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 orthopedic conditions, treatment and technology.</p> en-US (POSNA Staff) (POSNA Staff) Mon, 02 Nov 2020 00:00:00 -0700 OJS 60 Editor's Note <p>In this edition of JPOSNA, we are pleased to present a wide range of high-quality contributions, which include Current Concept Reviews, Invited Perspectives, POGO Travel Journal, and a Tumor Quiz. We also present to our membership two new initiatives.</p> <p>Michael Vitale will highlight the Master’s Surgical Technique concept in his Presidential note. We are indebted to Nick Fletcher and Matt Oetgen, who have volunteered to spearhead this while joining our Editorial Board. Our hope is to have two to three high-level surgical technique submissions with each edition. After publication, these will be housed in POSNAcademy, which has become the go-to reference for online pediatric orthopaedic surgical instruction. All POSNA members are encouraged to submit ideas for potential Master’s Surgical Technique manuscripts (with accompanying video or a narrated PowerPoint presentation) to</p> <p>Second, through Wade Shrader’s vision, we present a year-long Tutorial in Gait Analysis in Ambulatory Patients with Cerebral Palsy. In this edition, Kulkarni et al. demonstrate techniques to improve observational gait analysis. The advantage of online publishing is the ability to leverage electronic media, and in the next three editions, Hank Chambers will present case examples of ambulatory patients with cerebral palsy with history, physical examination findings, video, and available gait analysis data. By engaging outside experts in cerebral palsy, Hank will lead us through approaches to evaluation and help us to understand different options in treatment. I hope you are just as excited as I am to take this journey with Hank.</p> <p>What’s consistent throughout JPOSNA content? All submitted content and plans for the future come from you. Nick, Matt, and Hank were not asked to submit material, they contacted us at JPOSNA asking, “How can we help?” Two inquiries came in yesterday from POSNA members on relevant content for the next edition. The future for JPOSNA is bright because our Society is committed to making care for children better by contributing and teaching us all.</p> <p>Thank you,<br>Ken Noonan</p> Ken Noonan Copyright (c) 2020 JPOSNA Sat, 31 Oct 2020 09:43:08 -0600 Message from the President <p>Welcome to the November edition of the Journal of the Pediatric Orthopaedic Society of North America! As you can see, Editor in Chief Ken Noonan has been hard at work developing a leadership team poised to consistently deliver cutting-edge, informative, and valuable content to our members.</p> <p>This edition has special historical significance as it marks the launch of our “Masters Technique” series. Here you will find multimedia presentations detailing cutting-edge techniques in pediatric orthopaedics from experts in the field. These will be released in JPOSNA and then make their way to POSNAcademy, where they will exist as enduring content, searchable at any time. This is another way that POSNA is leveraging our electronic infrastructure and the passion and commitment of our members to bring best-in-class, practical educational value to our members. Kudos to Ken Noonan, Bryan Tompkins, and the contributors for making this first launch so successful!</p> <p>I would also like to take a moment to thank OrthoPediatrics, our very loyal industry partner, for sponsoring this special edition with inaugural content. It has been a true pleasure working with the leadership team at OrthoPediatrics over the last decade, as both organizations have grown in fantastic ways! I would particularly like to thank Peter Armstrong, MD, past Chief of Staff of the Shriners Hospital system from 2000 to 2012 and now Chief Medical Officer of OrthoPediatrics. His bridge between OrthoPediatrics and POSNA has allowed us to navigate various educational offerings at IPOS and POSNA together over the years. Together we have moved the needle for the benefit of children.</p> <p>Please enjoy this fantastic edition of JPOSNA. This is your journal to enjoy and contribute to. Please do not hesitate to reach out to Ken or me with thoughts on how we can do even better.</p> <p>Michael Vitale, MD, MPH<br>President, POSNA</p> Michael Vitale Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:03:21 -0600 Management of Pediatric Meniscal Root Tears <p>Tears of the posterior roots of the medial and lateral meniscus are relatively uncommon injuries, but can be seen concurrently with anterior crucial ligament (ACL) injuries in young athletes. Despite a wealth of research on the diagnostics and therapeutics of root tears in the adult population, pediatric root tears have been relatively understudied despite the increasing incidence of youth sports participation and thus increasing ACL injuries. With an understanding that repair of the meniscal root is paramount to positive outcomes in the adult population, it is therefore crucial to understand the incidence, presentation, and treatment of this pathology in pediatric patients as well. Our aim is to review the available literature on pediatric meniscal root tears, as well as special considerations for anatomy and diagnosis of this injury in children and adolescents.&nbsp;</p> Lacey Magee, Nishank Mehta, Margaret Wright, Tomasina Leska, Theodore Ganley Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:07:34 -0600 Proximal Valgus Femur Osteotomy for Coxa Vara <p>Coxa vara is a deformity of the proximal femur in which the femoral neck-shaft angle is decreased. This can be the result of an acquired deformity, metabolic disorder, congenital syndrome, or idiopathic (developmental). In this paper we primarily discuss developmental coxa vara but parsing out the etiology of the coxa vara has important implications in treatment. Coxa vara from a metabolic cause, for example, must be treated medically before a surgical intervention. In this paper, we discuss the unique radiographic characteristics of developmental coxa vara, as well as, radiographic measurements that can be used to determine severity. When surgical intervention is required, a proximal femoral valgus osteotomy is indicated. While proximal femoral valgus is a common deformity seen by pediatric orthopaedic surgeons, coxa vara is uncommon Most pediatric orthopaedic surgeons are facile with the varus proximal femur osteotomy but may not be as familiar with a valgus producing osteotomy. There are several planning and technical differences between the two procedures. With careful preoperative planning, the surgeon can avoid recurrence of the deformity. In this paper, we describe our pre-operative planning algorithm, our surgical technique, and post-operative protocol.</p> Evan Sheppard, Matthew Oetgen Copyright (c) 2020 JPOSNA Tue, 27 Oct 2020 18:35:23 -0600 Anterior Lumbar Vertebral Body Tethering in Adolescent Idiopathic Scoliosis <p>Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity in children. The traditional treatment for curves greater than 50 degrees is posterior spinal fusion with pedicle instrumentation for prevention of curve progression later in life. However, there is growing interest in non-fusion techniques such as anterior vertebral body tethering. Despite the common presentation of thoracolumbar and lumbar curves in AIS, descriptions of anterior vertebral body tethering for AIS have been largely limited to the thoracic vertebrae. The goal of this paper is to describe the technique of lumbar anterior vertebral body tethering which involves a combined thoracoscopic and mini-open approach to the spine with a transdiaphragmatic tether. The technique and reduction are aided by CT navigation and a radiolucent hinged spine surgery table. Dissemination of successful techniques is essential to advance non-fusion care for idiopathic scoliosis.</p> Courtney Baker, Todd Milbrandt, Dean Potter, Noelle Larson Copyright (c) 2020 JPOSNA Fri, 30 Oct 2020 09:31:54 -0600 Pelvic Ring Stabilization Using Anterior Subcutaneous Internal Fixation Bladder Exstrophy Repair <p><strong>BACKGROUND</strong></p> <p>Bladder exstrophy is a congenital condition involving malformation of anterior abdominal wall leading to an extruded bladder and other genitourinary and musculoskeletal system abnormalities. Orthopedically, patients with classic bladder exstrophy present with an “open” bony pelvis deformity with an obvious symphysis pubis diastasis. Multiple surgical techniques have been described for correction of the bony pelvis deformity in classic bladder exstrophy, including that described by Sponseller, et al. They described bilateral double iliac osteotomies and with anterior pelvic ring fixation using external fixator devices to maintain reduction. However, external fixators are cumbersome, unsightly and have an increased risk for pin tract infection due to its location and association to bladder defects, which may cause exposure to irritants and contaminants such as urine and feces. Furthermore, external fixators can be costly due to the complexity of the constructs to maintain the reduction. We believe subcutaneous anterior pelvic internal fixator (INFIX) is a an effective alternative for anterior pelvic ring fixation and stabilization in older bladder exstrophy patients.</p> <p><strong>METHODS</strong></p> <p>We described a 12-year-old female with bladder exstrophy who was treated using Sponseller’s technique for bony correction. However, the use of external fixation was substituted with the use of INFIX, which typically is reserved for adult pelvic trauma.</p> <p><strong>RESULTS</strong></p> <p>Preoperative imaging revealed 6.3 cm of anterior pubic symphysis diastasis. The immediate post-operative films yielded pelvis diastasis correction to 1.6 cm. Imaging post removal of implant demonstrated anterior symphysis diastasis of 2.9 cm, which represented a 1.3 cm increase since INFIX removal, but a 3.4 cm overall decrease from initial presentation.</p> <p><strong>CONCLUSION</strong></p> <p>INFIX is a novel fixation technique that is well tolerated and an effective alternative for anterior pelvic ring fixation and stabilization in older bladder exstrophy patients. In addition to the strength of the fixation, all these benefits, whether cosmetic, functional or monetary, can also add a potential psychological benefit to the patient and the caregiver.</p> <p><strong>LEVEL OF EVIDENCE</strong></p> <p>Level IV Therapeutic Studies – Investigating the Results of Treatment</p> Stefano Cardin, José A. Herrera-Soto, Pablo Marrero, Mark Rich, Hubert Swana, Joshua R. Langford Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:06:46 -0600 Osteotomy for Bladder Exstrophy: Commentary and Ten Tips for Success <p>Patients with Bladder Exstrophy, though rare, are cared for at most Children’s Hospitals. Although osteotomy is not always needed for closure, especially in the neonatal period, it can significantly increase the success treating those presenting late. Specific indications for osteotomy as part of a reconstruction include wide diastasis as seen in cloacal exstrophy, re-closure after failed initial repair, patients with persistent abnormal perineal appearance, and uterine prolapse due to a wide pelvic floor.</p> <p>In the osteotomy surgery, bony fixation is needed to both approximate the pelvis and to maintain it through healing. While fixation across the symphysial diastasis would be intuitively attractive, its profile and proximity to the reconstructed urethra limit its value to older children. For decades, an external fixator has been one of the main fixation options used in surgical reconstruction of the exstrophied pelvis. In this issue, Cardin and Herrera-Soto describe adaptation of an Internal Fixator (INFIX), a technique adapted from pelvic trauma, to reduce and stabilize the reconstructed pelvis. This provides several advantages: It avoids percutaneous pins, improves sitting and early mobilization, and likely improves comfort. The senior surgeon, Herrera-Soto, used pedicle screws and spinal rods to create the INFIX bridging the right and left sides. They also stabilize each side craniocaudally with screws. The result is an all-internal construct which allows early mobilization, early discharge, and can be left in place for many months (7+ in this article) until bony and soft tissue healing is mature.</p> <p>The INFIX concept is attractive, especially for older children such as the 12 year old subject of this case. One pre-condition, though, is to have enough tissue thickness to accommodate the screws and bar. If the metal bar is too close to the skin, it may risk wound breakdown. Cardin and Herrera-Soto used a 6.0 mm rod; for younger children, small-stature sets or even cervical instrumentation may be needed to implement this construct. &nbsp;The abdominal wall scarring is likely to be less, as there are no pin tracts to see.</p> <p>While this concept has significant appeal, one concern is the need to leave the iliac wounds open throughout the long surgery, which may increase the risk of infection. Also the INFIX does not allow progressive adjustability and requires another procedure for implant removal. The external fixation can be readily adjusted at bedside if necessary. It can also be removed in an awake setting without anesthesia when the osteotomies have healed. No implants are left internally. For many patients with exstrophy, especially larger children and adolescents, the stabilization described by Cardin and Herrera-Soto can lead to easier postoperative care and early mobilization. &nbsp;I look forward to using this technique on my older patients.</p> <p>Since bladder exstrophy reconstruction is a rare procedure for most pediatric orthopaedic surgeons, I would also like to offer “Ten Tips for Success” throughout the reconstructive process:</p> <ol> <li>Plan for hospitalization long enough to monitor bladder closure and urinary leakage.</li> <li>Tunneled epidural catheter can relieve osteotomy pain and bladder spasms. Tranexamic acid is also worthwhile to limit bleeding with the multiple osteotomies, especially in older children</li> <li>The pelvic anatomy is externally oriented in exstrophy. Maximize lighting and access. &nbsp;Watch for dislocated hips, pelvic asymmetry and unstable Sacro-Iliac joints in patients with cloacal exstrophy.</li> <li>Combined Anterior and posterior osteotomy is important for children above 2-3 years, as described in this case.</li> <li>Use Steinmann pin to localize level of osteotomy so that it exits near apex of sciatic notch. Allow enough bone caudally for fixation, whether using INFIX or External Fixation.</li> <li>If using external fixation, place two pins in each caudal segment, starting <em>lateral</em> to the Anterior Inferior Iliac Spine, with bi-cortical purchase. Then place one in each cranial segment.</li> <li>In older children, prevent excessive medial “slide” at osteotomy site, with loss of contact and risk to sciatic nerve. The inter-fragmental screws used by Herrera-Soto can help with this.</li> <li>For older children, I use inter-pubic fixation for the midline in addition, which can often be left in place for several years. A two-hole plate was initially used (Figure 1) but like Herrera-Soto, I also began to use pedicle screws for this, due to the poly-axial adjustable heads (Figure 2).</li> <li>A period of immobilization or traction can help to keep young children still and assist in management of urinary tubes. If used, the external fixator can be removed in clinic or bedside with oral analgesics and topical anesthetic.</li> <li>Explain to parents that some diastasis will recur due to the innate lower growth potential of the anterior pelvic rami, but this does not compromise the result</li> </ol> <p>The clinical science of exstrophy reconstruction has advanced steadily since the first successful case in the early 1950’s. The technique described by Cardin and Herrera-Soto provides additional options to improve clinical care.</p> <p>&nbsp;</p> <p><strong><u>References:</u></strong></p> <p>Sponseller, P.D., Bisson L., Gearhart, J.P., Jeffs, R.D., Magid, D., Fishman, E.: The Anatomy of the Pelvis in the Exstrophy Complex. <u>J. Bone Joint Surgery</u> 77-A: 177-189, 1995.</p> <p>Gearhart JP, Forschner DC, Jeffs RD, Ben-Chaim J, Sponseller PD: A combined vertical and horizontal pelvic osteotomy approach for primary and secondary repair of bladder exstrophy. Journal of Urology 155(2): 689-93, 1996.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <p>Okubadejo G, <u>Sponseller PD</u>, Gearhart JP: Orthopaedic Complications of management of Bladder Exstrophy. J. Pediatr. Orthop. 2003 Jul-Aug; 23(4):522-8.</p> <p>&nbsp;</p> Paul D. Sponseller, John P. Gearhart, Heather N. Di Carlo Copyright (c) 2020 JPOSNA Wed, 28 Oct 2020 19:39:54 -0600 Profile: John Emmett Hall, MD - A Great Surgeon and Even Better Man <p>Dr. John Hall was a preemminent surgeon, leader and man who's life lessons personally and professionally guided his patients, their families, his trainees and faculty and the societies he led and contributed to life long learning.&nbsp;</p> Peter Waters Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:01:28 -0600 Post-Natal Positioning through Babywearing: What the Orthopaedic Surgeon Needs to Know <p>Babywearing is the practice of using a swathe of fabric or purpose-built carrier to hold an infant or toddler close the caregiver’s torso, for multiple hours of the day. The child’s legs are often positioned in an “M” shape, with hips and knees flexed and abducted<strong>. </strong>There is increasing interest in the potential for babywearing to assist in hip development, as the “M” position assumed in most carriers is similar to the position achieved in harnesses/braces used in the treatment of developmental dysplasia of the hip (DDH). The association between low incidence of DDH in babywearing populations (Southern China, Aboriginal people of Western Australia, Central and Southern Africa, Malawi, and the Inuit/Eskimos of the circumpolar north) suggests that babywearing may play a role in optimal hip development, although genetics likely also contributes. Biomechanical studies have demonstrated optimal hip joint reaction forces while in baby carriers, with similar lower-extremity muscle activation as obtained in Pavlik harnesses. Ultrasound studies have shown that infant hips maintain normal ultrasound parameters while in baby carriers. In addition to its potential positive impact on hip development, babywearing stimulates caretaker-infant responsiveness, improves attachment and bonding, promotes language development, decreases infant crying, supports breastfeeding, and allows for caregiver multi-tasking. With improper use or insufficient care, asphyxia, falls/trauma, and baby-carrier purpura are potential complications. Energy expenditure of babywearing is less than arm-carrying, and effects on gait and posture can be minimized with proper positioning. Orthopedic surgeons may support their patient families that wish to babywear, as there are multiple non-orthopedic benefits, few potential complications if performed properly, and a promising potential for this form of post-natal positioning to have a positive impact on hip development. Future research should focus on prospective comparative studies of babywearing versus other post-natal positions and their impact on hip development.</p> Sreetha Sidharthan, Clare Kehoe, Emily Dodwell Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:05:51 -0600 Trends in Pediatric Orthopedic Fellowship <p>In this first publication of a two-part series on the pediatric orthopedic workforce supply and demand, we aim to analyze and discuss recent trends in pediatric orthopedic fellowship match data over the past five years. North American applicants successfully match at a 99.6% rate, and International medical graduates successfully match at a 43% rate. The number of applications submitted, interviews attended, and applicants ranked per program have all increased in recent years. Amongst, International medical graduate applicants, interviewing at 5 programs or more yields a 6.69 times more likely chance of successfully matching. Fellowship program directors report that the interview day performance and letters of recommendation are the 2 most important factors influencing rank position. Applicants matched at programs they ranked top 3 at an over 90% rate in the 2019 and 2020 match. The newer POSNA accreditating body aims to establish a standard for a comprehensive pediatric orthopedic training, and may become an important consideration for future fellowship applicants. With consideration of the workforce demand, this publication aims to provide information to answer whether these recent trends in the pediatric orthopedic fellowship match can address the needs of the workforce.&nbsp;</p> Aaron Wey, Christopher Makarewich, Paul Whiting, Alison Schiffern, Marcella Woiczik Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:08:23 -0600 Essentials of Pediatric Prosthetics <p>Caring for the limb deficient child may be initially daunting, but typically is quite rewarding for the orthopaedist and medical team. This article serves as a primer to those surgeons who are in training or infrequently treating this population. Insights are provided throughout to aid the orthopaedist in maneuvering the many facets of pediatric prosthetic care, including answers to questions common asked by surgeons or families. Involvement of the prosthetist early and then throughout the child’s care is crucial in achieving optimal outcomes in prosthetic design, fit, function and utilization. Although a multi-disciplinary team may not be available at all institutions, it is important to aim for this approach whenever possible. With the right balance of surgical, functional, prosthetic and therapeutic considerations, children with limb differences typically are able to keep up with their peers and participate in a variety of activities, such as school, sports and music.</p> Michelle Hall, Donald Cummings, Richard Welling Jr., Mary Kaleta, Kevin Koenig Jr., Jennifer Laine, Sara Morgan Copyright (c) 2020 JPOSNA Sun, 25 Oct 2020 09:44:58 -0600 From the Ground Up: Building a Pediatric Orthopaedic Clinical Research Program <p>To build a successful clinical research program in pediatric orthopaedics, you first need to start moving. Simple early steps and early success will build momentum. Advertise your program locally to recruit help from residents, students, departments, and hospitals. Utilize available local resources that often come with little to no cost. Solicit support from key stakeholders such as hospital systems, universities, and academic departments. Once your program gains some momentum and financial support, you can begin to add key personnel. It is then time for your mature research program to begin national and international collaborations and seek out large grants.</p> <p><strong>Key Concepts: </strong></p> <ul> <li>Start small and achieve early success in a new clinic research program.</li> <li>Improve your research skills by serving as a reviewer for research proposals, manuscripts, and grants.</li> <li>Collaborate as often as possible both within your institution and around the globe.</li> <li>Promote your programs research success to build momentum and recruit talented people.</li> </ul> Derek Kelly, Jeffrey Sawyer Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:04:16 -0600 QSVI: Interdisciplinary Optimization Clinic Decreases Infection in Neuromuscular/Syndromic Scoliosis Patients <p><strong>Background:</strong> Spinal surgery in pediatric neuromuscular and syndromic (NMS) patients is complicated and associated with numerous perioperative adverse events, unplanned reoperations, and suboptimal outcomes. SSIs are hospital acquired infections (HAIs), and they contribute to substantial morbidity in this patient population. This quality initiative (QI) focused on the development of a patient centered interdisciplinary medical optimization clinic and implementation of a standardized care pathway for NMS spinal fusion patients.</p> <p><strong>Methods:</strong> In late 2017, an interdisciplinary committee was formed with the purpose of creating a patient centered medical optimization clinic for surgical patients with neuromuscular and syndromic scoliosis. It was labeled, the Neuromuscular and Syndromic Spine Pathway (NSP) Clinic. All NSP patients had standardized pre-surgical assessment. &nbsp;The aims of the initiative were to 1) measure compliance to the implemented NSP clinical pathway by creating standardized order sets in the electronic medical record (EMR) (EPIC), 2) create a free patient mobile app to address the following: a. coordination of necessary pre-operative appointments/consults, and b. pre and post- operative education (video links, hospital tour, provider contact information, and 3) reduced HAI SSI in NMS spinal fusion patients with a target goal of zero. The committee retrospectively reviewed the prospectively collected data for all NMS spine SSIs from 1/1/2018 to 12/31/2019.&nbsp; All infections were reviewed using Root Cause Analysis (RCA) methodology.&nbsp; Infection rates were calculated using rolling 6 month averages.</p> <p><strong>Intervention:</strong> A “pilot” group of patients were evaluated and medically optimized through the NSP clinic. The NSP patient’s SSI risk was calculated using the Risk Severity Scale (RSS) pre-operatively<sup>16</sup>. This was compared to the actual HAI SSI rate to determine if the SSI risk could be positively modified through pre-operative medical optimization.</p> <p><strong>Results:</strong> From 1/2018 -12/2019, 160 NMS patients underwent spinal fusion. 29 (18%) of those were medically optimized in the NSP clinic. There were 13 M and 16 F patients. The average age was 12.8 years, pre-op cobb angle was 85.4°, the pre-operative kyphosis was 76.1°, and the average pre-operative BMI was 17.4. &nbsp;The average pre-operative SSI RSS was calculated to be 19.69%. 0/29 (0%) NSP patients developed a HAI SSI. (p = 0.015) Whereas, 9/131 (6.9%) NMS scoliosis fusion patients that were “not cleared” (NC) through the NSP clinic developed a HAI SSI. By utilizing RCA methodology, a common trend was observed. In 2018, 9/69 (13.0%) patients that were NC through the NSP clinic developed a HAI SSI.&nbsp; 7/9 (77.7%) of those infections were due to S. aureus species. This drove the implementation of the second initiative.</p> <p><strong>Second Intervention:</strong> The goal of this initiative was to create and implement a S. aureus screening and decolonization program for NMS scoliosis patients undergoing spinal fusion surgery at our institution. The pre- surgical screening was accomplished by culture of the anterior nares, tracheostomy tube, and/or gastrostomy tube sites. A positive culture for either methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) was followed by decolonization with nasal mupirocin (2x/day) and a daily CHG bath for five days prior to the surgical date. The protocol utilized rapid (Plan-Do-Check-Act) cycles with a goal to reduce the HAI SSI rate due to S. aureus species in NMS spinal fusion patients within 1 year.&nbsp;</p> <p><strong>Results:</strong> 68 NMS spinal fusion patients were screened for S. aureus colonization in 2019.&nbsp; Of the 68 patients screened, 36.8% (25/68) tested positive for S. aureus colonization. The prevalence of MSSA was 30.9% (21/68), while the prevalence of MRSA was 5.88% (4/68). The majority (68%) of organisms were culture positive in the anterior nares, 16 % from the gastrostomy tube, and 16% in both nares and gastrostomy tube. The HAI SSI rates for spinal fusion NMS patients decreased to 0/72 (0%) in 2019 (p= 0.003).</p> <p><strong>Conclusion:</strong> Patient centered interdisciplinary pre-operative medical optimization modified the SSI risk in this “pilot” group of NMS scoliosis patients. The NSP clinic cohort had a 20% predicted risk of developing a HAI SSI, and actual rate was 0%. In contrast, 6.9% of the NMS scoliosis fusion patients that were NC through the NSP clinic developed an HAI SSI. &nbsp;77.7% of those infections were due to S. aureus species. This drove the S. aureus screening and decolonization initiative which decreased the HAI SSI rate to zero within one year’s time. As a result of these QIs, <strong>ALL</strong> NMS spinal fusion patients at our institution are screened for S. aureus colonization, and medically optimized through the NSP clinic.</p> Amy McIntosh, Matthew Smith, Kerry Wilder Copyright (c) 2020 JPOSNA Mon, 26 Oct 2020 19:04:38 -0600 Acute Compartment Syndrome After Knee Manipulation Under Anesthesia for Post-Traumatic Arthrofibrosis <p>Arthrofibrosis of the knee is common in the setting of polytrauma, especially when early range of motion is limited by a patient’s medical status or willingness to participate in rehabilitation. It is clear that manipulation of the knee under anesthesia is an effective treatment for this condition and is considered a safe procedure with minimal risk to improve range of motion and participation in rehabilitation. Unfortunately, no procedure is without risk. The high risk of deep-vein thrombosis in this population means that many of these patients are on medications for prophylaxis and may alter their risk profile for certain procedures. The purpose of the current case study is to present a patient with post-traumatic knee arthrofibrosis on therapeutic anticoagulation for a deep-vein thrombosis who developed acute compartment syndrome after manipulation under anesthesia to highlight a rare but significant complication following this common procedure.</p> Andrew Kleven, Alexander Graf, Scott Van Valin Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:02:25 -0600 Failing to Appreciate that an Excessive Soft Tissue Envelope May Lead to Spinal MCGR Dysfunction <p>Surgical management of Early Onset Spinal Deformity with magnetically controlled growing rods (MCGR) is a common intervention. Multiple complications of the use of these devices have been reported in the literature.&nbsp; To date, failure of the device to lengthen due to the physical distance of the rods from the external controller due to patient body habitus has not been reported. Consideration of the resultant distance from the external remote controller to the rods should be part of preoperative planning and intraoperative decision-making.</p> James F. Mooney, III, Sarah Toner, Robert F. Murphy Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 18:57:34 -0600 High-Grade Pediatric Lumbar Spondylolisthesis: Expert Panel Approach <p>Management of the pediatric patient with a high-grade spondylolisthesis is challenging.&nbsp; Differences in treatment goals and technique exist between differing surgeons for differing patients.&nbsp; In this panel discussion, three experts discuss their approach to an adolescent with a Grade 3 spondylolisthesis.&nbsp; The authors discuss what’s important to consider and how to execute their treatment strategy.</p> Jennifer Bauer, Robert Cho, David Lebel, Timothy Hresko Copyright (c) 2020 JPOSNA Sun, 25 Oct 2020 09:43:15 -0600 Intraspinal Anomalies and Their Interplay with Spinal Deformity in Early Onset Scoliosis <p>Numerous articles have reported the presence of intraspinal anomalies in children with early onset scoliosis (EOS) and have found varying effect of neurosurgical intervention on the risk of spinal deformity progression.&nbsp; However, no study to date has performed a detailed analysis of the implications of intraspinal anomalies on scoliotic development and the implications of neurosurgical intervention on curve progression in children with EOS.&nbsp; This article reviewed the relevant information as it pertains to children &lt; 10 years of age with scoliosis associated with tethered cord, syringomyelia, and Arnold-Chiari (Chiari) malformations. The influence of aspect of the spinal anomaly of spinal deformity is reviewed as well as the identification of risk factors for curve progression following neurosurgical intervention.</p> Kenneth Shaw, Austin Shiver, Joshua Chern, Barunashish Brahma, Joshua Murphy, Nicholas Fletcher Copyright (c) 2020 JPOSNA Mon, 26 Oct 2020 19:07:34 -0600 Safe Return to Play Following ACL Reconstruction in Young Athletes <p>In order to reduce the risk of a second ACL injury following primary ACL reconstruction in young athletes, return to play (RTP) strategies are implemented that utilize temporal, psychological, and functional benchmarks. This strategy should be discussed with patients and their social support group prior to surgery in order to set proper expectations. Physiologically, time is needed for both graft maturation and incorporation as well as neuromuscular recovery. To monitor readiness for return to sport, validated measurement tools should be utilized along with functional assessments to address neuromuscular deficiencies. Patient reported outcome measures and psychological readiness should also be taken into account when assessing athletes’ readiness to return to play.&nbsp; As athletes transition back to sport, ACL injury prevention training programs should be implemented on an ongoing basis. There remains insufficient evidence to support the routine use of functional ACL bracing to prevent ACL re-injury.</p> Zachary Stinson, Jennifer Beck, Aristides Cruz, Matt Ellington, Curtis VandenBerg, Sasha Carsen, Stephanie Mayer, Allison Crepeau Copyright (c) 2020 JPOSNA Tue, 27 Oct 2020 18:59:12 -0600 Failure of Lateral Acetabular Growth 12 Years After Labral Splitting during Anteromedial Open Reduction of the Hip <p>A number of techniques are described to aid in open reduction for developmental dysplasia of the hip. Radial incision of an obstructive or inverted labrum has been considered as an effective means to “open” the acetabulum to facilitate anteromedial reduction.&nbsp;&nbsp; We present follow-up of a patient who underwent radial splitting of the labrum via an anteromedial approach at 14 months of age, which resulted in successful reduction of the hip. Twelve-year clinical follow-up reveals significant acetabular dysplasia, likely due to injury to the labrum and underlying secondary centers of ossification of the acetabulum. &nbsp;We recommend that surgeons use great caution when considering a labral incision or excision during anteromedial open reduction of the hip and consider other means of obtaining a stable reduction.</p> Stephanie Goldstein, Laura Bellaire, Pamela Lang Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:05:05 -0600 Evaluation and Management of Mid-shaft Clavicle Fractures in Adolescents <p>The rate of operative fixation for completely displaced mid-shaft clavicle fractures in adolescents has been increasing yearly over the last decade, largely driven by studies of adult populations, in whom the rate of nonunion is approximately 15% with non-operative treatment. However, nonunion and symptomatic malunion in younger populations remain rare. Recent studies suggest that functional outcomes are similar between conservative management and operative fixation in adolescents, with higher rates of complications and slightly decreased time to return to sport with operative fixation. Implant-related symptoms after surgery remains an important consideration, due to potential for reoperation for implant removal. Additionally, the cost of operative fixation is significantly higher than that of non-operative management. The aim of this review is to summarize the salient historical and more recent literature regarding displaced mid-shaft clavicle fractures in order to better understand treatment considerations and the natural history of these fractures in the adolescent.</p> Naveen Jasty, FACTS Study Group, Benton Heyworth Copyright (c) 2020 JPOSNA Wed, 28 Oct 2020 22:00:57 -0600 Where are we Walking? An Introduction to a JPOSNA Year-Long Series on Gait Analysis in Pediatric Orthopedics <p>Management of the ambulatory patient with cerebral palsy is complicated as each child has differences in the degree and extent of motor involvement; neurologic features (dystonia, ataxia) as well as other physical and social co-morbidities.&nbsp; No where else in pediatric orthopaedics is the care of these children/adolescents equally dependent on assessment tools and methods, treatment strategies, experience and the need for excellent support from our partners in rehabilitation medicine, occupational and physical therapy and orthotics. &nbsp;In this edition we begin a year-long study in this topic.</p> Wade Shrader Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 18:59:09 -0600 Enhancing Observational Gait Analysis – Techniques and Tips for Analyzing Gait Without a Gait Lab <p>In settings where three dimensional gait analysis is not feasible, observational gait analysis can provide important information about gait pathology.&nbsp; Among the validated scoring systems to organize the observations of gait, the Edinburgh Visual Gait Score (EVGS) is the most comprehensive and has the most favorable psychometrics.&nbsp; Improvements in mobile videography have created opportunities to obtain high-quality slow-motion video in a clinic setting.&nbsp; These videos can provide excellent documentation of gait pathology in the sagittal, coronal, and vertical planes.&nbsp; Free and low-cost video analysis software is now available on all mobile device platforms, allowing for slow-motion video analysis of gait with increased accuracy.&nbsp; By utilizing the appropriate technology with a validated scoring system, gait analysis outside the walls of a gait lab is possible.&nbsp; Though limitations of the mobile enhanced observational gait analysis technique require further study, the technique can facilitate improved documentation of gait pathology and improved communication between providers.&nbsp; <strong><em>&nbsp;</em></strong>In settings where three dimensional gait analysis is not feasible, observational gait analysis can provide important information about gait pathology.&nbsp; Among the validated scoring systems to organize the o<strong><em>&nbsp;</em></strong>In settings where three dimensional gait analysis is not feasible, observational gait analysis can provide important information about gait pathology.&nbsp; Among the validated scoring systems to organize the observations of gait, the Edinburgh Visual Gait Score (EVGS) is the most comprehensive and has the most favorable psychometrics.&nbsp; Improvements in mobile videography have created opportunities to obtain high-quality slow-motion video in a clinic setting.&nbsp; These videos can provide excellent documentation of gait pathology in the sagittal, coronal, and vertical planes.&nbsp; Free and low-cost video analysis software is now available on all mobile device platforms, allowing for slow-motion video analysis of gait with increased accuracy.&nbsp; By utilizing the appropriate technology with a validated scoring system, gait analysis outside the walls of a gait lab is possible.&nbsp; Though limitations of the mobile enhanced observational gait analysis technique require further study, the technique can facilitate improved documentation of gait pathology and improved communication between providers.&nbsp; bservations of gait, the Edinburgh Visual Gait Score (EVGS) is the most comprehensive and has the most favorable psychometrics.&nbsp; Improvements in mobile videography have created opportunities to obtain high-quality slow-motion video in a clinic setting.&nbsp; These videos can provide excellent documentation of gait pathology in the sagittal, coronal, and vertical planes.&nbsp; Free and low-cost video analysis software is now available on all mobile device platforms, allowing for slow-motion video analysis of gait with increased accuracy.&nbsp; By utilizing the appropriate technology with a validated scoring system, gait analysis outside the walls of a gait lab is possible.&nbsp; Though limitations of the mobile enhanced observational gait analysis technique require further study, the technique can facilitate improved documentation of gait pathology and improved communication between providers.&nbsp;&nbsp;</p> Vedant Ashok Kulkarni, Donald Kephart, Ramiro Olleac, Jon Davids Copyright (c) 2020 JPOSNA Sat, 31 Oct 2020 09:16:58 -0600 JPOSNA Tumor Quiz <div>This tumor quiz represents an interactive session where POSNA members are able to work through 9 clinical scenarios to challenge how they would address these 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 oncology to provide an evidenced-based approach to thinking through each tumor problem.&nbsp;</div> Alexandre Arkader, Tricia Bhatti, Vernon Tolo, Kristy Weber, Carol Morris Copyright (c) 2020 JPOSNA Sun, 25 Oct 2020 13:19:14 -0600 POGO Travel Journal Michael Heffernan, Harshadkumar Patel, Mark Lee Copyright (c) 2020 JPOSNA Sat, 24 Oct 2020 19:00:21 -0600