JPOSNA 2020-10-25T10:08:57-06:00 POSNA Staff Open Journal Systems <p><strong>JPOSNA</strong> (the <strong>Journal of the Pediatric Orthopedic Society of North America)</strong> is an open access online journal focusing on pediatric orthopedic conditions, treatment and technology.</p> Editor's Note 2020-08-03T13:01:12-06:00 Ken Noonan <p>Ernest Codman MD (Codman’s Triangle, Codman’s Shoulder Exercises) was a Harvard surgeon who first proposed to his colleagues in the early 1900’s that it might be a good idea to study and record the after-effects from surgery.&nbsp; He felt that the <em>“End Result” </em>should be recorded in order to improve care and results could be made public thus allowing patients to make informed decisions when selecting a provider.&nbsp; Considered the founder of outcomes research and studies for quality; he wasn’t exactly a favorite of his peers who felt that knowing how patients fared might affect their livelihood. &nbsp;Eventually he lost his Harvard appointment as result of his fervent desire to improve quality in the face of stiff peer pressure.&nbsp; Despite being ostracized for the majority of his career, he was a founding member of the American College of Surgeons and his focus on quality eventually led to today’s Joint Commission on Accreditation of Hospitals.</p> <p>It’s astounding that early physicians were afraid to learn and document their outcomes and equally amazing how far we have come in the evolution of outcomes research.&nbsp; We have evolved from simply recording the <em>“End Result”</em> as Codman advised; to keeping track of things like radiographic results.&nbsp; We now collect patient reported outcome measures as a means to understand methodology and the importance of evidence.&nbsp; We recognize a broader understanding that sustainable quality requires standardization and structure including checklists and guidelines.</p> <p><strong>Quality.&nbsp; Safety.&nbsp; Value.&nbsp; &nbsp;</strong></p> <p>If you are like me, prior to 2011-2012; these were words that I used in my professional life to describe efforts to provide excellent care with low complication rates and as cheaply as possible.&nbsp; Yet while we were practicing pediatric orthopaedics with these goals in mind, POSNA was on the forefront of expanding what these words mean to us now.&nbsp; Kevin Shea writes in this edition of JPOSNA about the history of the QSV initiative and its current directions at the patient level, system level and for all of society.&nbsp; Our President Michael Vitale, will let us peek into new POSNA initiatives to improve safety for our patients.&nbsp;&nbsp; In this edition of JPOSNA we are fortunate to have <strong>FOUR</strong> papers related to improving systems of care, safety and attempts to document the value of what we do.&nbsp; JPOSNA hopes to facilitate the pioneering work of Ernest Codman and POSNA; and we endeavor to become the destination for quality improvement manuscripts that seek to document the <u>Value</u> of <u>Safe</u>, High <u>Quality</u> Care for children with orthopaedic disorders.</p> 2020-07-26T18:29:41-06:00 Copyright (c) 2020 JPOSNA Message from the President 2020-10-25T10:08:57-06:00 Michael Vitale <p>Welcome to the next edition of JPOSNA. As you can see, Ken Noonan and his editorial team have been busy developing a spectacular new addition to POSNA offerings – and this is just the beginning. JPOSNA allows our membership to control the content and format of state-of-the-art pediatric orthopaedic education. Whether it be focused issues like this one on quality safety and value, technical surgical pieces replete with video, traditional research papers, or captured presentations from our meetings, JPOSNA serves as a home where we can invite our members to come and spend some time. While the name may change, JPOSNA will be our shared space to communicate. Keep an eye on this rapidly evolving exciting new part of POSNA!</p> <p>The current edition of JPOSNA is particularly exciting to me, and I hope to you. In pages below, you will hear how POSNA was one of the first organizations to embrace the area of quality, safety and value, leading the charge for many other societies. The QSV Council, led by Kevin Shea, is now our largest council with so much great work going on by so many of our members.</p> <p>You may have heard a bit about the next step in POSNA’s push to help make care better for kids with orthopaedic problems – the <em>POSNA Safe Surgery Program</em>. “Under construction” for about two years, this is a POSNA-led effort to have more ownership about what constitutes best practice and quality in our space.</p> <p>So many of our members have voiced concern and frustration that various outside rating schemes and reports are now setting the rulebook in this space. In the last weeks, I have heard from members questioning why their program is rated by an outside publication with criteria that some see as capricious and non-evidence based. Members from smaller programs, in particular, have expressed sentiment that the current rating systems are prejudiced for large programs with extensive resources.&nbsp; For smaller programs with minimal resources, our members are asked (pressured) to divert time and energy from their practices and research to respond to these surveys in an optimal way that brings <em>“prestige”</em> to their institution. POSNA certainly recognizes that high quality care in our space occurs in many programs- regardless of size or popular press rankings.&nbsp; Since we acknowledge that external ranking systems will persist and will not go away in the short term, we will look to align our efforts with those processes when appropriate, but also to focus on issues which we know to be more relevant for optimal patient care. &nbsp;</p> <p>Let me introduce you to the <em>“POSNA Safe Surgery Program”</em> which you may have heard a bit about in my recent video newsletter. While final details are still being worked out by our members and need to be approved by our board, there has been tremendous interest and effort in development.&nbsp; The primary goal of the <em>POSNA Safe Surgery Program</em> is to give expert clinicians a framework to decide best practices and optimum outcomes in each of your own specialties. You are the experts; you write the playbook.</p> <p>Rather than provide a quantitative ranking, we seek to “move the whole bell curve” to make care better for our patients and to also help our members advocate for the resources they need at home to do that. Over the last year, members of QSVI – Spine, Trauma and Sports (the first 3 areas to be addressed) have been hard at work creating these metrics. As a first step, we will only look at processes, but we have great hope about how this could evolve to better serve our members and patients. &nbsp;As opposed to existing entities, we are not looking to rank surgeons or even rank hospitals. Our members will tell us what is important and create the metrics for what constitutes “success” regardless of program size or volume. But when availability of subspecialty resource is important, we will celebrate that.</p> <p>A lot of this work is already done by POSNA in various places in various ways. For example, POSNA has supported position statements of various types and guidelines like the “Checklist to Optimize Response to Intraoperative Monitoring Change”. As part of <em>POSNA’s Safe Surgery Program</em>, QSVI/Spine has therefore recommended that use of intraoperative checklists be one of the metrics for safety. In this way, this program will centralize various efforts, and put POSNA members in a position to foster positive change.</p> <p>While these are admittedly small initial steps, there is certainly precedent in the efforts of the American College of Surgeons Childrens Surgical Verification Performance Improvement and Patient Safety (PIPS) Program.</p> <p>While some of the details of our new program still need to be finalized, our goal is to allow POSNA members to define what is important to our patients and our programs. I wanted to share a bit of this with you and invite you to reach out to me, Kevin Shea, Min Kocher or anyone of us on the presidential line or board of directors to discuss.</p> <p>For now, best wishes for the Summer.</p> 2020-07-26T18:28:47-06:00 Copyright (c) 2020 JPOSNA The History of POSNA Quality, Safety, Value Initiative Committee/Council – 2011-2020 2020-08-03T13:01:13-06:00 kevin shea James McCarthy Brian Brighton <p>POSNA QSVI Council has defined the current and future state for performance, quality improvement in pediatric orthopedics, and worked in collaboration with the POSNA membership to focus upon quality, value, outcomes.&nbsp; The past and current foci are described, along with an outline of some of the future goals for POSNA, its members, and the QSVI Council.&nbsp; POSNA QSVI Council will continue to advocate for patients, families, and our members to obtain the best resources and care environments for high quality, high value pediatric orthopedic care.</p> 2020-07-26T18:42:06-06:00 Copyright (c) 2020 JPOSNA Health Economics in Pediatric Orthopaedic Surgery 2020-08-03T13:01:13-06:00 Sebastian Orman, MD Edward J. Testa, MD Shyam A. Patel, MD Neill Y. Li, MD Peter D. Fabricant, MD, MPH Jeffrey A. Rihn, MD Aristides I. Cruz Jr., MD, MBA <p>Healthcare expenditures in the United States continue to rise without corresponding improvements in outcomes. Because of this, there is increasing pressure on physicians to consider the economic impacts of their medical decisions. Unfortunately, physicians in general are unfamiliar with interpreting and performing various health economic analyses. A basic understanding of health economics may help physicians understand and participate in key policy discussions which may shape the future of medicine and surgery.</p> <p>&nbsp;In the field of pediatric orthopaedics specifically, the literature involving health economic evaluation is sparse. This may be due to a combination of unfamiliarity with the topic and also difficulties with applying economic evaluation methods to the pediatric population. However, many interventions in this field are low cost with many potential benefits that accrue over a child’s long lifespan. Economic evaluation can help objectively quantify the impact of these interventions, as well as bolster responsible medical decision-making.</p> <p>To that end, the purpose of the current review is to introduce the pediatric orthopaedic community to commonly utilized healthcare economic tools including cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis with a focus on several key concepts including value, quality, time, cost, and discounting. To help illustrate these concepts, health economic literature relevant to pediatric orthopaedics is discussed. Finally, we highlight limitations inherent to health economic evaluations in general and those applicable to pediatric orthopaedics specifically. This discussion may help lay the groundwork for future studies and for further involvement in policy-making.</p> 2020-07-05T21:59:53-06:00 Copyright (c) 2020 JPOSNA Financial Impact of Surgical Care for Scoliosis, Developmental Hip Dysplasia, and Slipped Capital Femoral Epiphysis in Children 2020-08-03T13:01:13-06:00 Lane Koenig Jennifer Nguyen Elizabeth Hamlett Kevin Shea <p><strong>Background: </strong>While pediatric musculoskeletal (MSK) conditions contribute to the global burden of disease, national estimates of their prevalence and costs as well as the impact of surgery are virtually non-existent, particularly for non-trauma related conditions. &nbsp;In this paper, we provide national estimates of surgery frequency and hospital costs as well as identify gaps in our understanding of the financial impact of three non-trauma related pediatric MSK conditions: scoliosis, developmental hip dysplasia (DDH), and slipped capital femoral epiphysis (SCFE).&nbsp;</p> <p><strong>Method: </strong>The 2012 Kids’ Inpatient Database (KIDs), select State Ambulatory Surgery and Services Database (SASD), and U.S. Census Bureau data were used to estimate utilization, hospital costs, and separate inpatient and outpatient procedural volume. Charges were converted to costs using cost-to-charge ratios provided by KIDs and the Centers for Medicare &amp; Medicaid Services. A literature review was performed on the indirect costs associated with these conditions.</p> <p><strong>Results: </strong>In 2012, U.S. annual surgical procedure estimates were 9,607 for scoliosis, 2,554 for DDH, and 2,464 for SCFE. Inpatient surgery was more common for each of these conditions, with 94% of scoliosis, 73% of DDH, and 62% of SCFE surgeries performed in the inpatient hospital setting. Total annual hospital costs for the three surgeries were almost $400 million (2012 USD), with scoliosis surgery accounting for 91 percent of these costs. The literature review demonstrated an association between these conditions and long-term social health outcomes, but studies have not analyzed the long-term economic effects of these conditions.</p> <p><strong>Conclusion: </strong>Hospital costs related to surgery for scoliosis, DDH, and SCFE are significant but likely represent only a fraction of the full societal costs of these conditions, particularly if left untreated. Surgery has the potential to reduce the societal burden of these conditions through reduced disability and greater productivity. While we can document the cost to treat pediatric MSK conditions; more research is needed to fully appreciate what the financial burden would have been for the natural history of these conditions.</p> <p><strong>Key Concepts: </strong></p> <ol> <li>National estimates of the prevalence and costs of pediatric musculoskeletal conditions and the impact of surgery are virtually non-existent, particularly for non-trauma related conditions<strong>.</strong></li> <li>In 2012, U.S. annual surgical procedure estimates were 9,607 for scoliosis, 2,554 for DDH, and 2,464 for SCFE.</li> <li>Hospital costs related to surgery for scoliosis, DDH, and SCFE are significant but likely represent only a fraction of the full societal costs of these conditions.</li> <li>There are challenges with obtaining data on pediatric musculoskeletal conditions and measuring their long-term financial impact on patients and society.</li> </ol> 2020-07-26T18:43:02-06:00 Copyright (c) 2020 JPOSNA A Quality Improvement Initiative to Reduce Radiation Dose During Cast Treatment for Infantile Scoliosis 2020-08-03T13:01:13-06:00 Joseph Khoury Cheryl Lawing Maureen Maciel Kyle Achors Phillip Fontenot <p><strong>Introduction:</strong> We are a high volume referral center for cast treatment of early onset scoliosis. Assessing the progress of treatment and effectiveness of each cast requires frequent use of radiographs which increases the risk of malignancy in young patients over their lifetime. We felt that frequently omitting radiographs may lead to wasted anesthetics and sought to find another method to reduce the dose of radiation these patients receive over the course of treatment.</p> <p><strong>Methods:</strong> Spinal radiographs are typically performed before and after casting while under anesthesia. Spine radiograph technique dictates a grid be placed between the patient and cassette to absorb any radiation that had been deflected by the body and not travelling directly perpendicular to the cassette. Without the grid, a significantly lower dose may be used. The image quality is non-diagnostic and grainy but endplates are still discernable. We eliminated the use of a grid in our practice and adjusted the dose accordingly to optimize endplate visualization. To ensure that measurement accuracy was not severely decreased, inter and intra-rater variability was measured before and after this change by several observers.</p> <p><strong>Results:</strong> Obtaining spinal radiographs without the grid resulted in an 80% reduction in total radiation dose received at the skin while having no effect on inter and intra-rater reliability of Cobb angle measurements.&nbsp;&nbsp; These radiographs allow for monitoring of treatment progress and cast quality with each anesthetic without omitting potentially important information.</p> <p><strong>Conclusions:</strong> Omitting potentially important radiographs may not be the only option for the reduction of radiation exposure in children undergoing Mehta casting. This non-conventional technique reduces radiation dose by 5 fold while still allowing accurate measurement of Cobb angles and therefore the progress of treatment and quality of casting. We are currently investigating a similar technique for longitudinal follow up pelvis radiographs in the treatment of hip dysplasia and cerebral palsy.</p> 2020-07-14T14:35:27-06:00 Copyright (c) 2020 JPOSNA Being a Great Mentor and Mentee: Key Skills to Enhance the Future of Pediatric Orthopaedics 2020-08-03T13:01:13-06:00 Jack Flynn <p>Pediatric orthopaedics, like many fields in medicine, is truly an apprenticeship. We begin our five to six years of orthopaedic surgery training as a young intern, and our best learning is done alongside (or across from) a senior surgeon, in clinic or the operating room. From books and scientific studies (and now VuMedi and Orthobullets) we gain essential knowledge and some techniques. But let’s face it, we learn how to be a practicing pediatric orthopedist from our role models and mentors in residency and fellowship. Once we accept this essential truth, there is nowhere to hide from the fact that our roles as mentors and teachers are just as important as our roles as surgeons; because we are building the legacy that will care for our grandchildren and great-grandchildren. Learning to be a good mentor or mentee is a lifelong pursuit. At this stage of my career, and at risk of feeling imposter syndrome, I’ll reflect on how we can pay forward the gifts we’ve been given by being better at being both a mentor and mentee.</p> 2020-07-19T08:42:10-06:00 Copyright (c) 2020 JPOSNA The Peer Review Process for Clinical Abstracts and Manuscripts: Helpful Tips from the POSNA Evidence Based Medicine Committee 2020-08-03T13:01:13-06:00 Matthew Schmitz MATTRSCHMITZ@GMAIL.COM Bastrom Tracey Maegen Wallace <p>The review of abstracts and manuscripts for presentation or publication is an important part of the peer-review process. Many clinicians and scientists are often asked to review abstracts and manuscripts with little formal training in the process of these reviews. The following stresses the importance of abstract and manuscript review, a recommended process to go through to achieve quality reviews and how to give constructive feedback to authors in a concise yet complete and unbiased way.</p> 2020-07-05T22:03:41-06:00 Copyright (c) 2020 JPOSNA Education Disrupted by COVID-19? An Opportunity to Improve and Engage 2020-08-03T13:52:53-06:00 Joseph Yellin Brendan Striano Peter Waters George Dyer <p>The COVID-19 pandemic has touched every community and every part of the healthcare system, including the introduction of several new challenges for the healthcare providers and trainees.&nbsp; Studies have examined some of the difficulties that COVID-19 poses for education – for the faculty, residents, and other healthcare providers outside the hospital or self-quarantining in preparation for redeployment. This article describes the Harvard Combined Orthopaedic Residency Program’s (HCORP) proactive educational response to the instructional training gap created amid the COVID-19 pandemic. Herein, we introduce a new educational vehicle that allows for the smooth and reliable delivery of pediatric orthopedic didactics and trainee educational engagement for years to come. In addition to exploring how a virtual curriculum was used successfully, this narrative explores novel benefits made possible by the digital platform including the ease of involvement of trainees in disparate locations, the creation of a comprehensive digital archive of educational material, and the ability to extend the educational experience beyond HCORP trainees exclusively.</p> 2020-07-19T08:43:02-06:00 Copyright (c) 2020 JPOSNA Orthopaedic Management in Marfan Syndrome 2020-08-03T13:01:13-06:00 Alexandra Dunham Paul Sponseller <p>Marfan syndrome (MFS) is a variable autosomal dominant connective tissue disorder affecting multiple organ systems. Causative mutations in the fibrillin-1 protein lead to dysregulation of transforming growth factor-β (TGF-β). A diagnosis of MFS can be made using systemic evaluation combining clinical and genetic features. Because the condition is characterized by a variety of musculoskeletal manifestations, orthopaedic surgeons may be the first provider patients encounter. Common musculoskeletal manifestations of MFS include spine deformity, acetabular protrusion, limb length deformity, joint laxity, and foot pathology. Non-musculoskeletal manifestations include major cardiac and ocular conditions. Early identification is important for referral and prompt treatment of cardiovascular abnormalities, which can prevent premature mortality. As medical and surgical interventions have advanced, life expectancy for MFS patients has increased to late 70s. We must remain vigilant, suspect diagnosis, and engage in multidisciplinary care to promote musculoskeletal function at advanced ages.</p> 2020-07-25T16:57:18-06:00 Copyright (c) 2020 JPOSNA Pediatric Musculoskeletal Infection 2020-08-03T13:01:13-06:00 Stephanie N. Moore-Lotridge Breanne HY Gibson Matthew T Duvernay Jeffrey E. Martus Isaac P. Thomsen Jonathan G. Schoenecker <p>Few conditions in pediatric orthopaedics provoke more apprehension than a child with a musculoskeletal infection (MSKI). In addition to potential for devastating complications, the infectious organisms, technology to diagnose MSKI and pharmacology to treat MSKI evolve continuously. For these reasons, it is essential that pediatric orthopaedic surgeons be up to date on the current and future MSKI practices. In this review, current and potential future practices are systematically reviewed categorized by the four main tasks of the care team treating MSKI: determining 1) that location of the infection 2) is it an infection, and if so, what is the organism 3) how severe is the infection and 4) how to treat the infection. Finally, considering current events, the philosophy and tools highlighted for use in MSKI are paralleled in COVID-19 (SARS-CoV-2).</p> 2020-07-30T22:29:32-06:00 Copyright (c) 2020 JPOSNA Displaced Distal Radius Fractures in Children: To Reduce or Not to Reduce? To Pin or not to Pin? 2020-08-03T13:01:13-06:00 Walter Truong Andrew Howard Andrew Georgiadis <p>Displaced distal radius fractures in children are routinely treated with closed reduction under sedation, which adds risk and cost.&nbsp; Many metaphyseal fractures, especially in young children (under age 10), may have the capacity to remodel without reduction.&nbsp; Which fractures need treatment, at any given age?&nbsp; What other factors should we consider?&nbsp; Also, if we decide to reduce these fractures, do we need to pin them?&nbsp; This review summarizes the available literature and hopes to guide clinicians in treatment of children with distal radius fractures presenting to their practice.&nbsp;</p> <p>&nbsp;</p> <p><u>KEY POINTS:</u></p> <ol> <li>Displaced distal radius fractures often undergo sedated reduction in children.</li> <li>Remodeling potential of the metaphyseal distal radius is significant in both the sagittal and coronal planes.</li> <li>Complete remodeling without sequelae of 100% displaced and shortened distal radius fractures has been reported in children under age 10.</li> <li>Pinning eliminates risk of loss of reduction but may lead to unnecessary surgery in about 60% of cases.</li> <li>Large, prospective studies are ongoing or planned for the near future.</li> </ol> 2020-07-05T22:05:48-06:00 Copyright (c) 2020 JPOSNA Iatrogenic Physeal Separation During Attempted Reduction of an Obturator Hip Dislocation 2020-08-03T13:01:13-06:00 Luke Myhre Kevin Jones Ian Duensing Stephanie Holmes <p>Obturator hip dislocations are exceedingly rare, comprising &lt;5% of hip dislocations<sup>1</sup>, &nbsp;with an even smaller percentage of these dislocations involving penetration of the obturator foramen with an irreducible intrapelvic femoral head. There are no reports of this in the pediatric population. We report a case of a 16 year old male who presented with a trans obturator hip dislocation which was irreducible by closed means and underwent open reduction. The open reduction was complicated by intraoperative acute physeal separation, also known as epiphysiolysis. This was managed with reduction of the epiphysis and fixation with a fully threaded screw, followed by reduction and capsular repair. &nbsp;The combination of this injury and subsequent complication has not been previously reported in the literature.&nbsp; Our report and focused review of the relevant literature should guide clinicians who encounter a similar clinical scenario.&nbsp;</p> 2020-07-05T22:08:50-06:00 Copyright (c) 2020 JPOSNA Pediatric Patellofemoral Instability: Beyond the MPFL 2020-08-03T13:01:14-06:00 Kenneth Lin Alexandra Mackie Alexandra Aitchison Aristides Cruz Corinna Franklin Joseph Molony Kevin Shea Daniel Green Peter Fabricant <p>Pediatric patellofemoral instability is an increasingly common and debilitating problem. In recent years, there has been an improvement in diagnostic capabilities and greater knowledge of unique pediatric patellofemoral anatomy and pathophysiology. The spectrum of disease varies from a single traumatic dislocation, to recurrent dislocation, to obligatory dislocation in flexion or even fixed dislocation in severe or syndrome-associated cases. When treating pediatric patellofemoral instability, it is important to understand the benefits and limitations of nonoperative management. It is important to recognize the challenges imparted by the anatomy of the skeletally immature knee, specifically with regards to the physis, when considering surgical treatment.&nbsp; One must have a thorough understanding of common anatomic and pathophysiologic contributors to patellofemoral instability, such as coronal or axial plane malalignment, and concomitant osteochondral injury. For the very severe cases such as obligatory dislocation in flexion, special techniques may be required to achieve stability of the patellofemoral joint.</p> 2020-07-25T17:00:52-06:00 Copyright (c) 2020 JPOSNA Management of Fixed Dislocation of the Patella 2020-08-03T13:01:14-06:00 Casey Imbergamo Ryan Coene Matthew Milewski <p>Congenital dislocation of the patella is a rare condition which manifests as a permanent and irreducible patella fixed on the lateral aspect of the femoral condyle, usually present at birth. This condition is to be distinguished from habitual or obligate dislocation, in which the patella dislocates and relocates from its normal position in the trochlear groove spontaneously with flexion and extension of the knee. Congenital dislocation of the patella is frequently associated with a flexion contracture at the knee, genu valgus, foot deformity and external tibial torsion, along with various conditions including arthrogryposis, Down syndrome, and nail-patella syndrome, among others. Surgical correction is the only definitive treatment for this condition, which typically includes lateral release, medial stabilization, distal patellar tendon realignment, and proximal extensor lengthening if needed. Outcomes following surgical correction are generally satisfactory, with an improvement in function, range of motion, and quality of life for patients. The aim of this paper is to review the current understanding of congenital and habitual dislocation of the patella and provide an updated overview of the diagnosis and surgical management of these conditions.</p> 2020-07-25T16:57:57-06:00 Copyright (c) 2020 JPOSNA Acquired Distal Femoral Deformity After MPFL Reconstruction 2020-08-03T13:01:14-06:00 Arianna Trionfo Alay Shah Amir Misaghi Alexandre Arkader <p><strong>Background:</strong> While reconstruction of the medial patellofemoral ligament (MPFL) is one of the most frequently performed surgical procedures in skeletally immature patients with patellar instability, there is an inherent risk to the distal femoral physis during femoral tunnel placement</p> <p><strong>Methods:</strong> This case report describes a distal femoral valgus deformity caused by partial lateral physeal growth arrest after MPFL reconstruction. &nbsp;</p> <p><strong>Results:</strong> The acquired distal femoral valgus deformity was successfully treated with a distal femoral varus-producing osteotomy.&nbsp;</p> <p><strong>Conclusion:</strong> This case highlights the importance of understanding the distal femoral anatomy and avoiding areas where the physis may be violated.</p> 2020-07-19T22:46:02-06:00 Copyright (c) 2020 JPOSNA Evaluation of the Limping Child 2020-08-03T13:01:14-06:00 Jessica Burns Scott Mubarak <p>Evaluation of the etiology of a younger child (age &lt;5) with gait disturbance or refusal to walk is a critical skill for the orthopedic surgeon. The common causes are trauma and infection, which can often be delineated with a detailed history. Prompt diagnosis is critical to distinguish orthopedic emergencies from relatively benign processes and chronic problems such as arthritis. Physical examination should utilize the parent’s lap to keep the child comfortable. Examination should include evaluation of gait, supine and prone hip examination, and the crawl test. There are six radiographic views of the lower extremities that can assist in the diagnosis. In conjunction with the detailed history, thorough physical exam, and radiographs the orthopedic surgeon can determine the need for laboratory tests and other imaging.</p> 2020-07-05T22:12:28-06:00 Copyright (c) 2020 JPOSNA Keys to Building a Successful Pediatric Limb Reconstruction Program 2020-08-03T13:01:14-06:00 Christopher Iobst Mark Dahl John Birch Alexander Cherkashin Mikhail Samchukov <p>Pediatric limb reconstruction is a rewarding but demanding field.&nbsp; Based on the experience of three established limb reconstruction centers, this reference article is designed to help young surgeons learn the keys to building a successful pediatric limb reconstruction practice.&nbsp; Each element (education, clinic team, operating room team, patient volume, practice habits) is explained in a comprehensive,step-wise manner to guide the surgeon through the process.&nbsp;</p> 2020-07-14T14:34:25-06:00 Copyright (c) 2020 JPOSNA Painful Flatfoot in Children and Adolescents 2020-08-03T13:01:14-06:00 Arya Minaie Maksim Shlykov Pooya Hosseinzadeh Vincent Mosca <p>Pediatric flatfoot is ubiquitous with several etiologies, including that of being the normal shape of the child’s foot. More specifically, pediatric flatfoot can be categorized as either flexible or rigid, with the former being more common. Most flexible flatfeet are normal and do not cause pain or functional disability. They should not, in fact, be called deformities at all but, instead, anatomic shape variations. Rigid flatfeet are acquired deformities. Most are caused by tarsal coalitions which, like their flexible counterparts, are also usually asymptomatic. This fact contributes to their under-diagnosis in the general population and makes it imperative to consider the coexistence of a tarsal coalition in a child with foot pain in the setting of flatfoot. There are several etiologies for pain in pediatric feet that happen to be flat, including the association of a tendo-Achilles contracture, the aforementioned tarsal coalitions, muscle overuse in young children, inflammatory arthropathies, accessory naviculars, stress fractures, foreign bodies, infections, tumors, and chronic pain syndromes. They must be identified as such so that specific and targeted treatment can be instituted. Surgical management of symptomatic flatfoot, after failed non-operative treatment, is based on the utilization of osteotomies to correct the anatomic deformities. If the symptomatic flatfoot is associated with a tarsal coalition, surgical treatment may involve resection of the coalition with concurrent or staged deformity correction, or deformity correction alone. In the majority of cases, gastrocnemius recession or tendo-Achilles lengthening is required. Addressing other coincident deformities with the addition of concurrent osteotomies and soft tissue procedures are needed to ensure short and long-term success.</p> 2020-07-08T22:22:15-06:00 Copyright (c) 2020 JPOSNA Fibrous Dysplasia: Recent Developments and Modern Management Alternatives 2020-08-03T13:01:14-06:00 Soroush Baghdadi Alexandre Arkader <p>Fibrous dysplasia is a benign skeletal lesion that may present in monostotic or polyostotic forms, as well as associated with McCune-Albright syndrome. Mutation of the GNAS gene is responsible for the development of fibrous dysplasia. Pain, limp, deformity, and fractures are the main presenting symptoms. While any bone might be affected, proximal femoral involvement is the most problematic from an orthopaedic standpoint. Although medical treatment to limit the disease burden is available for the polyostotic disease, the mainstay of treatment in symptomatic cases is surgery. This current concept review is aimed at a comprehensive review of the current literature and recent developments in our understanding of fibrous dysplasia and novel treatments, with a focus on orthopaedic manifestations, particularly proximal femur deformity. We also explore the role of state-of-the-art technologies, including 3D printing, in the modern management of fibrous dysplasia.</p> 2020-07-05T22:01:06-06:00 Copyright (c) 2020 JPOSNA "Satisfaction of Search" Never Stop Looking -- Before and After Surgery 2020-08-04T08:23:25-06:00 Daniel Hong Stephanie Moore-Lotridge John Block Hernan Correa hernan.correa@Vanderbilt.Edu Jennifer Halpern Ginger Holt Christopher Stutz Jeff Martus Tim Schrader Jonathan Schoenecker <p><span class="Apple-converted-space">Diagnosing joint pain in the pediatric patient can be difficult considering the wide variety of possible pathology. Concurrent disease processes around the same joint confound assessment and can introduce cognitive bias where the surgeon most often focuses on the most common diagnoses, precluding further workup of other less common pathologies. Here, this concept is reiterated through two cases in which a synovial sarcoma, an extremely uncommon pediatric malignancy, was coincident with more common pathologies of the hip and knee. These cases highlight the importance of an unbiased evaluation of the patient and critical diagnostic workup as concurrent, unrelated pathologies do occur. Additionally, they highlight the importance of considering previously undiagnosed concurrent pathologies when patients deviate from normal recovery after surgery for their primary initially diagnosed pathology.</span></p> 2020-07-19T22:49:23-06:00 Copyright (c) 2020 JPOSNA Scientific Advances in the Understanding of Contracture Pathogenesis in Brachial Plexus Birth Injury 2020-08-03T13:01:14-06:00 Qingnian Goh Roger Cornwall <p>Pediatric orthopedic surgeons are frequently confronted with musculoskeletal contractures caused by pediatric neuromuscular conditions, including brachial plexus birth injury (BPBI). These contractures substantially limit function and quality of life in affected children, and frequently lead to skeletal dysplasia and dislocations. However, existing orthopedic treatments for these contractures do not restore normal function as they fail to address the underlying contracture pathophysiology, which remains largely unknown. Over the past decade, a wealth of scientific and clinical research has contributed to a deeper understanding of the pathogenesis of contractures in BPBI. This review summarizes this research, describing a journey of discovery that intertwines clinical observations and scientific investigations in animal models. This research comprehensively highlights the role of impaired longitudinal muscle growth in contracture pathogenesis, shifting the paradigm of contracture pathogenesis from a problem of muscle strength to a problem of muscle length, and from a mechanical to biological realm. Moreover, these research efforts have elucidated mechanisms governing longitudinal muscle growth and how they are perturbed by neonatal denervation. Most recently, this work has led to the proof of concept discovery that muscle contractures following BPBI can be pharmacologically prevented by targeting the underlying biological perturbations in neonatally denervated muscles. Although much work must be done before such a pharmacologic strategy can be translated to children, these discoveries hold promise for a new era in the pediatric orthopedic care of BPBI in which contractures are medically prevented rather than surgically treated.</p> 2020-07-26T08:22:36-06:00 Copyright (c) 2020 JPOSNA The Physis: Fundamental Knowledge to a Fantastic Future through Research 2020-08-03T13:01:14-06:00 Matthew Halanski Maegen Wallace <p>In this manuscript we highlight the proceedings of the 2018 AAOS/ORS Physeal Symposium.&nbsp;</p> 2020-07-26T08:24:48-06:00 Copyright (c) 2020 JPOSNA