JPOSNA <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> POSNA en-US JPOSNA Editor's Note <p>When the Inaugural edition of JPOSNA was released in November of 2019, COVID-19 was a distant threat and was barely on the minds of most Americans.&nbsp; As this second Edition is released; we have a million infected Americans and have lost close to 60,000 souls.&nbsp; Life has been altered in almost every way imaginable; historians and pundits will study this time for decades.</p> <p>For our membership and our profession, times have also changed.&nbsp; European colleagues are rounding as ICU fellows in makeshift hospitals that used to house travelers as hotels.&nbsp; American surgeons and providers have been redeployed to emergency rooms and medical units.&nbsp; Elective pediatric orthopaedic surgery has been temporarily cancelled.&nbsp; In the horror of this pandemic it is almost selfish to even think about the cancelled in-person POSNA Annual meeting this year.&nbsp; This meeting has been a gathering of like-minded individuals, a “family” dedicated to caring for children with orthopaedic conditions.</p> <p>Like our own familes who have adapted with social distancing, virtual education and Zoom meetings; POSNA has adapted with our 2020 virtual meeting.&nbsp; What hasn’t changed for our membership?&nbsp; It’s here on these pages.&nbsp; POSNA members doing what they do so well, and in a maelstrom of uncertainty.&nbsp; Authors, advisors and colleagues gathering their energy and dedication to children; writing content and showing each other how to be better at this vocation.&nbsp; Thank you to all who contribute, teach and guide us.</p> Ken Noonan Copyright (c) 2020 JPOSNA 2020-04-28 2020-04-28 2 1 How We Continued to Care for Our Patients <p><strong>Background:</strong> In response to the disruption that the COVID-19 pandemic caused to our health care system, our institution promptly implemented telemedicine to address the need for non-urgent, yet necessary, musculoskeletal (MSK) care. The aim of this paper is to outline the telemedicine strategies and infrastructure implemented by the Division of Orthopaedics at the Children’s Hospital of Philadelphia (CHOP). Our system can serve as an example of how to provide continued access to care in the setting of mandated office visit cancellations.</p> <p><strong>Methods: </strong>The Division of Orthopaedics developed and rapidly implemented new tools to make the&nbsp;transition to telemedicine possible. This involved leveraging existing infrastructure to develop clinical decision support, a centralized training platform, and access to real time data for quality improvement.&nbsp;</p> <p><strong>Results: </strong>Our division now conducts over 50% of visits via telemedicine. In the first three weeks of telemedicine, established patients accounted for the largest proportion of these visits, and knee injuries were the most common diagnoses encountered. To improve patient and provider experience, CHOP distributed hospital-wide surveys. Preliminary results indicated high satisfaction with the telemedicine experience.</p> <p><strong>Conclusion: </strong>The COVID-19 pandemic has required health care providers to rapidly implement telemedicine on a larger scale than ever before. Our approach allowed us to quickly adapt and continue providing care to our patients. We expect that the expansion of telemedicine will increase access to health care beyond the pandemic.&nbsp;</p> Tomasina Leska Lia McNeely Lawrence Wells Copyright (c) 2020 JPOSNA 2020-05-07 2020-05-07 2 1 The Emergence of Non-Operative Pediatric Orthopaedists (NOPO) to Increase Access to Orthopaedic Care for Children <p>Pediatric orthopaedic surgeons (POS) are faced with numerous changes including increased volume of referrals from pediatricians and family medicine physicians who do not feel comfortable managing “primary care orthopaedic conditions”. There is an emerging field of medicine, Non-Operative Pediatric Orthopaedics (NOPO), which has grown over the past 15 years. These physicians bridge the respective fields of Pediatrics and Pediatric Orthopaedics by providing the full spectrum of non-operative pediatric orthopaedic care while creating a symbiotic partnership with pediatric orthopaedic surgeons.</p> Melissa Bent Saji Azerf Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 POGO Travel Journal <p>Travel log from the mission trip to the Dominican Republic 2019</p> Jaime Gomez Shirvinda Wijesekera Andrew Moulton Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Gait Analysis at Your Fingertips: Accuracy and Reliability of Mobile App Enhanced Observational Gait Analysis in Children with Cerebral Palsy <p><strong>Recipient: Donald Kephart, MD </strong></p> <p><strong><u>Gait Analysis at Your Fingertips: Accuracy and Reliability of Mobile App Enhanced Observational Gait Analysis in Children with Cerebral Palsy</u></strong></p> <p>Donald T. Kephart, MD<sup>1</sup>; S. Reed Laing, BA<sup>2</sup>; Anita Bagley, PhD, MPH<sup>2</sup>; Jon R. Davids, MD<sup>3</sup>; Vedant A. Kulkarni, MD<sup>4</sup>, (1) UC Davis Medical Center, Sacramento, CA, (2) Shriners Hospitals for Children - Northern California, Sacramento, CA, (3) Shriners Hospitals for Children, Sacramento, CA, (4) Shriners Hospitals for Children - Northern California; UC Davis School of Medicine, Sacramento, CA</p> <p><strong>Purpose:</strong> Three-dimensional gait analysis (3DGA) allows for quantification of gait deviation that can inform decision-making for orthopaedic surgery in children with cerebral palsy (CP). Where 3DGA is unavailable, observational gait analysis (OGA) guided by the Edinburgh Visual Gait Score (EVGS) has been shown to have acceptable reliability. The addition of mobile application slow-motion video analysis may improve the accuracy and reliability of the OGA method. This study prospectively evaluates the accuracy and reliability of mobile app enhanced OGA when compared to the gold standard of 3DGA in children with CP.</p> <p><strong>Methods:</strong> All subjects gave their informed consent for this IRB approved prospective study. Slow-motion video was captured on an iPhone 8S while simultaneous 3DGA was acquired using a 12-camera infrared system at a children's hospital Motion Analysis Center. Using the Dartfish Express app on an iPad Pro, two observers made 17 quantitative measurements per limb guided by the EVGS [Figure 1]. Inter-class correlation coefficient (ICC) was used to compare reliability between observers and between methods. Pearson Correlation was used to assess the impact of transverse plane deviations on the accuracy of sagittal plane measurements.</p> <p><strong>Results:</strong> Ten subjects with CP were recruited for the study (7M, 3F; GMFCS II = 8, GMFCS III = 2; Mean 12.4y, range 7.7y to 16.4y). All subjects had significant gait deviation as measured by the Gait Profile Score (GPS), with a mean GPS of 14.10 (SD 4.18), nearly three times greater than the reference normal of 5.2 (SD 1.9). There was excellent overall reliability between raters (ICC 0.95) using mobile app enhanced OGA, and good overall reliability between OGA and 3DGA (ICC 0.89). For individual measurements, the reliability was excellent (ICC &gt; 0.9) for 6 measures, good (ICC 0.75 – 0.9) for 5 measures, moderate (ICC 0.5 – 0.75) for 5 measures, and poor (ICC &lt; 0.5) for 1 measure. The mean error between OGA measurement and 3DGA was 7.02°(SD 6.86°), with foot progression angle (FPA) and knee progression angle (KPA) having among the highest mean errors (12.85° and 10.33°, respectively) [Table 1]. Out of plane measurements substantially affected accuracy of the OGA method. If the FPA or KPA was greater than 20°, the accuracy of mid-stance ankle and knee position had substantially lower reliability and accuracy.</p> <p><strong>Conclusion</strong>: Mobile-enhanced OGA has good reliability between raters, allowing for enhanced communication about gait deviations in children with cerebral palsy using widely available technology. When compared to 3DGA, mobile-enhanced OGA has clinically acceptable measurement errors in the sagittal plane but should be used with caution to quantify transverse plane deviation. When rotation of the body segment exceeds 20 degrees, sagittal plane measurements become out of plane, resulting in decreased accuracy and reliability.</p> Donald Kephart Copyright (c) 2020 JPOSNA 2020-04-28 2020-04-28 2 1 A Substantial Reduction in Diameter of Autograft After Applying Circumferential Compression During ACL Reconstruction in Pediatric Population <p><strong>Recipient: Scott LaValva </strong></p> <p><strong><u>A Substantial Reduction in Diameter of Autograft After Applying Circumferential Compression during ACL Reconstruction in Pediatric Population</u></strong></p> <p>Scott M. LaValva<sup>1</sup>; Daniel Weltsch, MD<sup>1</sup>; Calvin Chan<sup>1</sup>; Kevin Dale, MD<sup>2</sup>; Ryan Koehler, MD<sup>2</sup>; Theodore J. Ganley, MD<sup>3</sup>; Todd Lawrence, MD, PhD<sup>1</sup>, (1) Children's Hospital of Philadelphia, Philadelphia, PA, (2) Vanderbilt University Medial Center, Nashville, TN, (3) Children’s Hospital of Philadelphia, Philadelphia, PA</p> <p><strong>Purpose:</strong> Over 130,000 anterior cruciate ligament reconstructions (ACLR) are performed annually in the United States (US) and are on the rise in both adult and pediatric populations. Previous studies have investigated the effect of tension and circumferential compression on the diameter of fresh-frozen allografts, but none have described its effect on ACL autografts harvested for implantation during the ACLR procedure. The purpose of this study was to elucidate how hamstring autograft diameter changes in response to tension and circumferential compression for ACLR in pediatric population.</p> <p><strong>Methods</strong> 135 ACLR surgeries (median age 15 [IQR 14-16] years; 50.4% male) were identified in two pediatric hospitals. Three orthopedic surgeons dictated hamstring autograft diameters at two time-points during graft preparation. Hamstring tendons were prepared in a standardized procedure. Autografts were tensioned to 15-20 pounds and their diameters were immediately measured using cylindrical sizing blocks (time-point 1). The graft was then compressed on both the tibial and femoral aspects using sizing blocks. After 10 minutes, diameters were measured again (time-point 2) before implantation. Comparisons were made between graft diameter at each time point. A random effects regression model was performed to capture any unexplained variance on the linear predictor scale and to determine correlations between demographics and graft characteristics.</p> <p><strong>Results </strong>The median initial diameter measurement of both femoral and tibial sides of the autograft during a longitudinal tension was 9.5 (IQR 9-10) mm. After adding circumferential pressure, the median final measurement of both sides was 8.5 (IQR 8-9) mm. The median graft diameter decreased by 1 mm on both sides of the graft after applying an additional circumferential pressure to the longitudinal tension, which was a statistically significant change (P&lt;0.001 for both). Only 3% of cases did not show any decrease in diameter between time points. There was no identified common feature that could explain this group of non-responsive cases. In the random effects model, the application of compression, shorter patient height, and decreased graft strand number were each statistically significant predictors of greater change in graft diameter.</p> <p><strong>Conclusions</strong> The pediatric and adolescent population necessitates a specific skill-set to achieve the fine equilibrium between implanting a well-restored biomechanical construct while avoiding unnecessary bone loss or disruption of the physis. This study suggests that optimizing graft preparation with circumferential compression would allow for the drilling of tunnels which are two (0.5 mm) sizes smaller while providing a better fit between the graft structural content and a relatively small bony tunnel. This paradigm shift is particularly applicable to pediatric, revision, and double bundle ACL reconstruction techniques, where space for tunnel drilling is limited.</p> Scott LaValva Copyright (c) 2020 JPOSNA 2020-04-28 2020-04-28 2 1 Acute Neurological Deficits in Instrumented Pediatric Cervical Spine Fusions <p><strong>Recipient: Bram Verhofste, MD </strong></p> <p><strong>&nbsp;</strong><strong><u>Acute Neurological Deficits in Instrumented Pediatric Cervical Spine Fusions</u></strong></p> <p>Bram P. Verhofste, MD<sup>1</sup>; Michael P. Glotzbecker, MD<sup>2</sup>; M Timothy Hresko, MD<sup>2</sup>; Patricia Miller, MS<sup>1</sup>; Craig M. Birch, MD<sup>1</sup>; Michael Troy, BS<sup>1</sup>; Nora P. O'Neill, BA<sup>1</sup>; Lawrence I. Karlin, MD<sup>2</sup>; John B. Emans, MD<sup>2</sup>; Mark R. Proctor, MD<sup>2</sup>; Daniel J. Hedequist, MD<sup>2</sup>, (1) Boston Children's Hospital, Boston, MA, (2) Boston Children's Hospital, Harvard Medical School, Boston, MA</p> <p><strong>Introduction:</strong> Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, little literature exists on new perioperative neurologic deficits in children. This study describes new perioperative neurologic deficits in pediatric cervical spine instrumentation and fusion.</p> <p><strong>Methods:</strong> A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurologic deficits were defined as the deterioration of preexisting neurologic function or the appearance of new neurologic symptoms.</p> <p><strong>Results:</strong> A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ±5.30 years were included. Instability (n=63) and deformity (n=41) were the most frequent indications. Syndromes were present in 39% (n=71). Eighty-seven (48%) children presented with preoperative neurologic deficits (16 sensory, 16 motor, and 55 combined deficits). A total of 178 (96.7%) cases improved or remained neurologically stable. New neurologic deficits occurred in six (3.3%) cases: three hemiparesis, one hemiplegia, one quadriplegia, and one quadriparesis (Table 1, Figure 1). Preoperative neurologic compromise was seen in four (67%) of these new deficits (three myelopathy, one sensory deficit) and five had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p=0.025). Three (50.0%) patients recovered within six months and the child with quadriparesis is expected to make a complete recovery. Hemiplegia persisted in one patient and one child died due a complication related to the tracheostomy. No association was found between etiology (p=0.46), preoperative neurological symptoms (p=0.65), age (p=0.56), halo (p=0.41), EBL (p=0.09), levels fused (p=0.09), approach (p=0.07), or fusion location (p=0.37).</p> <p><strong>Conclusion:</strong> An improvement of the preexisting neurologic deficit or stabilization of neurologic function was seen in 96.7% of children after cervical spine fusion. New or progressive neurologic deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurologic symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, likely due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurologic deficits are favorable and 50% experienced complete neurologic recovery within six months.</p> Bram Verhofste Copyright (c) 2020 JPOSNA 2020-05-04 2020-05-04 2 1 The Tolerance of the Anterior Humeral Line to Rotational Changes in Elbow Position <p><strong>Recipient: Benjamin Yao, BA </strong></p> <p><strong><u>The Tolerance of the Anterior Humeral Line to Rotational Changes in Elbow Position</u></strong></p> <p>Benjamin Yao, BA<sup>1</sup>; Cynthia Nguyen, MD<sup>2</sup>; Justine Ko, MD<sup>3</sup>; Raymond W. Liu, MD<sup>4</sup>, (1) Case Western Reserve University School of Medicine, Cleveland, OH, (2) Shriners for Children Medical Center, Pasadena, CA, (3) Northwestern University School of Medicine, Department of Emergency Medicine, Chicago, IL, (4) Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH</p> <p><strong>Introduction:</strong> Supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in X-ray projection can lead to significant changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish if rotational variations in elbow rotation lead to significant changes in AHL position and whether different AHL measurement techniques are more tolerant to rotation.</p> <p><strong>Methods:</strong> We utilized 10 pediatric humerus dry cadaveric specimens, and 50 pediatric patients with supracondylar humerus fractures with injury and follow up lateral radiographs where one view was rotated while the other was considered a good quality lateral. The 10 pediatric humerus dry cadavers were rotated along the axis of the humerus in 5-degree increments ranging from -20 to +20 degrees and imaged. Two investigators measured the position of the AHL by either drawing the line using the midshaft anterior humeral surface as a guide or only the distal humeral anterior surface. The 50 pediatric patients with supracondylar humerus fractures were also measured for the position of the AHL using the midshaft or distal humeral shaft as the primary guide. The proportion of capitellum posterior to the intersection of the AHL was calculated and analyzed.</p> <p><strong>Results:</strong> In determining AHL for the pediatric humerus dry cadaveric specimens, utilizing the midshaft humerus as a guide demonstrated a more consistent AHL position through the range of rotation variations in comparison to using the distal humerus as a guide (Figures 1 and 2). In addition, the mean value at each rotational position was within the middle third of the capitellum with the midshaft measurement except at -20 degrees, compared to the distal shaft measurement where +20, +15 and +10 of rotation brought the AHL out of the middle third. In the clinical radiographs comparison of AHL on the rotated lateral radiograph with the properly oriented lateral radiograph found excellent correlation when the midshaft humerus was utilized (ICC = 0.81), but poor correlation when the distal humerus was utilized (ICC = 0.14).</p> <p><strong>Conclusion:</strong> Our data suggests that radiographs rotated as much as 20 degrees can still provide an accurate anterior humeral line measurement, as long as the clinician uses the midshaft anterior humerus to draw the AHL. In contrast, drawing a distally based AHL provides much less tolerance to rotational position.</p> Benjamin Yao Copyright (c) 2020 JPOSNA 2020-05-04 2020-05-04 2 1 Critical Events Before Spinal Cord Injury in a Porcine Compression Model <p><strong>Recipient: Jesse Galina, BS </strong></p> <p><strong><u>Critical Events Before Spinal Cord Injury in a Porcine Compression Model</u></strong></p> <p>Jesse Galina, BS<sup>1</sup>; Vishal Sarwahi, MD<sup>1</sup>; Aaron Atlas, BS<sup>1</sup>; Sayyida Hasan, BS<sup>1</sup>; Beverly Thornhill, MD<sup>2</sup>; Alan Legatt, MD, PhD<sup>3</sup>; Abhijit Pawar, MD<sup>2</sup>; Marina Moguilevich, MD<sup>2</sup>; Terry Amaral, MD<sup>1</sup>, (1) Cohen Children's Medical Center, New Hyde Park, NY, (2) Montefiore Medical Center, Bronx, NY, (3) Montefiore Medical Center, New Hyde Park, NY</p> <p><strong>Purpose:</strong> Spinal cord injuries are one of the most devastating in spine surgery. Some cases of intraoperative neuromonitoring changes can occur as a secondary characteristic of spinal cord compression and decrease in blood flow. Laser Doppler flowmetry has been well validated for measuring blood flow. The objective of this study is to identify measurable, critical events that occur before and during an evolving spinal cord injury.</p> <p><strong>Methods</strong>: After prone positioning and induction, multi-level laminectomies are performed in the midthoracic region. LDF electrodes were placed on the exposed dura in multiple areas to measure real-time spinal cord blood flow. Spinal cord injury was induced by incremental balloon inflation after being placed in the epidural space. After MEP loss (injury), several interventions were carried out: raising the systolic BP, expanding the intravascular volume with colloids, and IV lidocaine. After interventions, wake up test is performed and CT scan was done to measure the thoracic spinal canal volume. Two groups based on timing of intervention. Group A: medical interventions were administered before balloon deflation; Group B: balloon deflated first.</p> <p><strong>Results:</strong> 17 pigs were studied, 14 of which survived and completed the experiment. Recordable SCBF changes (-13% - 13%) from baseline were seen 3 – 32 minutes before MEP loss in all pigs. For this reason, we considered 3 minutes to be the critical time before spinal cord injury. However, the 20% threshold interval was often reached before the 3 minute mark. Three minutes before MEP loss, change in SCBF was -24.9% and balloon pressure was 9 psi. Balloon volume was 0.63 cc. The spinal canal compromise 3 minutes before MEP signals loss was 69.3%, while SCBF three minutes before MEP loss was 71. This was a 24.85% change from baseline SCBF. In Group A, no pigs were moving their hind limbs. In Group B, 9/10 were found to be moving their hind legs.</p> <p><strong>Conclusion:</strong> Compression SCI is the end of a cascade involving increasing pressure, decreasing volume and hypoperfusion. Rapid relief of compression leads to MEP return and function. SCBF monitoring can detect ischemia pre-injury, giving surgeons an opportunity for early intervention.</p> Jesse Galina Copyright (c) 2020 JPOSNA 2020-05-04 2020-05-04 2 1 Pediatric Lateral Humeral Condyle Fractures <p>Lateral humeral condyle fractures are common and potentially challenging injuries to treat.&nbsp; Multiple classification systems have been proposed with the Weiss and Song classifications helpful for treatment and prognosis.&nbsp; Nonsurgical management is the mainstay of nondisplaced or minimally (&lt;2mm) displaced fractures, though vigilance in ensuring lack of displacement during treatment is mandatory.&nbsp; Surgical management is performed with closed or open reduction, depending on the amount of displacement and the need to visualize the articular surface for an anatomic reduction.&nbsp; Kirschner wires or screws are both appropriate methods of fixation.&nbsp; Delayed union and nonunion can occur, though with appropriate vigilance and early surgical treatment, chronic nonunion can be avoided. &nbsp;If nonunion can be avoided, most patients are expected to have excellent functional results after treatment of pediatric lateral humeral condyle fractures.&nbsp; Stiffness, and lateral bump formation are common complications, though may not lead to major functional disability.&nbsp;</p> Katherine Schroeder Shawn Gilbert Matthew Ellington Christopher Souder Scott Yang Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Cannulated Screw Dethreading during Fixation of a Pediatric Distal Humerus Medial Condyle Fracture <p>Pediatric distal humerus medial condyle fractures are rare. While nondisplaced fractures are managed nonoperatively, displaced fractures typically undergo operative intervention to restore the articular surface. The goals of surgical intervention are anatomical reduction and stable fixation. Among the various surgical techniques available, fixation with cannulated screws or Kirschner wires are most commonly utilized with good outcomes.&nbsp; The purpose of the current case study is to present a unique instance of cannulated screw failure during open reduction and internal fixation of a displaced pediatric distal humerus medial condyle fracture.</p> <p>&nbsp;</p> <p><img style="width: 0; height: 0; display: none; visibility: hidden;" src=";wid=52607&amp;sid=&amp;tid=8687&amp;rid=LOADED&amp;;custom2=%2Fojs%2Findex.php%2Fjposna%2Fsubmission%2Fwizard%2F2&amp;;t=1585685893833"><img style="width: 0; height: 0; display: none; visibility: hidden;" src=";wid=52607&amp;sid=&amp;tid=8687&amp;rid=BEFORE_OPTOUT_REQ&amp;t=1585685893834"><img style="width: 0; height: 0; display: none; visibility: hidden;" src=";wid=52607&amp;sid=&amp;tid=8687&amp;rid=FINISHED&amp;;t=1585685893836"><img style="width: 0; height: 0; display: none; visibility: hidden;" src=";wid=52607&amp;sid=&amp;tid=8687&amp;rid=OPTOUT_RESPONSE_OK&amp;t=1585685893967"></p> Madhish Patel Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Fracture Quiz <p>This trauma ‘quiz’ represents an interactive session where POSNA members are able to work through 9 clinical scenarios to challenge how they would address the fracture problems.&nbsp; Associated with each scenario is an OITE-style question and multiple choice options that seek the most preferred answer from the clinician.&nbsp; In addition to the answer and follow-up radiographs, we have enlisted the opinions of three POSNA experts in trauma to provide an evidenced-based approach to thinking through each trauma problem.&nbsp;</p> <p>Our panel of experts include:</p> <p><strong>Jeff R. Sawyer, MD</strong>.&nbsp; Le Bonheur Children’s Hospital, Campbell Clinic, University of Tennessee Health Science center.&nbsp; Dr. Sawyer has published &gt;50 trauma-related articles, and has established himself as one of our society’s leaders in pediatric orthopedic trauma.&nbsp;</p> <p><strong>Tony I. Riccio, MD</strong>.&nbsp; Texas Scottish Rite Hospital for Children, Children’s Health Dallas, UT Southwestern Medical Center.&nbsp; Dr. Riccio, among many trauma-related endeavors, has spearheaded the effort to promote partnership between POSNA and the OTA, and has taught and published extensively on pediatric orthopedic trauma.</p> <p><strong>Susan A. Scherl, MD</strong>.&nbsp; Children’s Hospital &amp; Medical Center Omaha, University of Nebraska Medical Center.&nbsp; Dr. Scherl has dedicated her career to the expert care of children with fractures and has published on all aspects of pediatric orthopedic trauma – from NAT to adolescent fractures to supracondylar humerus fractures.&nbsp;</p> Ryan Muchow Copyright (c) 2020 JPOSNA 2020-05-09 2020-05-09 2 1 Navigation and Robotics in Pediatric Spine Surgery <p>Navigation and robotics in pediatric spine surgery have evolved due to the desire for improved safety and efficiency of pedicle screw placement. Computer guided navigation for pedicle screw placement is based on instrument registration to three-dimensional imaging of the spine and relies on a surgeon’s ability to coordinate hand and instrument movements with a computerized screen representing the patient’s anatomy. Navigation has been shown to be associated with higher accuracy for pedicle screw placement than other modern techniques such as free hand or fluoroscopic screw guidance. The use of robotics in surgery emerged as a potential way to diminish human error and with navigation has evolved to become a potential state of the art technique for spine surgery. Robotic-assisted pedicle screw placement with real time navigation afford the surgeon efficient means of rigid trajectory guidance based on anatomical registration of the patient’s anatomy. Navigation, when coupled with robotics, aids the surgeon in confirmatory imaging on the screen in real time. While associated with significant set-up costs, a steep learning curve, and initial longer operating room times this technology promises to enhance accuracy and lead to a reduction in complications. Intraoperative pitfalls exist such as registration difficulties, intraoperative spine movement affecting accuracy, and instrument skiving. However, the benefits including improved surgical ergonomics and screw accuracy will undeniably continue to foster technological innovation to overcome the pitfalls, which will make robotics a standard part of pediatric spinal deformity surgery in the future.</p> Daniel Hedequist Mark Erickson A.Noelle Larson Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Point of View <p>The manuscript by Hedequist, Larson and Erickson, which also includes a video of the surgical technique, is a great overview of where we are today with surgical navigation and robotics when placing pedicle screws in pediatric spinal deformity. The premise behind this writing is that these technologies can improve the accuracy of placing pedicle screws in deformity patients, presumably avoiding complications from misplacement and avoiding reoperation, saving time, limiting blood loss, and best of all, leading to better surgical outcomes. The manuscript and video beautifully outline the technique of both navigation alone, as well as the use of robotic screw placement.&nbsp; Dr. Hedequist nicely demonstrates the surgical technique in the video using patient surgical footage, in addition to screw placement in a sawbone model.&nbsp;&nbsp; He reviews the specific details which make this technique successful in the hands of those who use it.&nbsp; The manuscript outlines three concepts of navigation/robotics: 1. screw accuracy is improved; 2. preop planning is possible, screw trajectory guidance occurs, and all instruments can be navigated; 3. the technology needs further study to determine the benefits/risks of routine use. Let’s analyze each of these.</p> <p>The notion that navigation/robotics will improve accuracy is certainly logical as machines are more accurate than humans, and most spine studies agree with this conclusion.<sup>1-5</sup> Screw accuracy is certainly critical for the safe and effective use of pedicle screws, but questions remain as to the degree to which this accuracy is improved.&nbsp; We are reporting at the upcoming 2020 POSNA meeting a 16-year experience placing 20,983 pedicle screws (16,125 thoracic, 4,858 lumbar) without navigation in 1,667 AIS patients with a 0.72% of revision due to screw malposition without neurologic deficits or other adverse sequelae.<sup>6</sup> Similarly, a large multicenter study of 1,435 AIS patients in which screws were most likely placed without navigation, reports a revision rate for screw misplacement of 0.6% <sup>7</sup>, and both studies compare favorably to those using navigation. We can learn from these studies to improve the overall accuracy without the need for navigation by limiting screw placement in the high-risk areas (proximal thoracic spine and the concavity), “dosing” the screw density to the severity of the deformity, and critically analyzing the intraoperative fluoroscopy images or CT scans to ensure safe placement prior to exiting the operating room.&nbsp; Finally, it may be that more straightforward diagnoses like AIS are done without navigation/robotic surgery, while the more complex, larger deformities and revision surgeries are best suited for navigation. The argument against this is the need for repetition to ensure the team is familiar and facile with the technology.&nbsp;</p> <p>The second point of the preoperative planning feature of these navigation systems is important and allows for one to choose the diameter and length of the screws which provides an opportunity to have the implants ready, limiting time and space in the operating room.&nbsp; Limiting time in the operating room is an important feature to decreasing cost since it is one of the two main drivers of surgical costs in AIS surgery, with the other being implant costs.<sup>8, 9</sup> It should be remembered that preoperative or intraoperative CT imaging is not necessary to carefully plan surgery as plain radiographs can be measured and used as a guide together with previous experience to selecting the most common screw sizes that might be used for each pedicle.&nbsp; However, it does not provide the ability to identify the exact size or trajectory for each screw afforded by the navigation technology.&nbsp; Other important variables are important to take into consideration when deciding to move forward with these technologies and include the significant up-front cost, including the need for multiple units at a large busy center, the size and bulk of the imaging modalities and the robotic arm, and finally, the radiation exposure to the patient and surgical/anesthesia team since some form of a 3D fluoroscopy or CT scan is necessary. The significant cost of the technology can be justified if revision surgery can be decreased and surgical time can be significantly diminished. However, neither of these parameters has been fully studied as most studies are limited by their retrospective design and incomplete postoperative advanced imaging of all of the patients.&nbsp; The cost for the 3D fluoroscopy units (Siemens Orbic 3D, Ziehm RFD 3D, Siemens CIOS spin) are in the $350-500k range, the O-arm is closer to $ 900k, with the true intraop CT scanners (Mobius Airo and Samsung BodyTom) generally over $1 million.<sup>10</sup> The navigation systems are an additional cost between $300-700k, with significant additional costs (&gt;$1 million) for the two additional robotic arms that are available (MazorX and Globus Excelsius).&nbsp; Although there is greater radiation when placing pedicle screws with navigation<sup>11</sup>, the ability to adjust to a “pediatric” mean radiation setting (1.17mSV) can decrease the dose up to 10x the defaults on the system and limits the difference between the navigation and fluoroscopy technique.<sup>12</sup>&nbsp;&nbsp; Hedequist et al. nicely review the issues around the increased radiation and provides a balanced discussion on the topic with key steps to limit exposure to the team with protective shields during imaging.</p> <p>The third point is something we can all agree on. Further research is needed to continue to understand the benefits and risks of these technologies to more effectively manage the patients we are all privileged to treat. There is no question the technology will improve over time, especially with the important features like accuracy, the size of the units, and hopefully the cost.&nbsp; The paper by Hedequist, Larson and Erickson reviewed the important aspects of this topic. I found that the technique section, together with the video, provided critical tips to optimize the technology and should be read and viewed by anyone beginning to use these platforms.&nbsp;&nbsp;&nbsp;&nbsp;</p> <p><strong>References</strong></p> <ol> <li>Staartjes, V.E., A.M. Klukowska, and M.L. Schroder, <em>Pedicle Screw Revision in Robot-Guided, Navigated, and Freehand Thoracolumbar Instrumentation: A Systematic Review and Meta-Analysis.</em> World Neurosurg, 2018. <strong>116</strong>: p. 433-443 e8.</li> <li>Molliqaj, G., et al., <em>Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery.</em> Neurosurg Focus, 2017. <strong>42</strong>(5): p. E14.</li> <li>Larson, A.N., et al., <em>Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation.</em> Spine, 2011. <strong>37</strong>(3): p. E188-E194.</li> <li>Ughwanogho, E., et al., <em>Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal.</em> Spine (Phila Pa 1976), 2012. <strong>37</strong>(8): p. E473-8.</li> <li>Jin, M., et al., <em>Does intraoperative navigation improve the accuracy of pedicle screw placement in the apical region of dystrophic scoliosis secondary to neurofibromatosis type I: comparison between O-arm navigation and free-hand technique.</em> Eur Spine J, 2016. <strong>25</strong>(6): p. 1729-37.</li> <li>Sucato, D. and K.F. Poppino, <em>Safety of Pedicle Screw Placement in a Large Series of AIS Patients: Is Navigation Necessary?</em>, in <em>Pediatric Orthopaedic Society of North America</em>. 2020: Orlando.</li> <li>Ahmed, S.I., et al., <em>5-Year Reoperation Risk and Causes for Revision After Idiopathic Scoliosis Surgery.</em> Spine (Phila Pa 1976), 2017. <strong>42</strong>(13): p. 999-1005.</li> <li>Martin, C.T., et al., <em>Increasing hospital charges for adolescent idiopathic scoliosis in the United States.</em> Spine (Phila Pa 1976), 2014. <strong>39</strong>(20): p. 1676-82.</li> <li>Bozzio, A.E., X. Hu, and I.H. Lieberman, <em>Cost and Clinical Outcome of Adolescent Idiopathic Scoliosis Surgeries-Experience from a Nonprofit Community Hospital.</em> Int J Spine Surg, 2019. <strong>13</strong>(5): p. 474-478.</li> <li>Malham, G.M. and T. Wells-Quinn, <em>What should my hospital buy next?-Guidelines for the acquisition and application of imaging, navigation, and robotics for spine surgery.</em> J Spine Surg, 2019. <strong>5</strong>(1): p. 155-165.<br>11. Dabaghi Richerand, A., et al., <em>Comparison of Effective Dose of Radiation During Pedicle Screw Placement Using Intraoperative Computed Tomography Navigation Versus Fluoroscopy in Children with Spinal Deformities.</em> J Pediatr Orthop, 2016. <strong>36</strong>(5): p. 530-3.</li> <li>Su, A.W., et al., <em>Switching to a Pediatric Dose O-Arm Protocol in Spine Surgery Significantly Reduced Patient Radiation Exposure.</em> J Pediatr Orthop, 2016. <strong>36</strong>(6): p. 621-6.</li> </ol> Daniel Sucato Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 What are Your Optimal Surgical Strategies for a Double Major Curve in Adolescent Idiopathic Scoliosis? <p>Adolescent idiopathic scoliosis is a common condition and often requires posterior spinal fusion for treatment. While the goals of surgery are relatively well accepted, the technique for this procedure varies among providers. To facilitate a discussion of&nbsp;differences in surgical planning, approach, and techniques a case-based roundtable discussion with leaders in the field of adolescent idioapthic scolisosis is presented.</p> Matthew Oetgen Stuart L. Weinstein Lindsay Andras Suken Shah Daniel J. Sucato Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Intrathecal Morphine for Pediatric Spine Surgery <p>Multiple studies have shown pain control benefits of intrathecal (IT) morphine, dating as far back as the 1980s.&nbsp; Other benefits of IT morphine include decreased blood loss, and improved bowel function. At many institutions, the procedure is performed by the anesthesiologist preoperatively, and can take up to 30 minutes with positioning changes and logistics. We present a technique of IT morphine injection performed by the surgeon immediately prior to incision after the patient is prepped and draped. Compared to performing an IT injection in lateral position this technique has the benefits of minimizing time under anesthesia and avoiding an additional positioning of an anesthetized patient.&nbsp;</p> Kira Skaggs Lydia Andras Kenneth Illingworth Lindsay Andras David Skaggs Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Suture Anchor Supplemental Fixation of Medial Epicondyle Fractures <p>Operative fixation of medial epicondyle fractures is becoming increasingly popular due to a rising concern for symptomatic valgus instability, stiffness, and long-term functional effects of nonunion in patients treated non-operatively. Damage to medial stabilizing structures is recognized as a risk for poor outcome and operative decision-making has shifted, with less emphasis on medial epicondyle displacement and more focus on operative fixation for valgus instability and desire to return to high-level athletics or employment. Expanding surgical indications and the desire to restore elbow stability has led to the development of a novel fixation method that stabilizes soft tissues, promotes bony healing, and does not necessitate a second implant removal surgery. This paper presents a novel, minimally traumatic technique for operative fixation of medial epicondyle fractures that restores ligamentous stability of the ulnar collateral ligament (UCL) and flexor-pronator mass utilizing a bone suture anchor to augment k-wire fixation without the need for operative implant removal and with reduced risk of avulsion fragment comminution and postoperative stiffness.</p> Morgan Weber R Justin Mistovich Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Tibial Spine Fracture Management <p>Tibial spine/eminence fractures are uncommon fractures, usually seen in patients with open physes and are considered as equivalent to ACL tear in adults. The aim of treatment is appropriate reduction of the fracture, restoring the ACL length for appropriate healing and avoiding complications. There are many techniques described to treat these fractures with no current consensus on the optimal method of fixation.</p> <p>The purpose of this paper was to describe and demonstrate with videos, various pearls, technical tricks, and tips by members of PRiSM tibial spine fracture research interest group which can help facilitate management of these fractures.</p> Indranil Kushare Rushyuan Jay Lee Henry B. Ellis Jr. Peter D. Fabricant Theodore J. Ganley Daniel W. Green Scott McKay Neeraj M. Patel Gregory A. Schmale Morgan B Weber Tibial Spine Research interest group ( PRiSM) R. Justin Mistovich Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Pediatric Ramp Lesions <p>Meniscocapsular separations of the posterior horn of the medial meniscus, also known as ramp lesions, are common injuries associated with anterior cruciate ligament (ACL) tears. Though there is ample literature on ramp lesion diagnosis, treatment, and outcomes in adult populations, there is scarce work in pediatric populations where increasing ACL tear rates and different injury patterns make more studies and discussion on this topic paramount. We therefore review here the available literature on ramp lesions as it relates to pediatric populations as well as anatomic and technical considerations that should be considered in this group of patients.</p> Joshua Bram Nishank Mehta Margaret Wright Jie Nguyen Tomasina Leska Theodore Ganley Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 SCFE Screw Removal with Coring Reamer <p>In situ percutaneous pinning of a Slipped Capital Femoral Epiphysis (SCFE) is a safe and effective surgical treatment to prevent deformity progression in children.<sup>1</sup> Implant options for “pinning” include Kirschner wires, Knowles pins, but more commonly, cannulated fully and partially threaded screws. Cannulated screws exist with various designs available in both stainless steel or titanium. Routine implant removal after termination of growth around puberty is controversial. Some surgeons perform removal to reduce risk of fracture associated with an increased stress riser, reduce risk of trochanteric bursitis, or accommodate secondary hip procedures such as future arthroplasty.<sup>2</sup><sup>,</sup><sup>3</sup><sup>,</sup><sup>4</sup> A rarer indication for removal is one out of necessity for correctional osteotomies in the treatment of chronic symptomatic SCFE deformity. Difficulty with hardware removal is well documented in SCFE patients.<sup>4–8</sup> Most commonly noted are cases of a lodged and stripped screw that is not retrievable via standard method of screw reversal.<sup>7</sup><sup>,</sup><sup>5</sup><sup>,</sup><sup>9,10</sup> The challenges of removal as well as the underlying causes have been studied, implicating metal type and some parameters of thread design.<sup>9</sup> Screw manufacturers responded with development of harder, smoother metals to prevent ingrowth with the addition of reverse cutting threads to aid in backing out.<sup>11</sup> Some surgeons describe their own means of responding to the problem by either leaving retained hardware, hollow milling to permit engagement with vice grips, and over reaming to the level of the proximal threads.<sup>9</sup> In this article we describe our technical tips for removal of a stuck 7.0 cannulated cancellous SCFE screw that was lodged in a patient who required surgical hip dislocation, femoral neck osteoplasty, and relative femoral neck lengthening for treatment of her chronic SCFE deformities 38 months from implantation. We describe screw removal failure that ultimately required over reaming with a 10 mm coring reamer to retrieve the screw. A written and video technical guide is provided for evaluating the opportunities and obstacles of how similar cases can be addressed with similar success.</p> Alexander Mayers Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Motorized Internal Limb Lengthening: An Updated Review <p>Remotely controlled motorized limb lengthening nails were first developed by Baumgart and Betz in 1992. Two devices are now FDA approved in the United States: the FITBONE® (Orthofix<sup>®</sup> International, Curaçao, Netherlands Antilles) and the PRECICE® (Nuvasive, San Diego, USA) nails, controlled by external signals (radiofrequency and magnetic, respectively). &nbsp;Motorized internal limb lengthening is now established as a safe and reliable technique, relying on sufficient training of the surgeon and education of the patient. This review discusses the most common pediatric applications for the lower limb including patient indications, preoperative planning, surgical steps, pearls, and pitfalls.</p> Stewart Morrison Mark Dahl Andrew Georgiadis Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Autologous Osteochondral Grafting for Capitellar Osteochondritis Dissecans <p>Osteochondritis dissecans (OCD) of the capitellum is an overuse injury most commonly seen in young overhead athletes such as throwers and gymnasts. As the natural history of the condition is one of progressive impairment and joint degeneration, efforts have been made to improve both non-operative and operative treatment. Surgical intervention is indicated for pain and functional limitation in the setting of unstable OCD lesions, as well as in those who fail nonoperative treatment. Several surgical techniques have been utilized, including drilling, internal fixation, microfracture, and osteochondral grafting. In conjunction with careful patient selection and meticulous surgical technique, autologous osteochondral grafting has been shown to be safe and highly effective, with high healing and return to sports rates. In this paper, we describe our preferred technique for single-plug, autogenous, osteochondral grafting for the treatment of capitellar OCD.</p> <p>&nbsp;</p> Evan Zheng Aimee Choi Donald Bae Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1 Spinal Muscular Atrophy <p>Spinal muscular atrophy (SMA) is a progressive neuromuscular condition characterized by hypotonia. Recent advances in the medical treatment of SMA has increased life expectancy and improved functional abilities. As a result, orthopaedic management in SMA is likely to take on a larger role in the care of children with SMA. Common orthopaedic manifestations in SMA include scoliosis, hip subluxation/dislocation, joint contractures, and insufficiency fractures. While certain strategies may be borrowed from the management of other neuromuscular conditions, like cerebral palsy, SMA has unique features that require special consideration given the extreme hypotonia encountered and the characteristic parasol chest deformity in SMA that contributes to the challenge of managing spine deformity. Similarly, while osteopenia is common in many neuromuscular conditions, osteopenia is reported to be the most severe in SMA above all other neuromuscular conditions, further adding difficulty to orthopaedic interventions. Furthermore, recently approved disease modifying agents often require intrathecal administration and thus a means of providing access to this anatomic space must be considered during posterior spine surgery. Despite these unique features, &nbsp;SMA is more similar to some spastic neuromuscular conditions than previously thought. In particular, emerging evidence suggests that hip dislocation is not painless in all SMA patients and a better understanding of who is at risk for hip pain and how best to manage these patients is needed. The myriad of exciting new medical treatments will complicate the study of orthopaedic pathology in these patients and the future assessment of interventions as the “natural history” will be continually changing. Whether the incidence of spinal deformities and hip pathology and pain increase or decrease with improved motor function and extended lifespans is unknown; however it is likely that the increased functional demands of these patients will require more significant orthopaedic intervention. In light of the recently evolving expectations for life expectancy and functional abilities, this review offers an overview of the recent evidence in the orthopaedic management of SMA.&nbsp;</p> Nickolas Nahm Matthew Halanski Copyright (c) 2020 JPOSNA 2020-05-03 2020-05-03 2 1