement POSNA Public Education and Media Relations Committee <p>This editorial from the Public Education and Media Relations Committee of the Pediatric Orthopaedic Society of North America (POSNA) provides a primer for pediatric orthopaedists on the use of social media in practice. It is an adjunct to the recently produced podcast focused on the same subject. Social media has proven to be a useful means for physicians to educate patients and colleagues, collaborate with peers, and promote causes and organizations to optimize overall orthopaedic patient care. Social media ambassador members from POSNA discuss ways to get started, use, and stay out of trouble when navigating the social media arena.</p> 2022-04-19T06:33:13-06:00 Copyright (c) 2022 JPOSNA® The Pin: An Orthopaedic Transformation 2022-05-01T17:33:50-06:00 Sarah E. Lindsay Stephanie Holmes Jonas Owen Ishaan Swarup Matthew Halsey <div>The stainless-steel pin has become an important part of operative orthopaedics over the last several decades. It is used&nbsp;in all subspecialties as tool to localize a lesion or to effectuate reduction, as a conduit for implant placement (screw or&nbsp;blade plate), as a guide for making an osteotomy, and as an implant that can stabilize bone whether it is placed in an&nbsp;open or percutaneous manner. While simple and ubiquitous to the craft of orthopaedics, it has revolutionized the care of&nbsp;children with orthopaedic conditions. This review highlights the history and the applications of the simple pin that can&nbsp;assist in obtaining good results in common problems.</div> <p>&nbsp;</p> 2022-04-27T16:31:48-06:00 Copyright (c) 2022 JPOSNA® Variations in the Preferred Treatment of Pediatric Forearm Fractures Among Practicing Orthopaedic Surgeons 2022-05-01T17:33:51-06:00 Devan D. Patel Nathan N. O'Hara Giorgina M. Giampaolo Joshua M. Abzug Aristides I. Cruz Jr. <p><strong>Background: </strong>Forearm fractures are common childhood injuries. Controversy remains on the optimal treatment for certain fractures. The goal of this study was to determine variation in the treatment of pediatric forearm fractures based on fracture patterns, patient demographics, and surgeon characteristics.</p> <p><strong>Methods: </strong>A survey was distributed to orthopedic surgeons consisting of 48 different cases of pediatric forearm fractures with possible treatment options. Each case included patient age and radiographs at three different time intervals: initial injury, post reduction, and first office follow-up. Respondents were asked if they would recommend non-surgical management, surgery with intramedullary nailing, or surgery with plate/screw fixation. Surgeon demographic data was also collected. The primary model investigated the effect of the attributes on the surgeon’s decision to operate.</p> <p><strong>Results: </strong>48 of 55 surgeons responded. Surgery was chosen as preferred treatment in 43% of the presented scenarios. Coronal plane angulation at first follow-up was associated with the greatest increase in marginal probability of operative treatment. For each degree increase in angulation, respondents were 5.2% more likely to operate on a patient. For each additional year of patient age, operative treatment probability increased by 3.9%. Surgeons’ sex, age, years in practice, and fellowship type were not associated with variations in treatment preferences.</p> <p><strong>Conclusions: </strong>Our study demonstrates significant variability in treatment recommendations amongst orthopedic surgeons with regard to pediatric forearm fractures. Patient age and coronal plane angulation at first follow-up increased the probability of choosing operative treatment among respondents. Surgeon characteristics did not predict treatment recommendations.</p> 2022-04-19T06:29:02-06:00 Copyright (c) 2022 JPOSNA® Pediatric Femoral Shaft Fracture Classification: An Intraobserver and Interobserver Reliability Study 2022-05-01T17:33:51-06:00 Padam Kumar Richard Hillesheim Jeffrey Sawyer James Beaty David Spence William Warner Benjamin Sheffer Derek M. Kelly <p><strong>Purpose:</strong> Fracture stability is important in choosing the optimal treatment for pediatric femoral fractures, although there is no consensus for characterizing a fracture as “stable” or “unstable.” The authors sought to measure interobserver and intraobserver reliability in classifying femoral fracture stability and examined the relationship between fracture ratio and perceived fracture stability and morphology.</p> <p><strong>Methods:</strong> Fracture ratios were calculated from anteroposterior and lateral radiographs from 65 children aged 5 to 12 years, who were treated for femoral shaft fractures at a level 1 pediatric trauma center. Deidentified radiographs were placed into a PowerPoint presentation in random order and were shown to six fellowship-trained pediatric orthopaedic surgeons at two time points, 4 months apart. Raters classified stability as “stable/unstable” and morphology as “spiral/oblique/transverse.” Cohen and Fleiss kappa (k) values were calculated to determine intraobserver and interobserver reliability. Generalized linear modeling was used to compare FR to rater fracture stability and morphology.</p> <p><strong>Results:</strong> The mean k for fracture stability for all raters was 0.68 (strong intraobserver agreement). The k for fracture stability during Round 1 was 0.53 (67.7% interobserver agreement, moderate). The k for fracture stability during Round 2 was 0.68 (75.4% interobserver agreement, strong). The mean k for fracture morphology for all raters was 0.79 (strong intraobserver agreement). The k for fracture morphology during Round 1 was 0.38 (15.4% agreement, fair). The k for fracture morphology during Round 2 was 0.46 (24.6% agreement, moderate). The average anteroposterior ratio in stable fractures was 1.32 compared with 1.78 in unstable fractures (P &lt; 0.001). The average lateral ratio in stable fractures was 1.34 compared with 2.10 in unstable fractures (P &lt; 0.001). Average anteroposterior and lateral ratios were highest in spiral fractures and lowest in transverse fractures (P &lt; 0.003).</p> <p><strong>Conclusions:</strong> Raters demonstrated strong intraobserver and interobserver agreement in classifying radiographic femoral fracture stability. Anteroposterior and lateral fracture ratios were significantly higher in unstable fractures.</p> 2022-04-19T11:19:38-06:00 Copyright (c) 2022 JPOSNA® Traumatic Hip Dislocations in the Pediatric Patient: Injury Patterns, Need for Axial Imaging, Outcomes, and Selective Hip Arthroscopy 2022-05-01T17:33:51-06:00 S. Clifton Willimon Anthony C. Egger Crystal A. Perkins <p><strong>Background:</strong>&nbsp; Traumatic hip dislocations are uncommon injuries in the pediatric population.&nbsp; Injury recognition and prompt closed reduction is standard of care.&nbsp; The purpose of this study is to describe injury patterns, treatment&nbsp;(including hip arthroscopy), and patient reported outcomes of traumatic hip dislocation in pediatric patients.&nbsp;</p> <p><strong>Methods:</strong>&nbsp; A retrospective review was performed&nbsp;of all patients&nbsp;less than 18 years of age treated for a traumatic hip dislocation between 2011 – 2017&nbsp;at a single center.&nbsp; Chart and radiographic review&nbsp;were performed, and&nbsp;patients were contacted to obtain outcome scores, including the Harris hip score&nbsp;(HHS)&nbsp;and&nbsp;hip outcome score&nbsp;(HOS).&nbsp;</p> <p><strong>Results:</strong>&nbsp; 23&nbsp;patients, 18 males and 5 females, with a mean age of 11.3 years (range 4 – 16)&nbsp;were included.&nbsp;&nbsp;The most common mechanisms of injury were motor vehicle crashes&nbsp;(8), football (7), and falls (3).&nbsp; The direction of hip dislocation was posterior (21) and obturator (2).&nbsp;</p> <p>Twenty patients had a CT to assess the hip reduction and associated injuries and 15 (75%) had a posterior wall acetabular fracture and 6 (30%) had an incarcerated fragment within the joint.&nbsp; 5 patients had an MRI and all had an associated posterior wall fracture and posterior labral tear.&nbsp;</p> <p>Fourteen patients were treated non-operatively. &nbsp;Patient-reported outcome scores were obtained in 10 patients (71%).&nbsp;&nbsp;Mean HOS-ADL, HOS-Sport, and mHHS were 75 (69 – 76), 32 (18 – 36), and 97 (85 – 100) respectively at a mean of 40 months after injury.&nbsp;</p> <p>Nine patients were treated operatively, including 5 patients with hip arthroscopy.&nbsp;&nbsp; Patient-reported outcome scores were obtained in 7 patients (78%).&nbsp;&nbsp;Mean HOS-ADL, HOS-Sport, and mHHS were 69 (50 – 76), 30 (14 – 36), and 86 (59 – 100) respectively at a mean of 34 months after surgery.&nbsp;</p> <p><strong>Conclusion:</strong>&nbsp; Traumatic hip dislocations in the pediatric population occur most frequently as isolated orthopaedic injuries&nbsp;in association with posterior wall acetabular fractures.&nbsp;&nbsp;Incarcerated fragments occurred in 30% of the patients, yet were commonly not recognized on plain radiographs alone.&nbsp; Axial imaging should be routinely obtained following reduction.&nbsp; Selective hip arthroscopy after traumatic hip dislocations&nbsp;is a viable less invasive method for treatment of incarcerated fragments and labral injury.</p> <p><strong>&nbsp;</strong><strong>Key Concepts</strong></p> <ol> <li>Pediatric and adolescent traumatic hip dislocations are rare and most often occur as an isolated orthopedic injury.</li> <li>Advanced axial imaging, preferably an MRI, should be obtained after reduction in all patients to evaluate for intra-articular pathology.</li> <li>Without incarcerated fragments, patients may be treated non-operatively with good mid-term functional outcome scores</li> <li>Selective hip arthroscopy may be effectively utilized in patients with intra-articular blocks to reduction and significant labral pathology.</li> </ol> <p><strong>Level of Evidence: IV</strong></p> 2022-04-20T00:00:00-06:00 Copyright (c) 2022 JPOSNA® Pediatric Pelvic and Acetabular Fractures: Diagnosis, Treatment, and Outcomes 2022-05-01T17:33:51-06:00 Nicholas Lopreiato Wendy E. Ramalingam <p>Pediatric orthopaedic surgeons routinely care for patients who sustain trauma due to unintentional injuries, including transportation-related injuries. While pelvic ring and acetabulum fractures are uncommon in this patient population, these injuries require thorough evaluation and individualized treatment to reduce associated morbidity and mortality. Trauma patients with pelvic fractures often have concomitant injuries to other organ systems, and their initial evaluation and management must begin with stabilization and evaluation for central nervous system and visceral injuries. A thorough orthopaedic evaluation is necessary to identify other extremity fractures and to determine the optimal treatment.</p> <p>Diagnosis and treatment of pediatric pelvic fractures is challenging due to the unique anatomy of the growing pelvis and varying injury patterns throughout childhood and adolescence. Radiographs and computed tomography can aid in appropriately classifying these fractures and aid in surgical planning. Fracture stability and deformity determine the need for surgical stabilization. Most pediatric pelvic fractures can be treated nonoperatively. For those that require surgical treatment, anterior and posterior pelvic fixation can be safely performed with appropriate planning and knowledge of the skeletally immature pelvis. Satisfactory outcomes can be obtained with correction of residual deformity or pelvic asymmetry less than 1 cm.</p> <p>The management of pediatric acetabulum fractures is similarly unique as treatment considerations include injury to the triradiate cartilage in addition to articular congruency and hip joint stability.&nbsp; The mechanism of injury in acetabulum fractures is frequently high energy trauma, however low energy mechanisms have been reported. &nbsp;MRI imaging is helpful to visualize the full extent of injury to the cartilaginous portions of the joint.&nbsp; Surgical intervention is reserved for patients with hip join instability, acetabulum incongruity &gt;2mm, or failure to maintain a concentric reduction after attempt at closed management.&nbsp; Although acetabulum fractures can result in early osteoarthritis and disturbances in acetabular development, favorable results are seen with both operative and nonoperative management.</p> 2022-04-28T06:13:59-06:00 Copyright (c) 2022 JPOSNA® Pain After Spine Fusion for Adolescent Idiopathic Scoliosis 2022-05-01T17:33:51-06:00 Manaf H. Younis Adam L. Haydel Lauren Saunee Rutledge C. Clement <p>Surgical correction of spinal deformity has shown good results in terms of pain reduction, but it is uncertain why some patients continue to have chronic pain following surgery. With the true prevalence and etiology of chronic back pain following posterior spinal fusion with instrumentation (PSF) for Adolescent idiopathic scoliosis (AIS) unknown, we sought to review the prevalence and potential causes of chronic back pain following PSF for AIS. After a thorough literature review, the true prevalence of chronic pain following surgery remains difficult to quantify. Definitions of chronic pain include severe pain within 6 months of surgery, pain at least one time in the two years following surgery, “persistent pain,” moderate to severe pain two years post-operatively, pain in the five years following surgery defined as often or very often, and many more. Given the lack of a cohesive definition, true prevalence of chronic pain remains unknown but ranged in previous studies from 16%-64.4% two years post-operatively. Many patients did not have an obvious etiology of pain identified. Potential causes included mechanical back pain, adjacent segment disease, pseudoarthrosis, implant-related failures, infection, and Proximal junctional failure. Common risk factors for these causes of chronic pain include high pre-operative pain levels and the degree and type of curve pre-operatively.</p> 2022-04-18T15:13:20-06:00 Copyright (c) 2022 JPOSNA® Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS 2022-05-01T17:33:51-06:00 Amy L. McIntosh Christopher McLeod <p><strong>Background</strong>: Our previous standardized postoperative pain management plan for AIS patients undergoing PSF included the placement of an epidural (EPI) catheter by the spine surgeon prior to fascial closure. The epidural was used for 24 hours, in conjunction with a multi-modal post-operative pain protocol.</p> <p><strong>Local Problem</strong>: The 2020 COVID-19 pandemic highlighted the need for our surgical AIS patients and their families to have private rooms/bathrooms. Epidural catheters require arterial line blood pressure monitoring to ensure safety. Unfortunately, the arterial lines could not be utilized in the private rooms due to lack of appropriate monitors, therefore we transitioned away from epidurals.</p> <p>Liposomal bupivacaine (LB) is an encapsulated local anesthetic that has a duration of action up to 72 hours.</p> <p><strong>Specific Aims: </strong>This quality initiative (QI) focused on the enhancement of the standardized postoperative care pathway for AIS patients undergoing PSF. The aims of the initiative were to 1) minimize<strong> narcotic usage, and 2) allow for earlier mobilization.</strong></p> <p><strong>Intervention</strong>: The (2020) LB cohort had a mixture of LB, bupivacaine HCL and normal saline injected into the fascial and subcutaneous layers of the incision prior to fascial closure. The (2019) control cohort had an epidural (EPI) catheter placed prior to fascial closure. The epidural infusion consisted of ropivacaine 0.1% (0.1-0.2 ml/kg/hr.) The cohorts received the same pain protocol (intravenous opioid with transition to oral opioid, as well as dexmedetomidine, acetaminophen, ketorolac, and diazepam).</p> <p><strong>Measures and Analysis</strong>: Two cohorts of prospective AIS patients that underwent PSF were retrospectively reviewed. They were compared regarding age, BMI, average preoperative major Cobb angle, average preoperative kyphosis, VAS pain scores and narcotic consumption. Time to ambulation, and length of stay (LOS) were also evaluated.&nbsp;</p> <p><strong>Results:</strong> 159 AIS patients were reviewed. There were no preoperative differences between the 2020 LB cohort (n =101) and the 2019 EPI cohort (n = 58) when comparing age (14.3 vs.15.0 years), average BMI (21.7 vs.20.8 kg/m2), preoperative major Cobb (60.7° vs.60.3°), or average preoperative kyphosis (25.7° vs. 27.1°). The LB cohort consumed similar morphine equivalents during the initial 24 hrs. (37.8mg vs.37.3mg), but less at 24-48 hrs. (37.2mg vs 41.0mg) (p=0.031), and 48-72hrs (23.3mg vs. 29.6mg) (p=0.015). The LB cohort ambulated 6.8 hrs. sooner (17.1 vs 23.9 hrs.) (p=.0001).</p> <p><strong>Summary</strong>: LB associated with less consumption of post-operative morphine equivalents and earlier ambulation.</p> 2022-04-19T11:11:46-06:00 Copyright (c) 2022 JPOSNA® Supervised Deep Breathing Exercises Improve Functional Aerobic Capacity in Patients with Severe Spinal Deformity 2022-05-01T17:33:51-06:00 Karina A. Zapata Kayla M. Clem Rupha H. Stevens Charu Sharma Amy L. McIntosh <p><strong>Background:</strong> Our institution has traditionally treated children with severe spine deformity using halo gravity traction (HGT) to improve curve magnitude and increase flexibility.</p> <p><strong>Local Problem:</strong> Assessing the non-radiographic benefits of HGT such as pulmonary function, is difficult. Pulmonary function is commonly reflected by pulmonary function testing (PFT) which is dependent on MAXIMAL patient effort.&nbsp; Six-minute walk test (6MWT) reflects functional exercise capacity.</p> <p><strong>Specific Aims:</strong> This quality initiative (QI) was performed to evaluate the addition of supervised deep breathing exercises (DBE) utilizing an incentive spirometer (IS) to supervised physical therapy exercise in patients with severe spinal deformity that require HGT.</p> <p><strong>Methodology:</strong> A QI core team was established with the aim of improving the pulmonary function aspect of our HGT program. The team consisted of 1 orthopaedic surgeon, 1 quality improvement program manager, 2 physical therapists (PTs), and 1 respiratory therapist (RT). The QI core team met every 4 to 6 weeks to discuss patients and processes.</p> <p><strong>Intervention:</strong> RTs supervised HGT patients performing DBE 4 times per day, and asked families to independently perform DBE 4 additional times per day.</p> <p>PTs performed the six-minute walk tests (6MWT). A pulse oximeter was used to monitor oxygen saturation levels. RTs performed the PFTs. The 6MWT and PFTs were performed prior to halo application, and every 2 weeks while in HGT treatment.</p> <p><strong>Results:</strong> The intervention HGT patients who received supervised DBE (n=14) demonstrated significantly improved 6MWT scores from 1440±546 feet pre-halo to 1663±398 feet pre-surgery (p=0.02).&nbsp; A historic cohort of HGT patients who did not receive supervised DBE (n=10) demonstrated no significant changes in 6MWT scores at 1493±391 feet pre-halo and 1477±406 feet pre-surgery. Averaged forced vital capacity worsened 4±10% and average forced expire volume in one second worsened 1±8%.</p> <p><strong>Conclusions:</strong> Children in HGT undergoing supervised DBE and physical therapy demonstrate improved functional aerobic capacity according to the 6MWT despite no improvement in pulmonary function tests.</p> <p>&nbsp;</p> 2022-04-19T11:23:23-06:00 Copyright (c) 2022 JPOSNA® Removal of Femoral Lengthening Nails 2022-05-01T17:33:52-06:00 Christopher Iobst Søren Kold Mindaugas Mikuzis <p>There is an orthopaedic adage that states, “No surgeon ever looks good taking out hardware.”&nbsp; This simple statement illustrates the frustration many of us have felt when faced with a hardware removal case. Since all internal lengthening nails are recommended for removal at the completion of treatment, any surgeon considering a patient for internal lengthening will eventually encounter a nail removal opportunity.&nbsp; As part of our limb reconstruction practices, the authors have removed hundreds of internal lengthening nails. We have developed techniques through trial and error over time to streamline and simplify the nail removal process.&nbsp; The goal of this article is to share our experience with you in the hopes that it makes your internal lengthening nail removal surgery as smooth and painless as possible.&nbsp;&nbsp;</p> 2022-04-19T07:01:29-06:00 Copyright (c) 2022 JPOSNA® Biomechanical Basis for Treatment of Pediatric Foot Deformities Part I: Mechanics of the Foot 2022-05-01T17:33:52-06:00 Renjit A. Varghese Gleeson Rebello Hitesh Shah Benjamin Joseph <p>The foot functions as a flexible structure during major part of the stance phase of the gait cycle but changes into a rigid structure in the terminal part of stance to enable a powerful push-off.</p> <p>This illustrated review describes the mechanics of the foot during inversion and eversion and explains in some detail how the calcaneum moves under a stationary talus in three planes simultaneously around a single oblique axis. The illustrations show how during eversion the calcaneum dorsiflexes, abducts and pronates while it plantarflexes, adducts and supinates during inversion. The talus remains static while the rest of the foot moves as a unit, referred to as the calcaneo-pedal unit (CPU), around the head of the talus. The socket-like hollow in the CPU consisting of the anterior and middle articular facets of the calcaneum, the articular fact of the navicular and the spring ligament constitute the “acetabulum pedis” which rotates around the talus.</p> <p>The foot, on occasion, functions like a twisted plate influencing the inter-relationship between the hindfoot and forefoot. This explains how a forefoot deformity may cause a secondary compensatory deformity of the hindfoot. &nbsp;&nbsp;</p> 2022-04-18T15:12:30-06:00 Copyright (c) 2022 JPOSNA® Biomechanical Basis for Treatment of Pediatric Foot Deformities Part II: Pathomechanics of Common Foot Deformities 2022-05-01T17:33:52-06:00 Renjit A. Varghese Gleeson Rebello Hitesh Shah Benjamin Joseph <p>The biomechanical basis for causation and treatment of pes planus, convex pes valgus (vertical talus), pes cavus, paralytic deformities and foot deformities in cerebral palsy are presented.</p> <p>In each instance, the altered alignment of the hindfoot and forefoot, the configuration of the medial longitudinal arch and the instability of the talo-navicular joint differ.</p> <p>The patterns of muscle imbalance across the axes of movement in paralytic deformities and the concept of treatment aimed at muscle rebalancing across these axes are graphically illustrated.</p> <p>The common deformities of the foot encountered in cerebral palsy are described, in particular, the different deformity patterns resulting from spasticity of the gastrocnemius. The importance of preserving the function of the soleus and avoiding over-lengthening of the gastroc-soleus is emphasized.</p> 2022-04-25T10:03:26-06:00 Copyright (c) 2022 JPOSNA® Evidence-Based Management Strategies for Pediatric Pes Cavus 2022-05-01T17:33:52-06:00 Katherine A. Rosenwasser Hyrum Judd Joshua E. Hyman <p>Pes cavus is defined as an abnormal elevation of the medial longitudinal arch of the foot. More than two-thirds of patients with pes cavus are found to have an underlying neurologic diagnosis driving a muscle imbalance within the foot. Expedient clinical diagnosis of underlying pathology is paramount to facilitate proper neuraxial imaging studies and a referral to pediatric neurology. Non-operative management is rarely sufficient and is typically indicated only in cases of mild deformity. Surgical management hinges heavily on physical and radiographic examination findings including the Coleman block test, which can help to determine the need for soft tissue or bony reconstruction. The goal of treatment in pes cavus is to obtain a painless, plantigrade, and supple foot.</p> 2022-04-19T11:07:43-06:00 Copyright (c) 2022 JPOSNA® Navicular Stress Fractures in Adolescent Athletes: Injury Characteristics and Outcomes of Surgical Fixation 2022-05-01T17:33:52-06:00 Anthony C. Egger Michelle Ramirez S. Clifton Willimon Crystal A. Perkins <p><strong>Background:</strong> Surgical treatment of navicular stress fractures (NSF) in athletes has been recommended secondary to the poor blood supply of the navicular and frequency of delayed union and refracture.&nbsp; Regardless of treatment, nonunion and persistent pain are complications described in adults.&nbsp; The purpose of this study was to describe patient and fracture characteristics and outcomes of surgical treatment of NSF in adolescents.&nbsp;&nbsp;&nbsp;</p> <p><strong>Methods:</strong> An IRB approved retrospective review was performed of patients less than 18 years of age treated with surgical screw fixation of NSF from 2014 – 2019.&nbsp; All patients were contacted for collection of patient reported outcome measures (PROMs).&nbsp;</p> <p><strong>Results:</strong> Five patients with a median age of 15.8 years (range 14 – 17 years) were included. Three patients, all baseball catchers, had a dorsal navicular osteophyte.&nbsp; All fractures were in the lateral third of the navicular.&nbsp; There were 3 type 2 fractures and 2 &nbsp;type 3 fractures.&nbsp; Median clinical follow-up was 7.1 months (range 5 – 14 months).&nbsp; No patient developed avascular necrosis.&nbsp; PROMs at a median of 61 months following surgery demonstrated that all patients returned to their primary sport at the same level and no patients reported refracture or subsequent surgeries.</p> <p><strong>Conclusions:</strong> In a cohort of adolescent patients, operative fixation of type 2 and 3 NSF results in reliable healing, no evidence for AVN, and excellent mid-term outcomes with full return to sports.&nbsp; These outcomes are in contrast to higher rates of non-union and inability to return to sports reported in the adult literature.&nbsp;</p> 2022-04-20T09:24:41-06:00 Copyright (c) 2022 JPOSNA® Over-Reaming the Humerus to Place an IM Lengthening Nail 2022-05-01T17:33:52-06:00 Achraf Jardaly Timothy W. Torrez Ezan A. Kothari Nicholas A. Andrews Shawn R. Gilbert <p>The fully implantable intramedullary nailing system is an elegant solution in limb lengthening that has become incredibly popular among both surgeons and patients. The system was initially used for lower extremity lengthening; however, it has also been used for humeral lengthening. In this case report, we describe a very difficult course of an infected nonunion secondary to humeral lengthening with an intramedullary device. The large atrophic nonunion was reconstructed in part with autogenous bone obtained in a minimally invasive fashion using a suction-based harvesting device. This case illustrates the importance of appropriate patient and implant selection and match and demonstrates the use of a novel suction-based bone harvester. Despite advances in the field of limb lengthening, the potential for major complications of these procedures should not be underestimated. &nbsp;&nbsp;</p> 2022-04-25T10:10:44-06:00 Copyright (c) 2022 JPOSNA® Raising the Young Athlete: Training and Injury Prevention Strategies 2022-05-01T17:33:52-06:00 Nicholas Bank Christian Hecht Amir Karimi Mohamed El-Abtah Lauren Huang R. Justin Mistovich <p>Participation in youth sports is at an all-time high, surpassing pre-pandemic levels. While this represents a growing opportunity for increased activity, socialization, and skill development in America’s young athletes, we must remain cognizant of the associated risks that threaten their long-term physical and psychological well-being. To optimize the risk-benefit ratio of the increasing involvement in organized sports, current sporting safety recommendations are needed. We sought to provide current concepts on optimal training methods, injury prevention strategies, and stakeholder education programs.</p> 2022-04-28T00:00:00-06:00 Copyright (c) 2022 JPOSNA® Management of Upper Extremity Manifestations of Cerebral Palsy 2022-05-01T17:33:52-06:00 Carley Vuillermin <p>This current concept review serves as an introduction and basis for the evaluation and treatment of upper extremity dysfunction in cerebral palsy.&nbsp; This article will provide a background on the management of the upper extremity manifestations of cerebral palsy following on from our lower extremity tutorial on the treatment of gait abnormalities in cerebral palsy last year. In this review we will discuss one approach to the classification, assessment, and current management modalities, nonoperative and operative. In successive editions of JPOSNA we will present panel discussions of patients with classic presentations and their treatment. Our hope is that upper extremity care will be a parallel consideration for all patients with cerebral palsy.</p> 2022-04-29T07:19:03-06:00 Copyright (c) 2022 JPOSNA®