JPOSNA <p><strong>JPOSNA</strong> (the <strong>Journal of the Pediatric Orthopaedic Society of North America)</strong> is an open access online journal focusing on pediatric orthopaedic conditions, treatment, and technology.</p> en-US (POSNA Staff) (POSNA Staff) Mon, 02 Aug 2021 08:38:39 -0600 OJS 60 Message from the President <p>It was rejuvenating to see each other again (in person and virtually), discuss the latest high-level research presentations, and catch up with old and new friends at the recent POSNA Annual Meeting in Dallas. Congratulations to Woody Sankar (Program Chair), Lindsay Andras (Pre-Course Chair), Matt Oetgen (Subspecialty Day Chair), Amy McIntosh and Dan Sucato (Local Hosts), and POSNA staff for organizing such a great meeting.&nbsp;</p> <p>I think the POSNA educational meetings are an excellent example of the challenges, resiliency, and innovation that has characterized POSNA’s response during the COVID pandemic. In May 2020, we pivoted very quickly to an all-virtual annual meeting that was successful and well attended.&nbsp; We decided to cancel IPOS in December 2020 since the hands-on interactive educational model could not be done effectively in a virtual format. In May 2021, we embraced a hybrid in-person and virtual model for the annual meeting that was also successful and well attended.&nbsp; These decisions required collaboration, innovation, creative thinking, and resiliency.&nbsp; They required tremendous effort and coordination from program chairs, the program committee, educational council, leadership, staff, technology, and finance.</p> Mininder S. Kocher Copyright (c) 2021 JPOSNA Tue, 27 Jul 2021 10:25:09 -0600 It’s Not a Stereotype if It's True . . . Right? Creating Welcoming Environments in Pediatric Orthopaedics <p>This issues of <em>JPOSNA</em> highlights three articles related to diversity within pediatric orthopaedics. This editorial provides a fourth perspective related to diversity that readers should be aware of as we educate the next generation of pediatric orthopaedic surgeons.&nbsp;</p> Jaysson Brooks, Michelle Caird Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:39:08 -0600 Just the Beginning – A Brief Look at the Past, Present, and Future of POSNA Diversity <p>The roots of the Justice, Equity, Diversity, and Inclusion (JEDI) Committee of POSNA started with a conversation among members concerned about the lack of diversity in orthopaedic surgery and persistent disparities in healthcare access and quality with a desire to do better for our patients and the profession. Then the events of 2020, including the deaths of George Floyd and Breonna Taylor, caused all of us to reflect and reevaluate how we could do better within all facets of our personal and professional lives. The committee started through the collective efforts of then POSNA President Michael Vitale, POSNA Board Members Coleen Sabatini and Bob Cho, and POSNA Committee Chairs Corinna Franklin and Selina Poon. The Presidential Line authorized forming a task force to evaluate where we were with regards to DEI initiatives and where we wanted to be.</p> Jaysson Brooks, Robert Cho, Corinna Franklin, Qusai Hammouri, Monica Payares-Lizano, Selina Poon, Coleen Sabatini, POSNA JEDI Committee Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:31:47 -0600 Racial Inequalities in the Delivery of Pain Medication in Pediatric Orthopaedics and a Call to Action <p>The murder of George Floyd and subsequent racial unrest has motivated our country to re-examine issues of racial justice, equity, diversity, and inequality in every sphere of society. Healthcare is not spared from this self-examination. Racial disparities in the United States healthcare system are endemic and persistent throughout medical and surgical specialties.<sup>4,6,7</sup> These disparities can manifest as lack of access, delays in diagnosis and care, and poor health outcomes.<sup>2,16</sup></p> James McCarthy, Jennifer Kelley, Alvin Crawford, Mara Karamitopoulos, Rachel Habib, Vidya Chidambaran, Dominique Laron Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:40:27 -0600 Practices to Enhance the Diversity of Pediatric Participants Consented into Orthopaedic Research <p>This quality improvement initiative describes challenges to recruiting racially, ethnically, and linguistically diverse infants into a pediatric orthopaedic multicenter research study. The orthopaedic research principal investigator consulted subject-matter experts in pediatric health equity, who provided analyses of baseline research protocols and consulted on improvements to recruitment and consent practices and processes. We describe the subject-matter expert consultation process and the recommendations for changing the research practices that led to increased study enrollment and participation of racially, ethnically, and linguistically diverse pediatric patients. Strategies include equitable remuneration for study participation, flexible study protocols, and visible diversity in patient study recruitment and information materials.</p> Nicole Tennerman, Ashley Tartarilla, Andrea Bauer, Valerie Ward Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:29:13 -0600 Management of Radial Neck Fractures <p>Radial neck fractures account for up to 10% of all pediatric elbow fractures, usually occurring as a result of valgus stress onto an outstretched arm. &nbsp;Most radial neck fractures occur through the periphyseal metaphyseal bone, with a smaller subset occurring through the physis. Treatment can depend on the fracture morphology, degree of displacement and/or angulation, age of the patient, and associated injuries. Stiffness following these injuries is common, but a number of other complications have also been described. &nbsp;This paper provides a brief review of radial neck fractures and offers guidance on their management and especially highlights less invasive methods to manage these fractures.</p> Kyle J. Miller, Kenneth Noonan Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:33:20 -0600 Achilles Lengthening <p>An equinus or plantarflexed positioning of the calcaneus relative to the tibia often results in shortening of the Achilles tendon, gastrocsoleus complex, or both. This may result in a number of patient symptoms including abnormal gait, pain with weight-bearing, toe walking, plantar forefoot callosities, and inability to properly fit into orthoses. When properly indicated, operative Achilles lengthening corrects fixed ankle equinus that exists with the knee flexed as well as extended. The ultimate goal is to improve ankle dorsiflexion, ideally to 10 degrees of ankle dorsiflexion past neutral with the knee flexed and 5 degrees with the knee fully extended. In this article, we discuss the clinical decision-making, various surgical techniques, and postoperative protocol of Achilles lengthening.</p> Sean Tabaie, Anthony Videckis Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:34:53 -0600 Limb Reconstruction and Lengthening <p>This edition of the <em>JPOSNA</em> Coding Corner allows us to share in a conversation between our coding expert, Sarah Wiskerchen (<strong>SW</strong>) from KarenZupko Associates, Inc. (KZA), and one of our Society’s leaders in limb lengthening and reconstruction, Christopher A. Iobst, MD (<strong>CAI</strong>). The questions are absolutely on point in order to help us navigate the world of osteotomies and external fixators while the answers provide clarity and direction for proper billing and documentation of the management of these complicated patients.&nbsp; Enjoy the dialogue and ensure you understand the proper difference between an osteotomy and an osteoplasty by conversation’s end!</p> Christopher Iobst, Sarah Wiskerchen, Ryan Muchow Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:20:07 -0600 Variation in Prescribing Patterns and Use of Opioids in Pediatric Orthopaedic Surgery Patients <p>Pediatric patients receiving opioid prescriptions after orthopaedic surgery are an at-risk population amidst the ongoing opioid epidemic in the United States. While there is significant literature about opioid prescribing patterns and consumption among the adult population, there is limited data in the pediatric population. As a result of this limited knowledge, there remains substantial variation in practice patterns surrounding opioid use. This review evaluates the current literature regarding variation in opioid prescribing patterns in pediatric orthopaedic surgery patients with the aim of increasing awareness of risks and potential interventions.</p> Marguerite Mullen, Michaela Procaccini, Aristides Cruz Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:36:34 -0600 Thoracic Insufficiency Syndrome <p>Thoracic insufficiency syndrome (TIS) is defined as an inability of the thorax to support normal respiration and lung growth. The majority of alveolar development occurs in the first 5 years of life and thus, this is a time of early vulnerability for the population with spine and chest wall differences. Rapid growth during this phase of life can quickly worsen chest and spine deformity. Advances have been made in the care of these patients with the orthopaedic focus on increasing thoracic volume to allow space for continued lung growth and development. Clinicians can group TIS patients based on their diagnoses but also the type of volume-depletion deformity (VDD) of their thorax. In doing this, there are guidelines for treatment and overall prognosis. Medical and surgical treatment options are constantly evolving and will ultimately be informed by obtaining accurate and reproducible pulmonary function data in the future.</p> Grant Hogue, John Emans Copyright (c) 2021 JPOSNA Wed, 28 Jul 2021 16:22:50 -0600 Instrumentation Strategies for Early Onset Scoliosis <p>Nonoperative and operative management for early onset scoliosis has changed significantly since the Harrington era 50 plus years ago.&nbsp; Surgeons learned quickly that a spine fusion in the growing child can result in a short thorax and the development of thoracic insufficiency syndrome. &nbsp;Techniques were developed and refined over the subsequent decades to allow for spinal growth, control spine and chest wall deformity, and limit pulmonary demise.&nbsp; This “growth-friendly” concept is the modern-day approach to management of early onset scoliosis. In this article, we review the history of growth-friendly instrumentation following the Harrington era and present the authors preferred techniques for both growth guidance and posterior distraction-based management of early onset scoliosis.</p> Jason Anari, Dominick Tuason, John Flynn, Behrooz Akbarnia Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:26:28 -0600 Postoperative Analgesia After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis <p>This PRISMA-compliant review includes data from 60 studies investigating 14 analgesic treatment modalities. Outcomes discussed included opioid consumption, pain scores, side effects, adverse events, patient satisfaction, resource utilization, and length of stay. Through literature searches of MEDLINE, Embase, The Cochrane Library, and 1200 studies were identified.&nbsp; After removing duplicates, 934 records were screened, and 92 full-text articles were assessed for eligibility. Thirty-two of these were excluded due to lack of sufficient evidence of the efficacy of the analgesic modality or for irrelevant outcome measures. 60 full text articles were included in this review. The aim of this systematic review is to document efficacy, safety and quality of evidence of analgesic interventions after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Potent analgesia with IV opioids or epidural anesthesia remains the cornerstone of postoperative analgesia following PSF for AIS. A diverse set of analgesic adjuvants are under investigation with promising results including GABA-analogues, intrathecal anesthesia, nonsteroidal anti-inflammatory drugs and acetaminophen, ketamine, spinal nerve block, alpha 2 agonists, glucocorticoids, and muscle relaxants. Psychiatric interventions and patient education were also evaluated.</p> Aadit Shah, Eduard Pey, Stephen Bowen, James Barsi Copyright (c) 2021 JPOSNA Tue, 27 Jul 2021 16:05:30 -0600 Sleep Optimization in the Young Athlete <p>Young athletes commonly suffer from both acute and chronic sleep deprivation. This has been linked to increased injury rates and decreased athletic and neurocognitive performance. Conversely, sleep optimization in young athletes can lead to improved athletic performance and greater competitive success, with improvement in metrics such as speed, endurance, reaction time, accuracy, alertness, and overall well-being. When aiming to optimize sleep, key elements such as sleep duration, quality, and regularity must be addressed. Clinicians can assess baseline sleep hygiene in young athletes, and educate them on proper methods to optimize sleep. Such methods include limiting screen time before bed, getting exposure to sunlight in the early morning, maintaining an optimal bedroom temperature, avoiding caffeine, and maintaining a consistent sleep schedule throughout the week. &nbsp;</p> Casey Imbergamo, Aneesh Patankar, Matthew Milewski Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:38:04 -0600 Plica Syndrome of the Knee <p>Anterior knee pain is a common complaint in the pediatric and adolescent population.&nbsp; Multiple etiologies can be responsible for the onset of pain in this demographic.&nbsp; One etiology of this pain can be a pathologic plica.&nbsp; Plica are synovial folds within the knee that can become inflamed / fibrotic through both acute and chronic processes.&nbsp; A focused physical exam with appropriate imaging can lead to this diagnosis, particularly when other pathologies have been ruled out.&nbsp; Conservative management in the form of rest, anti-inflammatories, and physical therapy can help to alleviate the vast majority of cases that present with pain.&nbsp; In selected cases, arthroscopic resection can lead to good functional results.</p> Nirav K. Pandya Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:15:37 -0600 Management of Congenital Dislocation of the Knee <p>Congenital knee dislocation is a rare disorder and the published literature largely consists of small case series. Congenital knee dislocation represents a broad spectrum of severity from hyperextension to frank dislocation. It can be isolated or be present in syndromic infants with concomitant joint disorders such as clubfoot or developmental dysplasia of the hip. Hyperextended knees can be reduced with serial casting alone in the neonatal period and do not require further treatment. Surgical treatment of the congenital knee dislocation results in satisfactory outcomes in the majority of reported cases, although outcomes are highly dependent on the degree of concomitant joint involvement. Treatment decisions are often based on radiographic findings and passive range of motion of the knee. Described procedures include percutaneous or mini-open quadriceps tenotomy, VY quadricepsplasty, and femoral shortening. The current review summarizes the most up-to-date literature on the surgical management of congenital knee dislocation.</p> Bridget Ellsworth, Brody Dawkins, Sofia Hidalgo Perea, Daniel Green Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:18:23 -0600 Transverse Plane Deviations in Spastic Diplegia: An Expert Panel Case Review <p>A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most patients in orthopaedics. Many times, an appropriate visual inspection of gait can reveal the most important pathologies seen in a general pediatric orthopaedic practice. However, some conditions, such as cerebral palsy (CP), often present with significant gait complexities and multiple impairments that negatively affect patient mobility. The use of advanced instrumented gait and motion analysis has become an essential piece of high-quality care of children with CP. In this edition, we discuss evaluation and management of transverse plane deviations. In this series, a group of gait experts will be presenting principles and tips to help us all improve in the evaluation of gait in patients with CP. This case will include clinical information, physical examination data, pertinent radiographs, links to gait videos, and motion analysis data. &nbsp;</p> Wade Shrader, Lane Wimberly, Jason Rhodes, Jeremy Bauer Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:28:07 -0600 Gastrostomy Tubes in Children with Nonambulatory Cerebral Palsy and Neuromuscular Scoliosis: An Enemy or an Ally? <p>Gastrostomy tubes or equivalent invasive nutritional support devices are an important component for maintaining appropriate nutrition for children with cerebral palsy who have oromotor dysfunction.&nbsp; Although these interventions have been shown to produce positive influences on the child’s health and nutrition status, they have also been associated with increased complication rates following spinal deformity surgery. Understanding the current status of the literature on this topic as well as the gaps in knowledge are crucial to gaining a thorough understanding of the role of these feeding devices in the postoperative complication profile for these at-risk patients and avenues for future research efforts.</p> Austin Shiver, Kenneth Shaw, Joshua Murphy, Nicholas Fletcher Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:23:52 -0600 Gastrostomy Tubes in Patients With Cerebral Palsy Undergoing Surgery - Usually an Ally, but the Devil Is In the Details <p>In this issue of JPOSNA, Dr. Shiver et al. review data about the role of an enterostomy feeding tube (gastrostomy/G-tube, jejunostomy/J-tube, or gastro-jejunostomy/G-J tube) in patients with cerebral palsy undergoing spinal surgery for neuromuscular scoliosis.<sup>1</sup> The authors quite rightly comment that spinal surgery in these patients represents a significant intervention that may result in a number of respiratory, gastrointestinal, and infectious complications.&nbsp; These complications can have a tremendous medical, social, and psychological impact on the patient and the patient’s family, so understanding a particular patient’s risk factors before surgery is an important part of preoperative planning.&nbsp; As pediatric hospitalists who often co-manage these patients at our institution—including seeing these patients preoperatively with an emphasis on their nutritional status<sup>2</sup>—we greatly appreciate the opportunity to comment on this paper.</p> David Rappaport, Emily Fingado Copyright (c) 2021 JPOSNA Wed, 12 May 2021 00:00:00 -0600 Pediatric Foot and Ankle Trauma: Expert Panel Approach <p>Pediatric foot and ankle trauma, particularly severe cases, can be difficult to treat. Treatment can take the form of hybrid fixation with a combination of pediatric and adult techniques. Many fractures can be managed non operatively or with percutaneous fixation. However, as children approach adulthood, they also require rigid fixation techniques. The cases presented here span a wide spectrum of ages and fracture types, and the invited panel has presented both usual and unusual approaches to treatment.&nbsp;</p> <ul> <li>Case #1: &nbsp;<a href="" target="_blank" rel="noopener">Metatarsal Fractures</a></li> <li>Case #2: &nbsp;<a href="" target="_blank" rel="noopener">Midfoot Injury</a></li> <li>Case #3:&nbsp; <a href="" target="_blank" rel="noopener">Floating Ankle Injury</a></li> <li>Case #4:&nbsp; <a href="" target="_blank" rel="noopener">Lisfranc Injury</a></li> <li>Case #5:&nbsp; <a href="" target="_blank" rel="noopener">Navicular Fracture</a></li> <li>Case #6:&nbsp; <a href="" target="_blank" rel="noopener">Bilateral Talus Fractures with AVN</a></li> <li>Case #7:&nbsp; <a href="" target="_blank" rel="noopener">Calcaneus Fracture</a></li> <li>Case #8:&nbsp; <a href="" target="_blank" rel="noopener">Chopart Joint Injury</a></li> <li>Case #9:&nbsp; <a href="" target="_blank" rel="noopener">Talar Dome Injury</a></li> </ul> Alice Chu, Stephanie M. Holmes, Robert M. Kay, William L. Hennrikus, Brian G. Smith Copyright (c) 2021 JPOSNA Sat, 31 Jul 2021 11:05:02 -0600 Presidential Address <p>This was a trying year at every level—personally, professionally, and also for our Society, POSNA. In fact, in an email about one month before our annual meeting, Min Kocher shared his thoughts that this was very much a “wartime year” for our presidential line. Unfortunately, challenges of all different flavors will come to all of us from time to time. As in the song “Life During Wartime,” the Talking Heads recount, “The sound of gun fire, off in the distance, I’m getting used to it now.”&nbsp;</p> <p>While no one seeks out hard times, the realities of experience, chance, and time will often interact in ways where the road ahead seems steep and challenging. In those times where all seems lost and a peaceful future seems very far away, focusing on early, small wins can make a tremendous difference. It is in these times that we must focus more on <em>trajectory</em> rather than position. Over time, small wins accumulate and allow massive differences in outcome. The fundamental lesson of the Stockdale paradox is that we must face current realities but have a long view on outcomes.</p> <p>It has been a true pleasure to serve as your president during these times, and I have learned so much along the way.</p> Michael Vitale Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 00:00:00 -0600 Effectiveness of Various Cast Covers in the Pediatric Population <p><strong>Purpose:</strong> We explore the efficacy of different options as well as their cost across growing age cohorts encountered in a pediatric practice.</p> <p><strong>Methods:</strong> Short arm casts were applied to mannequin models representing the arms of pediatric patients ages 3, 6, and 12 years old. The mass of each cast was then measured in grams. Casts were then completely submerged in water for 1 minute and the difference in mass was calculated. This was repeated six times per cast cover group across for all three age groups. There was a control group without a cast cover and eight additional groups of various cast cover types. Effectiveness of a cast was subjectively determined based on amount of absorption compared to the starting mass, and this was compared among the various groups using a non-parametric statistical test.</p> <p><strong>Results:</strong> For the different cast cover types across all age groups, the Kruskall-Wallis test was used to analyze the entire dataset. A single plastic bag with duct tape was the most effective in reducing absorption (mean of 3.2 g absorption, 4.4 g SD). The results for the remaining cast covers were as follows. Many, but not all, of the eight groups had less absorption than the control with statistical significance at an alpha level of 0.05. These groups included the double plastic bag rubber band cover (p=0.0112), single plastic bag with duct tape cover (p&lt;0.0001), DryPro (p&lt;0.0001), Bloccs (p&lt;0.0001), Walgreens (p=0.0010), and Freedom covers (p&lt;0.0001). The plastic bag with duct tape cover additionally had significantly less absorption than the Press N Seal. (p=0.0045). The Curad group was found to not be statistically different from the control; in addition, the DryPro (p=0.0049), Bloccs (p&lt;0.0001), Freedom (p=0.0031), and plastic bag with duct tape (p&lt;0.0001) covers had significantly less absorption than this cover. Finally, a cost analysis was performed and demonstrated that a single plastic bag with duct tape was found to be the most cost efficient in theory, but the Walgreens cast cover was least expensive in actual cost.</p> <p><strong>Conclusions:</strong> Our study indicated that a single plastic bag with duct tape was both one of the most effective cast covers at reducing absorption as well as one of the most cost effective across all age groups.</p> <p><strong>Significance: </strong>The use of a single plastic bag with duct tape was both one of the most effective cast covers at reducing absorption as well as one of the most cost-effective across all age groups.</p> Amit Parekh, John Y. Moon, David W. Roberts, Verena M. Schreiber Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 14:51:45 -0600 Operative Versus Nonoperative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Sub-stratified Cohort Analysis <p><strong>Purpose</strong>: There has been a recent shift towards operative management of mid-shaft clavicle fractures in adults and adolescents. This has been largely based on studies in the adult population that showed reduced rates of nonunion, symptomatic malunion and better short-term functional outcomes.&nbsp; For injuries with a comminuted “Z-type” fracture pattern, characterized by vertical positioning of a segmental fragment, it is commonly accepted to treat surgically due to concerns about healing and bony prominence. The purpose of this study was to assess the clinical, radiographic, and patient-reported outcome measures (PROs) in adolescents with comminuted Z-type mid-shaft clavicle fractures by comparing an operative and nonoperative cohort.</p> <p><strong>Methods</strong>: Patients aged 10 to 18 years treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at one of eight geographically diverse pediatric centers were screened and enrolled at the time of injury. Inclusion criteria were a comminuted Z-type fragment ≥1cm in size, with &gt;35 degrees of angulation relative to the long axis of the clavicle, and &gt;100% fracture displacement at time of presentation. Clinical course, complications, validated PROs, quality of life metrics, and satisfaction scores were analyzed and compared between the operative (Op) and nonoperative (NonOp) cohorts.</p> <p><strong>Results</strong>: Eighty-two patients (37 NonOp, 45 Op) were included, 60 (73%) of whom provided 2-year PROs with similar response rates between treatment cohorts. There were no significant differences in demographics or fracture characteristics in the two cohorts other than fracture shortening being greater in the operative cohort&nbsp;(mean 29mm) compared to the nonoperative cohort (mean 23mm, p=0.01). This confounder was controlled for in both regression analysis and propensity score matching. There was no statistically significant difference in the rates of nonunion (none), delayed union (Op 2%, NonOp 0%, p=1.0), symptomatic malunion (Op 0%, NonOp 3%, p=0.4), refracture (Op 4%, NonOp 3%, p=1.0), unexpected surgery (Op 11% vs. NonOp 5%, p=0.45), or clinically significant complications (Op 16%, NonOp 5%, p=0.17) between cohorts. There were no differences in PROs (Table 1), even when controlling for fracture shortening.</p> <p><strong>Conclusions</strong>: Z-type mid-shaft clavicle fractures are one of the most severe fracture patterns seen in adolescent shoulders. Yet, in this comparative investigation of 2-year PROs and complications, surgery appears to offer no benefit over nonoperative management.&nbsp;</p> <p><strong>Significance:</strong> The comparable natural histories between this study’s operative and nonoperative cohorts are critical for surgeons and their adolescent patients to understand when deciding appropriate management, particularly when reviewing what are often very concerning appearing initial radiographs.</p> Coleen S. Sabatini, Eric W. Edmonds, Elizabeth Liotta, Katelyn Hergott, Donald S. Bae, Michael T. Busch, Henry Bone Ellis, Mininder S. Kocher, G. Ying Li, Jeffrey Jerome Nepple, Nirav Kiritkumar Pandya, Andrew Pennock, Crystal Perkins, David D. Spence, David Williams, Samuel Clifton Willimon, Philip Wilson, Benton E. Heyworth, FACTS Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 15:16:20 -0600 Activation of a Central Immunosuppressive Cascade Prevents Ischemia Reperfusion Injury After Acute Compartment Syndrome in a Murine Model <p><strong>Purpose:</strong> Occurring when interstitial pressure exceeds perfusion pressure, acute compartment syndrome (ACS) results in warm ischemia and cell death due to impaired aerobic metabolism. Following surgical decompression and reperfusion of the extremity, there is a robust innate inflammatory response that results in further tissue injury due to the production of reactive oxygen species and local capillary dysfunction. In addition to prompt diagnosis and reperfusion of the compartment, therapies which limit the secondary ischemia reperfusion injury (IRI) may be helpful to improve outcomes in patients with ACS. Varenicline (Chantix™) activates a novel immunosuppressive cascade and is effective at reducing IRI in following testicular torsion and pyelonephritis. We hypothesized that varenicline administration would reduce IRI following a compartment syndrome model in a mouse. &nbsp;</p> <p><strong>Methods:</strong> Using an established model, warm hindlimb ischemia was induced in mature CD-1 mice by placing an orthodontic rubber band around the hindlimb for 90 minutes. In the treatment group, varenicline (1µg/gram) was administered as an intraperitoneal injection 60 minutes after the onset of ischemia. The degree of acute inflammation was quantified using Fluorescent Activated Cell Sorting, 24 hours following reperfusion. The expression of pro-fibrotic genes in the gastrocnemius muscle were evaluated 7 days following reperfusion and histologic evaluation of fibrosis with trichrome staining was performed 14 days following reperfusion of the limb.&nbsp;</p> <p><strong>Results:</strong> Treatment with varenicline reduced the acute leukocyte infiltrate 24 hours after reperfusion (3.08% vs 0.86%, P≤0.01, n=16). Treatment with varenicline reduced the expression of the pro-fibrotic genes (measured in relative expression) (Collagen1a1 (1.73 vs. 0.31), Collagen1a3 (1.85 vs. 0.42), Vimentin (2.11 vs 0.38) and Actin (1.82 vs. 0.56) P≤0.05, n=16 7 days following reperfusion. Histologic evidence of collagen deposition was also significantly reduced (3.45% vs. 1.89%, P≤0.005, n=20) 14 days following reperfusion in animals treated with varenicline.</p> <p><strong>Conclusions:</strong> Varenicline administration reduces acute inflammation and long-term fibrosis of the gastrocnemius muscle following warm hindlimb ischemia in a mouse.</p> <p><strong>Significance:</strong> Varenicline represents a potentially novel FDA approved adjunct to the current management of acute compartment syndrome and extremity ischemia. Administration of this medication appears to have the potential to mitigate post-injury inflammation and fibrosis which may lead to improved functional outcomes following this condition. Further studies are needed to define the optimal dosing and administration regimens.</p> Austin Grayce Hester, Nazanin Omidi, Daniel Paul Casella, Matthew E. Oetgen Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 15:46:51 -0600 Nonoperative Management of Femoroacetabular Impingement: Clinical Outcomes at 5-years – A Prospective Study <p><strong>Purpose:</strong> Our purpose is to present 5-year outcomes data utilizing a nonoperative protocol on a consecutive series of patients with FAI syndrome.</p> <p><strong>Methods:</strong> Between 2013 and 2016, patients were prospectively recruited in a nonoperative FAI study. The protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were offered an intraarticular steroid injection. Patients with recurrent symptoms were offered arthroscopic treatment. Patient-reported outcomes, including the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS), were collected 1-, 2-, and 5-years after enrollment. We present the 5-year data. Statistical analysis was performed to determine outcomes based on FAI type and treatment.</p> <p><strong>Results:</strong> One hundred thirty-three hips in 100 patients were enrolled. Sixty-seven hips in 50 patients were available for 5-year follow-up. At enrollment, the mean mHHS and NAHS were 69.6±13.1 and 76.3±14.7, respectively. In total, 73% of the cohort was managed nonoperatively. Of the 11 patients requiring surgery, six (55%) converted to surgery within 1 year of enrollment, four (36%) converted to surgery between 1 and 2 years, and one patient converted to surgery between 2 and 5 years. At final follow-up, the mean mHHS and NAHS were 89.6±10.7 and 88.0±12.1, respectively. At 1-year follow-up, only the activity modification group made a significant increase in mHHS and NAHS (p&lt;0.03). By 2-year follow-up, all three treatment groups had made statistically significant improvements in mHHS and NAHS (p&lt;0.05). By 5-year follow-up, the activity modification group and the scope group had maintained their statistically significant improvement in mHHS and NAHS (p&lt;0.03). There was no significant difference in mHHS or NAHS between treatment groups at 5-year follow-up (p&gt;0.4) (Table 1) and no difference in proportion of hips meeting the MCID for mHHS based on treatment course (p=0.961). There was no difference in mHHS or NAHS between FAI types at any time point (p&gt;0.06) (Table 2) or in the proportion of hips that met MCID among FAI types (p=0.511). Seventy-two percent of patients returned to the same or similar sport/activity level, and there was no difference in the proportion of patients that returned to sports/activities among treatment type (p=0.095) or FAI type (p=0.273).</p> <p><strong>Conclusions:</strong> Nonoperative management of FAI syndrome is effective in a majority of adolescent patients with robust improvements in patient-reported outcomes persisting at 5-year follow-up.</p> <p><strong>Significance:</strong> Nonoperative management can be successful for a large portion of adolescent patients with symptomatic FAI syndrome with durable outcomes at 5-year follow-up.</p> Andrew Zogby, James David Bomar, Kristina Parvanta Johnson, Vidyadhar V. Upasani, Andrew Pennock Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 15:56:34 -0600 Tibial Spine/Eminence Fracture – Suture Fixation <p>Tibial eminence fractures are a bony avulsion of the anterior cruciate ligament (ACL) tibial insertion. They most commonly occur in pediatric patients, and anatomic reduction with stable fixation are important for good outcomes following surgical treatment. Fracture reduction can be performed via open or arthroscopic surgical techniques and stability can be achieved via screw or suture fixation. This video demonstrates specific techniques, technical tips, and pearls for arthroscopic suture fixation of tibial eminence avulsion fractures.</p> Indranil Kushare, R. Justin Mistovich, John A. Shilt, Aristides I. Cruz Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 15:58:24 -0600 What are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? <p><strong>Purpose:</strong> The uncommon nature of tibial spine fractures may result in delayed presentation, diagnosis, and treatment. Elucidation of the contributing factors to such delays may provide an opportunity to improve patient care. The purpose of this study is to evaluate risk factors for and perioperative consequences of delayed surgical treatment of pediatric tibial spine fractures.</p> <p><strong>Methods:</strong> We performed a retrospective cohort study of tibial spine fractures treated surgically at 10 institutions between 2000 and 2019. Demographic and preoperative data were collected as was information regarding intra-operative management and findings. Attention was focused on delays in evaluation and treatment, which were treated as both continuous and categorical variables. Surgery ≥21 days after injury was considered “delayed.” Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.</p> <p><strong>Results:</strong> A total of 368 subjects (mean age 11.7±2.9 years) were included. The median time between injury and surgery was 11 days (interquartile range 13 days). In multivariate analysis, patients that underwent delayed surgery had 2.3 times higher odds of having seen another provider before the treating surgeon (95% CI 1.1-4.8, p=0.02) and 3.8 times higher odds of having undergone magnetic resonance imaging (MRI; 95% CI 2.1-6.9, p&lt;0.001). These subjects were also 2.4 times more likely to have public insurance (95% CI 1.3-4.2, p=0.003). Children that had a surgical delay were 3.8 times more likely to have been diagnosed with a tibial spine fracture later than one week after injury (95% CI 1.1-14.3, p=0.04) and were 5.8 times more likely to have obtained MRI more than one week after injury (95% CI 1.6-20.8, p=0.007). Finally, patients that underwent delayed surgery had 3.3 times higher odds of their procedure lasting greater than 2.5 hours (95% CI 1.4-7.9, p=0.006). Surgical delay did not result in increased concomitant meniscal or chondral injuries.</p> <p><strong>Conclusions:</strong> Public insurance and visiting multiple providers prior to surgery led to treatment delays. Delays in initial diagnosis and MRI were also contributing factors. While a surgical delay of ≥21 days did not result in more concomitant injuries, it was predictive of longer surgical time, possibly reflecting the greater complexity of these cases. These results provide an opportunity to optimize care for children that are at highest risk for delayed treatment.</p> <p><strong>Significance:</strong> This is the first study to identify risk factors for and immediate consequences of delayed surgery for pediatric tibial spine fractures. These results can be used to optimize care for at-risk children.</p> Neeraj Patel, Tomasina Leska, Theodore J. Ganley, Julien Aoyama, Aristides I. Cruz, Henry Bone Ellis, Peter D. Fabricant, Daniel W. Green, Jason E. Jagodzinski, Benjamin Johnson, Indranil Kushare, R. Jay Lee, Scott D. McKay, Jason Rhodes, Brant Sachleben, Mary Catherine Sargent, Gregory A. Schmale, Yi-Meng Yen, R. Justin Mistovich, Tibial Spine Research Group Copyright (c) 2021 JPOSNA Mon, 26 Jul 2021 16:02:58 -0600