JPOSNA® 2021-11-17T07:10:25-07:00 POSNA Staff Open Journal Systems <p><em><strong>JPOSNA</strong></em><strong>®</strong> (the <strong>Journal of the Pediatric Orthopaedic Society of North America)</strong> is an open access journal focusing on pediatric orthopaedic conditions, treatment, and technology.</p> Editor's Note 2021-11-02T13:07:51-06:00 Ken Noonan <p>In this edition, we would like to highlight the amazing contributions from Wade Shrader and Grant Hogue over the last year. We are fortunate to have Wade’s Tutorial on Gait Analysis in Cerebral Palsy and Grant’s Symposium on Early Onset Scoliosis; both of these spanned the last year and are comprehensive reviews. I am sure you learned as much as I did from these excellent programs.&nbsp;</p> <p>When trying to accept change in our lives, it’s often been recounted, “the only constant is change.” Yet, Ben Franklin best expressed its value, “When you’re finished changing, you’re finished.” <em>JPOSNA</em> is now the official journal for POSNA, and we are changing from a singular educational journal to one that will begin publishing original research. While we are excited for this, we will continue to produce educational material that is highly valued. In this current edition, I would like to point out the obvious and the hidden.</p> <p>When reviewing the table of contents, hopefully you will recognize the contributions from colleagues from around the world—Singapore, Japan, and Australia. Perhaps this is best seen in Jennifer Laine’s triumphant collection of cases of congenital pseudarthroses of the tibia and with the opinions from surgeons from the USA, Korea, Norway, and India. <em>JPOSNA</em> seeks to be of value to pediatric orthopaedists worldwide; this edition moves in that direction.</p> <p>There are two important papers that may not seem relevant to some. Karen Bovid, Jaysson Brooks, and Michael Heffernan have written an essay on the Ethics of Outreach. It’s a MUST READ for anyone who does outreach, yet there is much we can all learn and adapt in our home practices. On the surface, the EOS paper by Hiroko Matsumoto and Brian Snyder may not appear to be of interest to the non-spine surgeon, yet it is a tutorial for anyone who wants to design and execute clinical research. <em>JPOSNA</em> seeks to be of value for all pediatric orthopaedists regardless of subspecialty interest. We believe these two papers highlight this focus.</p> <p>Exciting times for <em>JPOSNA</em> are here; our Society is refining its own Journal. As we grow, we welcome your comments, your questions, and any help you can provide to make our Journal the best it can be.</p> 2021-10-29T03:28:35-06:00 Copyright (c) 2021 JPOSNA Message from the President 2021-11-01T13:49:16-06:00 Mininder S. Kocher <p>In early October, POSNA announced to membership that <em>JPOSNA</em> will become the <em>official</em> journal of POSNA as of 12/31/21, and that the <em>Journal of Pediatric Orthopaedics</em> (<em>JPO</em>) will change to an <em>affiliated </em>journal of POSNA. This decision was approved by the POSNA Board of Directors at the September board meeting in Chicago. This was after 2 years of careful consideration and analysis led by President-Elect Jeff Sawyer and publications consultant Paula Gantz.&nbsp;</p> <p>I want to provide more detail and perspective about this decision. Historically, <em>JPO</em> listed itself as the official journal of POSNA; however, we did not have an official relationship with a contract and revenue to POSNA until January 2017. The POSNA/<em>JPO</em> relationship was strong with the <em>JPO</em> editor sitting on the POSNA Board and advocating for the dissemination of pediatric orthopaedics scientific research. However, there were also challenges with Wolters Kluwer in terms of communication, trying to increase page counts, and adopting innovative content presentation. The revenue to POSNA remained fairly limited.&nbsp;</p> <p>Many orthopaedic subspecialty organizations do “own” their own journals which allows them to advance scientific publication, innovate with flexibility, increase their online presence, publish society news, and generate more revenue. This can be seen, for example, with the <em>American Journal of Sports Medicine</em> and AOSSM, the <em>Journal of Shoulder and Elbow Surgery</em> and ASES, and the <em>Journal of Hand Surgery</em> and ASSH. To explore these options for the benefit of POSNA and its members, we did our due diligence by discussing publication with other societies, engaging a consultant, and sending an RFP to a number of medical publishers. We learned that the medical publishing world is changing dramatically: margins and advertising are declining, online publishing is becoming more dominant, getting indexed in PubMed/Index Medicus is a long and involved process, and the focus is on bundling journals to institutional subscribers, not individual subscribers. We received only one proposal from publishers for a new publication which would have been revenue negative, limited in scope (four online publications yearly), and would require increasing POSNA staff and expertise. However, the publishers were very impressed with <em>JPOSNA</em> and thought that this would be an attractive product in the future were it able to publish original scientific research.&nbsp;</p> <p>The decision to have <em>JPOSNA</em> be the <em>official</em> journal of POSNA will allow us to publish original scientific research after January 1, 2022. Our relationship with <em>JPO</em> and its editors, Drs. Hensinger and Thompson, remains strong. <em>JPO</em> is an important journal to the field of pediatric orthopaedics and to our membership. As an affiliated journal of POSNA, members get a reduced subscription rate to <em>JPO</em>, although most of our membership has <em>JPO</em> access through their institutions. <em>JPOSNA</em> will be able to add to <em>JPO</em> to increase the number of scientific publications in our field.&nbsp;</p> <p>I think the innovation and breadth of <em>JPOSNA</em> offerings is well-demonstrated in this issue: you can delve into master’s technique for patella sleeve fracture and learn the essentials of concussion for sideline management. There are topics representing the breadth of pediatric orthopaedics including deformity, CP, spine, sports, and fractures. There are sections highlighting QSVI, the final installment in a series on EOS, and the ethics of global outreach. Congratulations to Ken Noonan (Editor-in-Chief), Lisa DuShane (POSNA Communications Specialist), and the <em>JPOSNA</em> Editorial Board on another fantastic edition of <em>JPOSNA</em>.&nbsp;</p> 2021-10-30T15:48:23-06:00 Copyright (c) 2021 JPOSNA Patellar Sleeve Fracture: Open Reduction and Internal Fixation 2021-11-01T13:49:17-06:00 Andrew Georgiadis Shea M. Comadoll <p>Patellar sleeve fractures are a rare injury comprising less than 1% of all pediatric fractures. They are characterized by an outer sleeve of cartilage pulled away from the osseous patella. The most common pattern is an osteochondral fracture at the inferior patellar pole but lateral or medial based injuries are also reported. Multiple fixation methods are described, depending on fracture pattern, osseous fragment size, and surgeon preference. The specific technique of patellar sleeve fixation utilizing transosseous suture placement is described and illustrated with an accompanying video.</p> 2021-10-20T09:34:50-06:00 Copyright (c) 2021 JPOSNA Arthroscopic Saucerization and Repair of the Lateral Discoid Meniscus 2021-11-01T13:49:17-06:00 Gin Way Law Dave Lee Shobhit Gupta James HP Hui <p>Surgical treatment of the symptomatic discoid lateral meniscus has undergone a paradigm shift since recognition of the development of accelerated osteoarthritis with subtotal meniscectomies. Current strategies have shifted towards meniscus preservation, and meniscoplasty is considered the gold standard of treatment at present. Meniscoplasty with saucerization of the meniscus recreates the standard crescent shape for improved shock absorption, load transmission and joint stability. This has shown good mid- to long-term outcomes in children and adolescents in the literature. As the discoid lateral meniscus is also associated with intrasubstance degeneration and meniscus tears, concomitant meniscus repair should be performed in line with efforts for meniscus preservation. In this technique manuscript, we detail our saucerization technique, considerations for meniscus repair, and tips to achieve a successful outcome.</p> 2021-10-24T07:32:18-06:00 Copyright (c) 2021 JPOSNA Simple Measures to Reduce Opioid Prescriptions Following Pediatric Spinal Fusion Surgery: A Multidisciplinary Quality Improvement Project 2021-11-01T13:49:17-06:00 Andrew Winsauer Charu Sharma Stacie Bukowsky Sandi Greenberg Craig Birch Brandon Ramo <p><strong>Background:</strong> The opioid epidemic is one of the biggest challenges facing modern healthcare. Among the adolescent and young adult population opioid overdose is one of the leading causes of death.</p> <p><strong>Local Problem: </strong>Within pediatric orthopaedics, spinal fusion is a common procedure making up 7% of the surgical volume at our institution. Spinal fusion also has high postoperative opioid prescribing rates. Review of baseline data showed that there was wide variability in prescribing habits. The goal of this quality initiative was to reduce and standardize post-operative opioid prescribing following spinal fusion procedures.</p> <p><strong>Methods: </strong>Data, including opiate-prescribing habits and a patient survey to assess patient and parent satisfaction with pain control, was collected retrospectively in the pre-intervention phase for 99 consecutive Adolescent and Juvenile Idiopathic Scoliosis patients undergoing spinal fusion surgery. This was followed with 2 PDSA cycles following implementation of a new protocol during which prospective surveys were administered to a total of 273 patients. Physician prescribing data was collected for 150 patients during the sustain phase.</p> <p><strong>Interventions: </strong>A multi-pronged approached was utilized consisting of the following aspects: 1) Instruction to orthopaedic trainees to limit opioid prescriptions to 45 and 40 for PDSA cycles 1 and 2, respectively. 2) A pharmacy-led education program with an opioid tapering handout given to families and encouragement of usage of non-opioid pain control. 3) A call to the prescribing physician from pharmacy if the prescribed dosage was greater than the maximum allowed.</p> <p><strong>Results: </strong>There was a significant reduction in opioid prescriptions from a preintervention mean of 48.5 doses to a PDSA 1 mean of 39.0, PDSA 2 mean of 37.5, and a sustain phase mean of 36.4 (p=0.000). This represented an estimated reduction of 22.8% over the course of the study. During this time, there was no significant change in patient and parent reported postoperative pain.</p> <p><strong>Conclusions: </strong>Through simple measures, our institution was able to significantly reduce total opioid prescriptions following spinal fusion surgeries while maintaining good pain control.</p> 2021-10-22T12:22:49-06:00 Copyright (c) 2021 JPOSNA First Do No Harm: Ethical Considerations of Pediatric Orthopaedic Global Outreach 2021-11-01T13:49:17-06:00 Karen Bovid Jaysson Brooks Michael Heffernan <p>The purpose of this editorial is to introduce the ethical considerations surrounding pediatric orthopaedic global outreach and stimulate discussion about how to best approach this work.&nbsp; Bidirectional exchange with partner surgeons in low- and middle-income countries forms the foundation of successful outreach.&nbsp; Fostering these relationships and approaching outreach with humility and curiosity allows for a genuine needs assessment. The outreach program can then be designed to address the needs of the target community. Success should not only be defined as the number of surgeries performed, but also the number of healthcare workers trained and sustainable programs created at the host site. Remember that nurses, physical therapists, and surgical technologists also desire training. Finally, it is important to understand and identify any implicit or explicit bias before pursuing global outreach as that may hinder successful outcomes and bidirectional exchange with host surgeons.</p> 2021-10-21T06:33:11-06:00 Copyright (c) 2021 JPOSNA Coding Corner: Coding Challenges in Common Pediatric Sports Surgeries of the Knee 2021-11-01T13:49:17-06:00 Emily Niu Sarah Wiskerchen Jennifer Beck Aristides Cruz POSNA QSVI Sports Committee <p>Coding and billing for procedures is necessary but possibly the least enjoyable aspects of performing surgery. Additionally, proper documentation is crucial to support procedural coding and billing.&nbsp; Unfortunately, these are also areas in which orthopaedic surgeons receive the least consistent training, which can lead to enormous variability in how different surgeons code and bill for the same procedure. Pediatric sports medicine is a relatively younger subspecialty within pediatric orthopaedics and as such, techniques and approaches to surgery continue to evolve. As a result, many of the procedures performed may not have well established—or indeed any—corresponding CPT codes.</p> <p>This article presents case scenarios for common knee pathologies often 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 operative report documentation.</p> 2021-10-18T06:48:08-06:00 Copyright (c) 2021 JPOSNA Arteriovenous Fistula After Percutaneous Osteotomy 2021-11-01T13:49:17-06:00 Steven Frick Danika Baskar <p>While undergoing a distal femoral osteotomy to facilitate expandable femoral rod placement, a 3 year old with osteogenesis imperfecta (OI) sustained an injury to the femoral artery and vein that subsequently led to the development of an arteriovenous (AV) fistula and overgrowth of her lower extremity. Percutaneous osteotomies performed at the apex of the typically deformed femur in OI patients place the femoral artery at risk in the distal third of the thigh. Strategies to decrease this risk are presented.</p> 2021-10-01T00:00:00-06:00 Copyright (c) 2021 JPOSNA The Bare Bones of Concussion: What the Sideline Orthopaedic Surgeon Needs to Know 2021-11-01T13:49:17-06:00 Michael Beasley Christina Master <p>Concussions have become one of the highest profile and most controversial injuries in sport, with scrutiny by athletes and their families, coaches, medical personnel, and the media dramatically increasing in recent years. With growing awareness and knowledge of concussion, assessment has progressed from minimal on-field examination and rapid return to play, to extensive on- and off-the-field comprehensive physical and neurologic examinations, computerized neurocognitive testing, advanced oculovestibular evaluations, and individualized return-to-play protocols. Orthopaedic surgeons covering sporting events, especially those fellowship-trained in sports medicine and designated as team physicians, are expected to have competency in recognizing mechanisms of concussive injury, participate in on-field assessments, and contribute to the initial management and return-to-play protocols of athletes. Having an awareness of concussion epidemiology, available diagnostic testing, possible complications associated with repetitive concussions, and local legislation involving concussed athletes will prepare the team physician-surgeon to be a critical contributing member of the medical team.</p> 2021-10-11T06:58:34-06:00 Copyright (c) 2021 JPOSNA Operative Management of Pediatric Medial Epicondyle Fractures: Lessons Better Learned the Easy Way 2021-11-01T13:49:17-06:00 Alexander Hallwachs Morgan Weber Raymond Liu Keith Baldwin Justin Mistovich <p class="Body" style="line-height: 200%; tab-stops: 63.0pt;"><span style="font-family: 'Times New Roman',serif; color: windowtext;">Medial epicondyle fractures account for up to 20% of all pediatric elbow fractures.<sup>1,2</sup> While nonoperative management has been traditionally described as successful, an average of 49% of patients develop a nonunion with conservative treatment. Historical studies lack specific patient reported functional outcome metrics or return to sport data.<sup>13,14,16</sup> There is a trend toward operative fixation due to a rising concern for symptomatic valgus instability, stiffness, and long-term functional effects of nonunion in patients treated non-operatively. Operative decision-making focuses on the prevention of chronic valgus instability and desire to return to high-level athletics or future employment. </span></p> <p class="Body" style="line-height: 200%; tab-stops: 63.0pt;"><span style="font-family: 'Times New Roman',serif; color: windowtext;">&nbsp;</span><span style="font-family: 'Times New Roman',serif; color: windowtext;">Nonetheless, surgical treatment is not without risk, including postoperative stiffness, comminution of the medical epicondyle fragment, nerve damage, persistent rotational instability of the fragment, nonunion, and symptomatic hardware.</span></p> <p class="Body" style="line-height: 200%; tab-stops: 63.0pt;"><span style="font-family: 'Times New Roman',serif; color: windowtext;">&nbsp;</span><span style="font-family: 'Times New Roman',serif; color: windowtext;">In order to assist the surgeon considering operative management for a medial epicondyle fracture, we have compiled a series of challenging cases due to delayed presentation or complications, as well as several unique techniques that may be helpful to either prevent or navigate one’s way out of these situations. </span></p> 2021-10-21T18:25:38-06:00 Copyright (c) 2021 JPOSNA Early Onset Scoliosis Series–An Editor’s Perspective 2021-11-01T13:49:17-06:00 Jennifer Bauer <p>This volume marks the third and final volume of the Early Onset Scoliosis (EOS) article series. This was our first topical spine series for <em>JPOSNA</em> and it was a huge achievement and contribution to the literature, with several articles in each volume and a multitude of instructional multimedia. We congratulate and thank each of the authors, especially Dr. Grant Hogue who led the effort, and the Pediatric Spine Study Group (PSSG) for their important work that has set the standard for <em>JPOSNA</em> series to come.</p> 2021-10-01T14:32:33-06:00 Copyright (c) 2021 JPOSNA From the Wild West to the Moon: The Future of Early Onset Scoliosis 2021-11-01T13:49:17-06:00 Michael Glotzbecker <p>n/a</p> 2021-09-24T09:27:20-06:00 Copyright (c) 2021 JPOSNA Improving the Quality of EOS Clinical Research: A Step-by-Step Guide 2021-11-01T13:49:17-06:00 Hiroko Matsumoto Brian Snyder <p>Conducting high-quality research in early onset scoliosis (EOS) is challenging, requiring the assistance of PhD trained biostatisticians and epidemiologists with expertise in research methodology. Biostatisticians develop theoretical and statistical methods to analyze data in support of evidence-based decision-making. Epidemiologists provide empirical confirmation of disease processes, identifying factors that affect prognosis to guide the process toward clinical relevancy. Within each step in the study process, there are important principles that investigators can apply to improve the quality of research in EOS:</p> <ul> <li>Ask a research question that tests a hypothesis or formulate a hypothesis that answers a research question worth answering</li> <li>Formulate a focused, testable hypothesis</li> <li>Create a study design that tests the hypothesis (i.e. results prove/disprove hypothesis)</li> <li>Identify appropriate patient cohorts (treatment, controls) according to inclusion/exclusion criteria established <em>a priori</em> (prospective and retrospective studies)</li> <li>Specify the variables (categorical or quantitative – discrete and/or continuous) to be measured: <ol> <li>Variables hypothesized to impact outcomes <ol> <li>Independent - patient cohort, gender, treatment method</li> <li>Co-variates (e.g. medical co-morbidities, age, habitus, socioeconomic status, physical abilities)</li> </ol> </li> <li>Dependent variables - objective measures of outcomes that reflect disease pathophysiology, treatment and/or prevention: clinical biomarkers, image-based anatomy, HRQOL)</li> </ol> </li> <li>Analyze data using applicable statistical tests <ol> <li>Sample size (power) calculations are predicated on the type of statistical tests that will be applied to the data and require specification <em>of a pre-determined effect size</em> (i.e., strength of the relationship between the independent and dependent variables) and an estimate of the extent of variation in the dependent variables</li> </ol> </li> <li>Interpret results established on appropriately powered statistical tests in support/rejection of the hypothesis</li> </ul> <p>These points, as relevant to early onset scoliosis (EOS) research can be illustrated through an example of a retrospective <em>de novo</em> study identifying risk factors for increased mortality and decreased health-related quality of life (HRQoL) in EOS patients with cerebral palsy (CP) undergoing spine surgery.</p> 2021-10-31T10:49:46-06:00 Copyright (c) 2021 JPOSNA Update in Nonoperative Management of Adolescent Idiopathic Scoliosis to Prevent Progression 2021-11-01T13:49:17-06:00 Brett Shannon W. G. Stuart Mackenzie Arun Hariharan Suken Shah <p>The primary goal of nonoperative treatment of adolescent idiopathic scoliosis (AIS) is to prevent curve progression. The risk of progression and estimation of growth remaining should be performed through a combination of serial X-rays, menarche history, serial height measurement, triradiate cartilage status, Risser grade, and Sanders Skeletal Maturation Stage with a left-hand bone age X-ray. For AIS patients with growth remaining and a curve magnitude between 25 and 45 degrees, conservative treatment with a rigid thoracolumbosacral orthosis (TLSO) is indicated. Rigid TLSOs (e.g., Wilmington, Boston, Rigo-Cheneau) are superior to other brace types, but there is insufficient evidence to recommend a specific type of rigid TLSO. Brace wear for at least 13 hours per day is indicated until skeletal maturity to limit curve progression. Physiotherapeutic scoliosis-specific exercises (PSSE) should be considered in addition to bracing for patients with moderate curves because there is growing evidence that PSSE improve overall patient-perceived back status when used as an adjunct to brace treatment. However, PSSE have not been shown to decrease the likelihood of curve progression for patients with mild curves; therefore, insufficient evidence exists to recommend PSSE for asymptomatic patients with mild curves. The nonoperative treatment of AIS remains an active area of investigation, and further research is needed to better compare brace types, optimize brace weaning, and understand the effectiveness of PSSE.</p> 2021-10-05T07:06:53-06:00 Copyright (c) 2021 JPOSNA How and When to Use Hooks to Improve Deformity Correction 2021-11-01T13:49:18-06:00 Jonathon Lentz Frederick Mun Krishna Suresh Mari Groves Paul Sponseller <p>Hooks play an important role in helping to achieve fixation during posterior spinal fusion (PSF) in patients with spinal deformity. This article reviews the different types of hooks used in PSF, advantages and disadvantages, indications, and multiple surgical techniques for insertion based on hook type.</p> 2021-10-05T08:30:01-06:00 Copyright (c) 2021 JPOSNA Youth Elbow Throwing Injuries 2021-11-01T13:49:18-06:00 James Dove David Painter Edward Testa Jonathan Schiller Peter Kriz Aristides Cruz <p>Youth elbow throwing injuries have been increasing among the pediatric population as more children participate in overhead sports, compete at high levels, and specialize in a single sport at an earlier age. The majority of these elbow injuries are attributable to overuse. In order to decrease the incidence of elbow injuries, recommendations and guidelines have been established and adopted by the Little League Baseball organization and other youth baseball organizations in America. There has been some success with these guidelines as they have been shown to decrease the risk of developing injury. Despite having guidelines, however, adolescents who compete in overhead sports remain at high risk of developing overuse injury, and the spectrum of injury is commonly seen in pediatric orthopedic offices. In this review, we describe six different elbow injuries associated with overuse and their specific management and treatment strategies: medial epicondyle apophysitis, medial epicondyle fracture, capitellar osteochondritis dissecans, Panner’s disease, UCL sprain, and olecranon stress injury. The purpose of this review is to highlight the spectrum of overuse elbow injuries seen in the pediatric population and briefly summarize the management of each injury.</p> 2021-10-11T09:45:08-06:00 Copyright (c) 2021 JPOSNA Physical Exam for Sports Medicine Knee Injuries in Pediatric Patients 2021-11-01T13:49:18-06:00 Jennifer J. Beck Emily L. Niu Aristides I. Cruz Jr. Andrew Pennock Zachary Stinson Allison E. Crepeau Curtis VandenBerg Kevin G. Shea Pamela J. Lang Henry Bone Ellis Jr. <p>The clinical examination of the child or adolescent with a knee injury or pain can vary based on the age of the patient as well as the acuity of the problem. When pediatric patients present with thigh or vague knee pain, the importance of the hip examination cannot be overemphasized. Evaluating the uninjured extremity first is particularly valuable to building trust and confidence with a scared, nervous patient. Having the patient describe and point to locations of symptoms can assist in prioritizing physical exam maneuvers as creating pain through exam will limit later exam compliance. There are four primary elements of the exam: observation, palpation, static stability examination, and dynamic assessment. This review article will summarize physical exam techniques and pertinent findings for meniscus, ligament, and patellofemoral pathology.</p> 2021-10-22T10:50:43-06:00 Copyright (c) 2021 JPOSNA Angulated Innominate Osteotomy (AIO): A Salter Osteotomy Without a Bone Graft 2021-11-01T13:49:18-06:00 Makoto Kamegaya Takashi Saisu Youhei Tomaru <p>We first proposed the angulated innominate osteotomy (AIO) as an innominate osteotomy using no bone graft in 2014. Since then, more than 50 hips in developmental dysplasia of the hip (DDH) have undergone the AIO with the following advantages: 1. Avoidance of iliac crest deformity due to sacrifice of Anterior Superior Iliac Spine (ASIS), 2. Avoidance of postoperative lengthening of the ilium, 3. Less evidence of postoperative displacement loss according to direct contact between both iliac fragments, 4. Shorter time for bone union and earlier full weight bearing permission.</p> <p>There have been no complications found so far.</p> <p>The introduction and part of the results have already been reported<sup>1).</sup></p> <p>In this report, more surgical details and knack of technique are mentioned with illustrations.</p> 2021-10-15T07:07:17-06:00 Copyright (c) 2021 JPOSNA Femoral Neck Bone Stress Injuries in Pediatrics and Adolescents: Diagnosis, Etiology, and Treatment 2021-11-17T07:10:25-07:00 Danielle Magrini Eric D. Nussbaum Katherine H. Rizzone Naomi J. Brown <p>Femoral neck bone stress injuries (FNBSI) are an uncommon diagnosis of groin or hip pain in the adolescent athlete. The true incidence is currently unknown and needs to be considered in the young athlete with atraumatic hip or groin pain. The current literature is sparse in describing the workup and treatment of FNBSI in the adolescent and pediatric population, and the literature lacks consensus of FNBSI nomenclature and appropriate use of imaging for all ages. This leads to inconsistency in understanding the etiology of the injury, prevalence of injury, workup of risk factors for FNBSI, and communication of diagnosis and management. The purpose of this Current Concept Review is to explore the pathophysiology, risk factors and clinical presentation for pediatric and adolescent femoral neck bone stress injuries, discuss existing classification of atraumatic FNBSI, and review imaging tools available to clinicians caring for young athletes. FNBSI occurs as young as age 5 and incidence increases during adolescence. Females are more at risk than males, as are certain sports.&nbsp;Initial imaging of choice is x-rays of the pelvis, followed by an MRI if there is suspicion for a FNBSI. Compression sided FNBSI less than 50% femoral neck width have a high success rate in non-operative treatment, while surgical fixation should be considered for tension sided injury, compression injury &gt;50% femoral neck width, or for those who fail conservative management.</p> 2021-10-19T19:09:09-06:00 Copyright (c) 2021 JPOSNA Crouch Gait in Spastic Diplegia: Patient Outcome and An Expert Panel Case Review 2021-11-01T13:49:18-06:00 Wade Shrader Tom Novacheck James McCarthy Paulo Selber <p>In this edition, we conclude our year long series on gait analysis in cerebral palsy.&nbsp; This comprehensive discussion has included a focus on observational gait analysis, the methods of quantitative gait analysis, and its application for clinical decision-making. This edition focuses on severe crouch gait, a common pathology in CP with increased knee flexion, progressive knee flexion contractures, and increased energy demands with increased patellar-femoral moments that can cause early degenerative changes. Another group of outstanding experts in CP discuss the surgical treatment of this common pathology.&nbsp;&nbsp;</p> 2021-10-24T12:56:00-06:00 Copyright (c) 2021 JPOSNA Arthrodesis of the First Metatarsophalangeal Joint in Adolescents with Cerebral Palsy 2021-11-01T13:49:18-06:00 Min Jia Tang Ken Ye Samuel K. Van de Velde Erich Rutz Kerr Graham <p>Symptomatic hallux valgus (HV) and hallux flexus (HF) affect 2% of adolescents with cerebral palsy.<sup>1</sup> Management of bunions is largely divided into arthrodesis and non-fusion surgery, with the latter including soft tissue balancing and corrective osteotomies.<sup>2,3</sup>&nbsp;However, due to the high recurrence rate and lower patient satisfaction it is generally accepted that fusion of the first metatarsophalangeal joint (1<sup>st</sup> MTPJ fusion) is the primary treatment of choice in symptomatic bunions.<sup>3</sup> This aligns with our experience where the long-term outcome of non-fusion operations have been unpredictable. Approximately 50% of patients in our center have required a revision fusion for salvage with an additional 25% experiencing ongoing symptoms but declining further surgery. In our center, only 25% of patients had a successful outcome with non-fusion surgery (unpublished data).</p> <p>Although the literature supports the role of arthrodesis, there is less agreement about the method of achieving fusion.<sup> 7</sup> Fixation with Kirschner wires, screws, and dorsal plates have has been reported with variable success rates.<sup> 2,4,5,6</sup> Historically, at our institution, we performed 1<sup>st</sup> MTPJ arthrodesis by inserting K-wires in a longitudinal fashion, sometimes combined with an oblique screw, followed by 6 weeks when we recommended non-weight-bearing. We frequently noted wear and tear of the casts, loosening of the K-wires and a high prevalence of pin site infections because of inability to comply with long periods of restricted weight-bearing and activities.</p> <p>In this paper, we describe our surgical technique which we adapted from the technique described by Coughlin and colleagues—preparation of the joint surfaces using cup and cone reamers and fixation with a dorsal plate. Initially, we used a 4-hole Vitallium plate, but our current preference is to use a more robust locking plate.<sup>8</sup> The use of these plates has allowed accurate alignment of the fusion and early mobilisation after surgery.<sup>8</sup> We have adopted plate fixation as our primary means of fixation for symptomatic bunions in adolescents and young adults with cerebral palsy.</p> 2021-10-13T06:40:21-06:00 Copyright (c) 2021 JPOSNA Evidence-Based Treatment and Outcomes of Tibial Bone Stress Injuries 2021-11-01T13:49:18-06:00 Naveen Jasty Paige Dyrek Japsimran Kaur Kathryn E. Ackerman Emily Kraus Benton Heyworth <p>Bone stress injury (BSI) of the tibia, a spectrum of impairments that include conditions commonly referred to as medial tibial stress syndrome (MTSS), tibial stress reaction, and tibial stress fracture, is relatively common in athletes of various ages and levels of competition. While simple rest from the offending activities remains the primary method of treatment, identification of nutritional, hormonal, and biomechanical risk factors is crucial to prevent persistent or recurrent injury. Perhaps the most basic and important mechanical risk factor, especially in those with chronic or recurrent injury, may be abnormalities in gait and ankle flexibility, which can range from subtle to severe. While magnetic resonance imaging-based (MRI) injury grading can provide a framework for expected healing time, treatment must be individualized and evolution of a patient’s symptoms should guide the progression to return to sport after a prescribed period of rest. The vast majority of tibial BSIs can be managed nonoperatively and surgery is largely reserved for those who have undergone exhaustive conservative management without success, those with multiple recurrences, or high-level competitive athletes with the most severe grades of injury. The current review aims to highlight current concepts in the treatment of tibial BSI, with a particular focus on the high-risk population of adolescent athletes.</p> 2021-10-29T12:50:37-06:00 Copyright (c) 2021 JPOSNA Complex Decisions in the Management of Congenital Pseudarthrosis of the Tibia 2021-11-01T13:49:18-06:00 Jennifer Laine In-Ho Choi Mark Dahl John Herzenberg Joachim Horn Christopher Iobst Charles Johnston Benjamin Joseph Philip K. McClure Kenneth Noonan Hitesh Shah <p>Congenital pseudarthrosis of the tibia, or congenital tibial dysplasia, is one of the most challenging conditions in pediatric orthopaedics. In children who present in a pre-fracture state, the initial goal is fracture prevention.&nbsp; Once the tibia has fractured, the goals of treatment pivot to achieving – and maintaining – union.&nbsp; Treatment approaches are varied and may include:&nbsp; pseudarthrosis resection, intramedullary(IM) fixation, circular external fixation, internal fixation, vascularized fibular grafting, biologics, guided growth, or a combination of approaches. Unfortunately, the treatment of this condition is often fraught with complications and it is not unusual for a child to undergo multiple procedures.&nbsp;</p> <p>The goals of this case discussion are to highlight how experts approach these complex cases, to emphasize the key components of decision-making, to demonstrate clinical and technical pearls, and to feature the heterogeneity of this condition and its treatment.</p> 2021-10-31T10:51:05-06:00 Copyright (c) 2021 JPOSNA