JPOSNA <p>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> en-US (POSNA Staff) (POSNA Staff) Fri, 08 Nov 2019 00:00:00 -0700 OJS 60 Editor's Note <p>Welcome to the inaugural edition of the<em> Journal of the Pediatric Orthopaedic Society of North America, JPOSNA</em>!</p> <p>Several months ago, our President Steve Frick and the POSNA Board of Directors commissioned the development of an electronic journal to complement current offerings such as the <em>Journal of Pediatric Orthopaedics</em> and the <em>Journal of Bone and Joint Surgery</em>. As our society has grown, there has been parallel growth in the complexity of the procedures we perform in an ever-increasing scope of practice (hand, sports medicine, young hip salvage, and growing spine to name a few). The board felt that an electronic journal that is managed by our society would allow us to present visual media such as surgical techniques, and publish content that current journals don’t have room for. This includes Current Concept Reviews, Panel Discussions, Proceedings from the Annual Meeting and IPOS, to name a few. In addition, JPOSNA will serve as way to highlight the direction of POSNA and the accomplishments of our volunteer society such as POGO, highlighted in this edition.</p> <p>We need to illuminate the electronic expertise of our resident whiz kid Bryan Tompkins and highlight the hard work and editing from Teri Stech and Lisa DuShane from POSNA HQ. The associate editorial board has produced, in very short order, articles that comprise this first edition. We are indebted to this group. In addition to content described above, and in an effort to learn what we can do better, we present our first “Don’t Do This Case Report.”</p> <p>In time, please look for announcements for content that you can contribute to this journal and to help us with our singular mission, to improve care for children with musculoskeletal conditions worldwide. Please let me know of suggestions or ideas you have, to make this the best journal for our society.</p> Ken Noonan Copyright (c) 2019 JPOSNA Tue, 05 Nov 2019 01:55:16 -0700 President's Message <p>It is my pleasure to introduce the inaugural issue of the<strong> <em>Journal of the Pediatric Orthopaedic Society of North America</em> (<em>JPOSNA</em>)</strong>. Pediatric Orthopaedics has shown consistent growth as evidenced by the steady increase in POSNA membership. As expected, the maturation of pediatric orthopaedics as a specialty has been accompanied by an expansion of the associated body of knowledge and an increase in subspecialization. It is becoming more common for pediatric orthopaedic fellowship graduates to further subspecialize by completing a second fellowship.</p> <p>This growth and subspecialization has resulted in an increased demand for avenues to share knowledge. For many years the <em>Journal of Pediatric Orthopaedics</em> (<em>JPO</em>) has provided an outlet for publication of original scientific research. This resource continues to play a vital role in our specialty. The goal of <em>JPOSNA</em> is to supplement the information in <em>JPO</em> by providing a platform for our members and POSNA to publish information that does not meet the goals of <em>JPO</em>. The initial plan is to publish case reports, review articles, panel discussions, and POSNA notifications.</p> <p>POSNA is grateful to Kenneth Noonan, MD for accepting the role as the journal’s first editor. It is a big responsibility that will be accompanied by many challenges. Ken’s knowledge, insight, energy, and organizational skills will ensure the journals success.</p> <p>Please enjoy this new POSNA member benefit.</p> Stephen Albanese Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 00:00:00 -0600 International Pediatric Orthopaedic Symposium (IPOS) Lisa DuShane Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 00:00:00 -0600 Current Concepts: Surgeon Wellness and Burnout <p>Physician wellness and burnout have been an increasing source of debate, while physician depression and suicide continue to be on the rise.&nbsp; The Pediatric Orthopedic Society of North American has been on the forefront of addressing these issues throughout the creation of a Physician Wellness Task Force, membership surveys, and a pre-course at the annual meeting directly addressing this topic.&nbsp; However, physician members of POSNA still report a burnout rate of almost forty percent.&nbsp; Despite hard questions being asked, there continues to be significant debate about how best to address physician burnout and focus on physician wellness.</p> <p><strong>Key Concepts:</strong></p> <ol> <li>Occupational burnout is the constellation of emotional exhaustion, depersonalization, and a perceived lack of personal accomplishment.</li> <li>Physician burnout can lead to increased complications and medical errors.</li> <li>Physician burnout requires a multi-faceted approach to prevent and treat, including both personal and institutional strategies.</li> <li>POSNA continues to develop and implement strategies to help their members prevent burnout and focus on wellness.</li> </ol> Sarah Walker, Rachel Goldstein Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:14:07 -0700 Current Concept Review: The Role of Bisphophonates in Pediatric Orthopaedics: What do we know after 50 years? <p>The first described case of bisphosphonate use in a pediatric patient was 50 years ago, in 1969.&nbsp; Since then, bisphosphonates have been used for therapy in a wide variety of pediatric conditions, especially those of osteoporosis and bone fragility.&nbsp; Bisphosphonates have become standard medical therapy for moderate and severe osteogenesis imperfecta, with studies consistently showing improvements in bone mineral density.&nbsp; Despite the widespread use in this condition, there are no firm guidelines on treatment regimen or duration.&nbsp;&nbsp; Bisphosphonates have also been explored in the therapy of pediatric secondary osteoporosis.&nbsp; Although many studies have shown promising results, the evidence is not strong enough to inform clinical management conclusively.&nbsp; Clinical study of bisphosphonate use in avascular necrosis has not been as promising as the data from preclinical, animal model work.&nbsp; Although multiple studies have shown that bisphosphonate therapy improves pediatric bone mineral density, further study is needed to understand better the appropriate indications and treatment, as well as the clinical impact, including fracture reduction and effects on pain and quality of life.</p> <p><strong>Key Points</strong></p> <ol> <li>Bisphosphonates are accepted therapy for moderate and severe osteogenesis imperfecta.&nbsp; Studies consistently show improved bone mineral density, and many studies report decreased fracture risk.</li> <li>Small studies have shown improvements in bone mineral density in patients with secondary osteoporosis from cerebral palsy and with glucocorticoid-induced osteoporosis in Duchenne muscular dystrophy</li> <li>Clinical study of bisphosphonates for pediatric AVN of the hip is limited and does not currently support use to prevent femoral head deformity. Bisphosphonates may decrease pain in AVN.</li> <li>Short-term use of bisphosphonates is considered safe and well-tolerated in the pediatric population.&nbsp; Long-term effects of bisphosphonate use remain unknown.</li> </ol> Jennifer Laine, Allen Kadado, Chrystina James, Susan Novotny Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:26:09 -0700 Pediatric Orthopedic Global Outreach (POGO) Committee <p>The field of global health has undergone remarkable growth and development over the past half century. Pediatric orthopedists have been at the forefront of much of this work. From the beginning, these individuals have understood what it means to perform global outreach and have helped our profession and Society focus on how to do so in meaningful and impactful ways. In 2001, the Children’s Orthopedics in Underserved Regions (COUR) committee was formed to help POSNA members carry out this work in resource-limited environments. The COUR committee was initially approached and asked to consider changing the name to better reflect the modern verbiage used in the field. As we began to consider and explore this request, it became apparent that this also was an opportunity to recognize the evolved role the committee has for our membership and the Society. After a thorough process of consultation and debate, the committee recommended that the name be changed to the Pediatric Orthopedic Global Outreach (POGO) committee. After review, the Board of Directors approved this name change in September 2019. In this manuscript we present the history, rationale for change, and vision for the future. The mission of POGO will be carried out through a combination of Education, Coordination, and Research. While the name of the committee has changed to POGO, the principals that made COUR so successful remains at its core. This is an opportunity to build on the work of the visionary leaders who laid the foundation for us to shape the future.</p> Eric Fornari, Richard M. Schwend, Michael J. Heffernan Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:53:16 -0700 "TRASH" Lesions of the Pediatric Lower Extremity <p>TRASH lesions have been coined as a group of pediatric elbow injuries which are underappreciated on radiographs, and which “if treated insufficiently result in chronic long-term consequences.”1 We describe a series of injuries in the pediatric lower extremity, which are similar to elbow TRASH lesions, in that they are often overlooked or dismissed as inconsequential and may have serious ramifications if managed inappropriately. These injuries include traumatic hip dislocations with subsequent intraarticular pathology, greater trochanteric avulsion fractures, patellar sleeve fractures, minimally displaced proximal tibial metaphyseal fractures, and minimally displaced Salter-Harris III and IV fractures of the medial malleolus. Making the correct diagnosis and implementing appropriate treatment, including adequate follow up, is paramount.</p> <p><strong>Key Points:</strong></p> <ul> <li>Traumatic hip dislocations in the pediatric and adolescent hip populations can result in intraarticular pathology, which is not visualized on advanced imaging.</li> <li>Greater trochanteric avulsion fractures, while rare, may be complicated by avascular necrosis of the femoral head.</li> <li>Patellar sleeve fractures may be easily missed on radiographs, and inadequate management can result in significant sequelae.</li> <li>Proximal tibial metaphyseal fractures, even when nondisplaced, may result in posttraumatic genu valgum, and caregivers should be warned of this possibility.</li> <li>Non- and minimally displaced Salter-Harris III and IV fractures of the medial malleolus can lead to premature physeal closure, and radiographic follow up of these injuries is warranted.</li> </ul> Stephanie Holmes Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:38:02 -0700 Don't Do This Case Report <p><span data-contrast="auto">Operative treatment with formal irrigation and debridement has classically been considered the standard of care</span><span data-contrast="auto"> for open forearm fractures</span><span data-contrast="auto">. Considerable debate exists regarding the management of type 1 open forearm fractures in the pediatric population.</span><span data-contrast="auto"> Several recent studies have demonstrated that nonoperative management consisting of local wound irrigation and debridement in the emergency department, followed by closed reduction and casting with a course of antibiotics may be an appropriate treatment option for these fractures.&nbsp; </span><span data-contrast="auto">The purpose of the current </span><span data-contrast="auto">case </span><span data-contrast="auto">study i</span><span data-contrast="auto">s to present two cases of </span><span data-contrast="auto">open </span><span data-contrast="auto">forearm </span><span data-contrast="auto">fractures</span><span data-contrast="auto">,</span> <span data-contrast="auto">which were designated as type 1 fractures, </span><span data-contrast="auto">in young children that resulted in devastating outcomes following </span><span data-contrast="auto">emergency d</span><span data-contrast="auto">epartment wound management and fracture care</span><span data-contrast="auto">.</span></p> Julie Samora, Carley Vuillermin, Peter Waters Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:59:51 -0700 Surgical Technique: Power Pedicle Preparation and Screw Insertion in the Treatment of Pediatric Spinal Deformity <p>Pedicle screw fixation has been shown to be safe and effective treatment for spinal deformity <sup>1-6</sup>, and is the mainstay of posterior spinal instrumentation. Classically, pedicle preparation and screw insertion has been performed with manual tools and a manual technique. At our institution, power pedicle preparation and screw insertion has been used for the last 12 years with over 20,000 pedicle screws. &nbsp;Power pedicle preparation has the potential to decrease the force required for insertion on the patient, increase proprioception for the surgeon, increase accuracy, and possibly decreasing the incidence of overuse injuries for the spine surgeon.&nbsp;</p> Kenneth David Illingworth, MD, Lindsay M. Andras, MD, Amy A. Claeson, PhD, David L. Skaggs, MD, MMM Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:49:44 -0700 Growth Modulation for Childhood Scoliosis <p><strong>Study Design:</strong> Literature Review</p> <p><strong>Background: </strong>This white paper reviews the early reported outcomes of anterior vertebral body tethering (AVBT) and provides a brief update on the recent changes in regulatory status.</p> <p>Growth modulation by AVBT has the potential to transform scoliosis treatment in children and adolescents by reducing spinal curvature without definitive fusion. To date, nearly all patients with anterior vertebral body tethering (AVBT) have been treated in off-label use, sometimes with controversial indications.&nbsp;</p> <p><strong>Methods: </strong>A literature review was conducted of published papers and abstracts from national conferences.&nbsp; We searched PubMed for “vertebral body stapling” and “vertebral body tethering,” including only primary research. We also reviewed the last 10 programs of ICEOS, SRS, and POSNA.&nbsp; Regulatory officials within the spinal device industry and the FDA were also consulted.</p> <p><strong>Results: </strong>Early published experience (5 papers) in 67 patients and unpublished data (8 presentations) in over 200 patients suggests that AVBT can effectively prevent curve progression in the majority of skeletally immature patients. Rates of complications and secondary surgery for curve progression or overcorrection are variable and necessitate further investigation.</p> <p><strong>Conclusions: </strong>With the recent FDA regulatory approval of the vertebral tether under and Humanitarian Device Exemption (HDE) mechanism, we are poised to better understand the long term outcomes of this novel and potentially disruptive approach to the treatment of pediatric spine deformity.</p> <p><strong>Level V</strong></p> Lisa Bonsignore-Opp, Josh Murphy, David Skaggs, Patrick Cahill, Laurel Blakemore, Stefan Parent, Amer Samdani, Tricia St.Hilaire, Michael Vitale Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:57:09 -0700 Current Concept Review: OCD Lesions of the Knee <p>Osteochondritis dissecans (OCD) of the knee is a condition that has continued to perplex the orthopaedic community in its origin, despite clear advances in identification and treatment. The incidence of this potentially disabling condition has remained relatively steady, but with a shifting distribution towards young, athletic males as the primarily affected demographic. The condition commonly presents insidiously as vague knee pain but may advance to overt mechanical symptoms due to loose body formation in the joint. OCD lesions are typically classified with magnetic resonance imaging (MRI) as either stable or unstable based on the mechanical integrity of the fragment and the state of the underlying subchondral bone. The purpose of this paper is to review the current understanding of pediatric OCD of the knee, contemporary treatment principles including methods to promote OCD lesion healing, fixation methods, and salvage techniques.&nbsp;</p> Nathan Grimm, Richard Danilkowicz, Kevin Shea Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:39:36 -0700 Skeletally Immature Anterior Cruciate Ligament Reconstruction <p>Anterior cruciate ligament (ACL) tears account for a significant and increaseing number of sports related injuries in young athletes.&nbsp; There are several described techniques for "physeal respecting" ACL reconstruction.&nbsp; Each described technique distinguishes itself in a variety of ways.&nbsp; The goal of this invited perspectives article is to dicuss pediatric sports medicine experts' approach, preferred ACL reconstruction techniques, and rationale when evaluating a skeletally immature patient with an ACL tear.&nbsp;&nbsp;</p> Aristides Cruz, Nirav Pandya, Theodore Ganley, Mininder Kocher Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:55:40 -0700 Current Concept Review: The Role of Bracing in Pediatric Orthopaedics <p><strong>Background: </strong>Many&nbsp;pediatric conditions of the lower extremity are self-limiting and have no known long-term prognostic effects. The Pediatric Orthopaedic Society of North America (POSNA), the American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) all have analogous guidelines regarding the use of orthotics for benign lower limb pathologies, but it is unknown whether clinicians adhere to these guidelines.</p> <p><strong>Methods: </strong>A review of current recommendations for treatment of four common benign lower limb conditions and Blount’s disease was performed. The recommendations were used as a basis to determine adherence of providers regarding treatment of the described conditions. An anonymous online survey was then distributed to POSNA members (N=1402). Respondents were queried regarding practice, education, frequency and reason for prescribing orthotics for flexible metatarsus adductus (MA), painless flexible flatfeet (PFF), internal tibial torsion (ITT)&nbsp;and femoral anteversion (FA).</p> <p><strong>Results: </strong>The online response rate was 26.1 % (366). Pediatric orthopaedic fellowship trained members comprised of 87.4% of the respondents.</p> <p>A majority of members reported “never” prescribing orthotics for FA (83%; 304) in comparison to the other conditions—75% (275) for ITT, 48% (176) for PFF, and 35% (127) for MA. Few reported “always” or “almost always” prescribing orthotics for any of the benign conditions; 3.6% (13) for MA, 1.1% (4) for PFF, 0.8% (3) for ITT, and 0.5% (2) for FA.</p> <p>Members without pediatric orthopaedic fellowship training are more likely to “always” or “almost always” prescribe orthotics for PFF than fellowship-trained clinicians (14.3% vs. 0.6%; p&lt;0.001). Long practicing POSNA members were more likely to prescribe orthotics for ITT (p&lt;0.001, B = 0.068) and FA (p = 0.009, B = 0.034).</p> <p>Physical therapists were the most common prescribers for MA, ITT, and FA, and podiatrists for PFF.</p> <p><strong>Conclusions<em>: </em></strong>Most POSNA members adhered to the recommended guidelines for orthotics prescription for the conditions surveyed. Adherence to recommendations were less common among long practicing members and non-pediatric orthopaedic fellowship-trained providers.</p> <p><strong>Level of Evidence:</strong> II</p> Selina Poon, Brett Lullo, Cynthia Nguyen, Ebubechi Okwumabua, Marilan Luong, Meghan Imrie, Geordy Gantsoudes , Robert Cho Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:54:22 -0700 Current Concept Review: Management of the Complex Clubfoot <p>Along with syndromic or neuromuscular clubfoot, complex (“atypical”) clubfoot represents a category of clubfoot that is difficult to treat using the Ponseti method. It is important to identify this type of foot early because the treatment and prognosis are different from that of idiopathic clubfoot. Some cases can be seen from birth while other cases are iatrogenically caused, but in both instances the anatomic features and treatment are the same. In infantile cases, consideration to complex idiopathic clubfeet should be given with the anatomic presence of a deep plantar crease and hyperextended first toe. In iatrogenic cases, the provider may be alerted by cast failure and slippage. Parents should be made aware of the increased difficulty in treating complex clubfoot, and be prepared for additional cast time, early or repeat Achilles tenotomy, or difficulty with brace wear.</p> Alice Chu, Hugh Nachamie, Wallace Lehman Copyright (c) 2019 JPOSNA Fri, 08 Nov 2019 13:05:53 -0700 Current Concept Review: Management of Spinal Deformity in Cerebral Palsy <p>Scoliosis is common in cerebral palsy (CP), typified by rapidly progressive curves that impact patient function and quality of life. <span lang="EN-GB">With age, these curves become rigid, resulting in functional disabilities including sitting imbalance, decubitus ulcers, decreased socialisation, increased caregiver demands, and, in some cases, decreased pulmonary function. </span>&nbsp;The incidence of scoliosis has been correlated to disease severity, necessitating clinical and radiographic surveillance based on functional level according to the Gross Motor Function Classification System (GMFCS).</p> <p><span lang="EN-GB">The use of bracing for scoliosis in CP is to support the collapsing spine rather than to prevent curve progression, and should not be expected to alter natural history. </span>Scoliosis correction surgery, however, is indicated for progressive curves greater than 40-50°, with the primary surgical goals being achieved with a balanced spine over a level pelvis, allowing for a more stable sitting platform and improved quality of life. Identifying and treating the causes of concomitant pelvic obliquity are important to achieve optimal sitting balance. Hip displacement and scoliosis are often coincident in CP, but the order of surgical management remains controversial.</p> <p>The mainstay of treatment for scoliosis involves posterior instrumentation and fusion from the upper thoracic spine to the pelvis. Though several options are available, the best evidence to date would suggest that segmental pedicle screw fixation achieves better curve correction and an improved risk profile over other implant choices. Often proposed as a benefit of scoliosis surgery in CP, the true impact of curve correction on pulmonary function has not been well studied and is currently unknown. Substantial comorbidities increase the peri-operative risk profile – including swallowing difficulties, aspiration risk, recurrent respiratory infections, epilepsy, and malnutrition – necessitating patient counseling and mitigating strategies to optimize surgical outcomes. Optimizing medical and nutritional management pre- and peri-operatively are important to tip the balance in favour of benefits over risks. The best evidence to date would suggest that scoliosis surgery improves quality of life and is warranted in spite of the risks involved.</p> Jason Howard, Julieanne Sees, M. Wade Shrader Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:59:09 -0700 Point of View <p>Commentary on this issue's Current Concepts Review article on the&nbsp; "<a href="" target="_blank" rel="noopener">Management of Spinal Deformity in Cerebral Palsy</a>"</p> William Warner Copyright (c) 2019 JPOSNA Fri, 08 Nov 2019 13:41:46 -0700 POSNA 2019 Annual Meeting: Presidential Address <p>"Tips for Achieving Success in Life and Work" by Peter M. Waters, MD, MSSc(Ed) from Boston Children’s Hospital, Boston, MA.</p> Peter Waters Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 16:24:34 -0700 POSNA 2019 Annual Meeting: Best Video <p>Calcaneal displacement osteotomy is a well-established surgery for correction of rigid heel varus or valgus deformity in young patients. We describe a percutaneous technique of doing this surgery which can help avoid possible complications of open surgery.</p> Indranil Kushare, Jeffrey Shilt Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 16:52:28 -0700 POSNA 2019 Annual Meeting: Best Clinical Paper <p><strong>Purpose: </strong>To investigate the two-year functional outcomes and complications following operative versus non-operative treatment of completely displaced midshaft clavicle fractures in adolescents.</p> <p><strong>Methods:&nbsp; </strong>All patients 10-18 years old treated for a midshaft clavicle fracture between August, 2013 and August, 2018 at one of 8 geographically diverse, high-volume, tertiary-care pediatric centers were enrolled, with independent treatment decisions determined by individual providers. The sub-population of patients with completely displaced fractures was prospectively followed for over 2 years. Clinical course, complications, validated patient-reported outcome measures (PROs), quality of life metrics, and satisfaction scores were analyzed. To address the ceiling effect of the PRO/satisfaction data following clavicle injuries, a priori thresholds for ‘suboptimal’ scores were established (ASES scores &lt;90, QuickDASH scores &gt;10, EQ-5D &lt;0.80). According to ‘intention to treat’ statistical principles, one post-operative complication (and a subsequent secondary operation) was analyzed within the non-operative cohort, given that the patient represented a ‘crossover’ from the non-operative to the operative treatment group.</p> <p><strong>Results: </strong>Of the 909 patients enrolled in the prospective study, 417 patients (45.9%) demonstrated completely displaced fractures and maintained enrollment over the study period, 277 (66%) of whom had reached two year follow up, and 151 of whom provided adequate PRO data, representing a 55% response rate. Of these patients, 55 (36%) underwent operative treatment, while 96 (64%) were treated non-operatively. Those treated surgically showed no difference in gender distribution (76% males,p=0.43), athletic participation (p=0.76), or fracture pattern (p=0.18), but were older (mean age 15.3 vs. 13.5 years, p&lt;0.001) and had greater shortening (p&lt;0.001) than those treated non-operatively. Within the subset with adequate complication data, listed in Table 1, complications were less common in non-surgical than surgical patients (p=0.0003), but this difference did not reach significance when sensory deficits were excluded (p=0.17). There was no difference in secondary surgeries (p=0.43). While greater percentages of operative than non-operative patients reported suboptimal PRO/satisfaction scores (ASES: 15% vs. 5%, QuickDASH 11% vs. 5%, satisfaction 11% vs. 5%), these differences did not reach significance (p=0.07, 0.20, 0.06, respectively).</p> <p><strong>Conclusion:&nbsp; </strong>At eight large pediatric centers with many surgeons making independent treatment decisions, non-operative treatment of adolescent clavicle fractures demonstrated lower complication rates and similar satisfaction and functional outcomes.</p> <p><strong>Significance:&nbsp; </strong>These data establish a comprehensive functional assessment of adolescents treated for clavicle fractures, which represents the epidemiological sub-population most affected by this condition. Unlike several adult studies demonstrating superiority in operative treatment, this adolescent study demonstrates equivalent function and fewer complications associated with non-operative treatment.</p> Benton E. Heyworth, MD, Andrew T. Pennock, MD, Ying Li, MD, Leslie A. Kalish, ScD, Brittany Dragonetti, BA, Henry B. Ellis, MD, Jeffrey Nepple, MD, S. Clifton Willimon, MD, David Spence, MD, Nirav K. Pandya, MD, Mininder S. Kocher, MD, MPH, Eric W. Edmonds, MD, Philip Wilson, MD, Michael Busch, MD, Coleen Sabatini, MD, Donald S. Bae, MD Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:04:05 -0700 POSNA 2019 Annual Meeting: Best Basic Science Paper <p><strong>Purpose:</strong> Neonatal brachial plexus injury (NBPI) causes disabling contractures that cannot be fully prevented or corrected, largely because their pathophysiology is incompletely understood. Research in a mouse model has shown that contractures result at least in part from impaired postnatal muscle growth, but the mechanism of this impaired muscle growth is unknown. The current work uses a mouse model to experimentally assess and correct muscle protein imbalance (synthesis versus degradation) as a mechanism of impaired muscle growth and contractures following NBPI.</p> <p><strong>Methods:</strong> Unilateral global (C5-T1) NBPIs were surgically created in 5-day-old mice, which permanently denervates the forelimb and reliably causes shoulder and elbow contractures 4 weeks post-NBPI. Protein synthesis was measured in denervated and contralateral control elbow flexor muscles within 4 weeks post-NBPI by incorporation of puromycin, a nucleoside analog, and by expression of major structural and contractile proteins by RNA-sequencing and Western blot. Protein degradation was similarly measured by K48-linkage specific polyubiquitin, an indicator of protein degradation by the proteasome pathway, and by expression of protein degradation markers by RNA-sequencing. Subsequently, to test the ability of proteasome inhibition to prevent contractures, bortezomib, a 20S proteasome inhibitor, was co-administrated with [Gly14]-Humanin G ([Gly14]-HN, to limit bortezomib toxicity) systemically for 4 weeks post-NBPI. Saline and [Gly14]-HN alone were administered separately as controls. Shoulder and elbow contractures were measured 4 weeks post-NBPI, and denervated and control elbow flexor muscles were assayed for 20S proteasome activity, volume and cross-sectional area (CSA) by microCT, and sarcomere length by DIC microscopy.</p> <p><strong>Results:&nbsp;</strong> NBPI did not reduce muscle protein synthesis, measured either by puromycin incorporation or by RNA and protein levels of all major structural and contractile proteins. However, NBPI increased protein degradation, as indicated by a doubling of K48-linkage specific polyubiquitin and increased expression of Trim63/MurF1, a driver of proteasome-mediated protein degradation. Bortezomib + [Gly14]-HN effectively prevented contractures following NBPI compared to saline and [Gly14]-HN alone (p&lt;0.001). Bortezomib blunted the denervation-induced increase in proteasome activity (p&lt;0.001), and rescued muscle growth in volume (p&lt;0.0001), CSA (p&lt;0.001), and sarcomere length (p=0.03).</p> <p><strong>Conclusion:</strong> Contractures following NBPI are associated with increased muscle protein degradation counteracting normal protein synthesis. Inhibition of the proteasome pathway of protein degradation improves growth of denervated muscle and prevents contractures following NBPI.</p> <p><strong>Significance:&nbsp;</strong> This study identifies a pathophysiologic mechanism of impaired muscle growth and contracture formation following neonatal brachial plexus injury, and demonstrates the first ever successful pharmacologic strategy to prevent these contractures by targeting a causative molecular mechanism.</p> Sia Nikolaou, Liangjun Hu, Roger Cornwall Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:08:20 -0700 POSNA 2019 Annual Meeting: Best Trauma Paper <p><strong>Purpose:</strong> One quality measure used by USNWR and other entities is time to treatment for isolated pediatric femoral shaft fracture. Hospitals that are able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department receive more points towards a better pediatric orthopedic ranking. Therefore, it is important to determine whether the 18 hour cut-off time to treatment of pediatric femur shaft fractures actually affects clinical outcomes. We hypothesize that there are no differences in outcomes and complication rates for patients who receive treatment within 18 hours compared to those who receive treatment after than 18 hours.<br><br><strong>Methods:</strong> A retrospective review was conducted to compare clinical outcomes of 174 pediatric patients (age &lt; 16) with isolated femur shaft fractures (Injury Severity Score = 9) from 1997 to 2017 at a single level I pediatric trauma center. The two groups compared were those receiving treatment within 18 hours of ED admission (N = 87) or greater than 18 hours (N = 87).<br><br><strong>Results:</strong> Patient, injury, and surgical characteristics were similar between the early and delayed treatment groups, including mean age (7.5 vs. 8.1 years) with almost identical numbers of children in age categories: 0-4 years, 4-9, 10-13, and 14-15 years. Patients who received treatment within 18 hours were more frequently immobilized post-operatively (70.1% versus 52.9%, p = 0.0362) and had a shorter median length of stay in the hospital (2 vs. 3 days, p = 0.0047). There were no statistical differences in any outcomes including surgical site infection, time to weight-bearing (48 days vs 53 days), time to complete radiologic fracture healing (259 vs. 232 days), range of motion, angular deformity, leg length discrepancy, loss of reduction, or persistent pain/tenderness.<br><br><strong>Conclusions:</strong> Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes, but may result in one additional day of hospitalization.<br><br><strong>Significance:</strong> It is important that national quality measures are supported by evidence based data so that as hospitals seek to meet quality standards, patient outcomes will also improve. Treatment of a femoral shaft fracture with 18 hours resulted in one day shorter length of stay but no long-term detectible differences in patient outcomes.</p> Todd Milbrandt, Anthony Stans, Jennifer Grauberger, William Shaughness, Noelle Larson Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 17:45:05 -0700 POSNA 2019 Annual Meeting: Best QSVI Paper <p><strong>Purpose: </strong>There is a paucity of data defining safe transport protocols for children treated with hip spica casting. No current restraint device has been tested using casted anthropomorphic test devices (ATDs). Our goal was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD.</p> <p><strong>Methods:</strong> Using an ATD simulating a 3-year-old child, dynamic crash sled tests simulating a frontal crash were performed in accordance with Federal Motor Vehicle Safety Standards 213 (FMVSS 213). Sensors within the ATD recorded: HIC<sub>36</sub> (Head Injury Criterion score; predictive of skull fracture), neck injury assessment (Nij), chest compression, chest acceleration, and pelvic injury assessment. Test crash video visual assessment was performed (Figures 1&amp;2). The ATD was casted in a double-leg spica. Five restraint devices were tested: seat designed for spica-casted children (Merrit Wallenberg), modified restraint harness (Modified EZ-On-Vest), commercially available booster seat (Britax Parkway SGL Booster), and two commercially available forward-facing car seats able to accommodate the casted ATD (Diono Radian R100, Graco Nautilus 65 LX). One test was performed for each restraint system. All tests were performed at 30 MPH on a deceleration sled.</p> <p><strong>Results:</strong> Although the presence of the cast increased many of the injury metrics measured, all 5 seats that were tested passed current FMVSS 213 federal guidelines for the head and chest. However, there were marked differences between the 5 restraint options (Figures 3-5). No single seat performed best in all metrics. Additionally, visual analysis of the video from the test crash of the EZ-On-Vest demonstrated that the face and upper extremities of the ATD are impacted during the crash. The ATD does not have a way to record injury to the extremities, thus this is not captured in the quantitative data.</p> <p><strong>Conclusions: </strong>Per the FMVSS 213 standard, these results suggest safe transport in the five evaluated restraint systems is possible with the child properly fitted and restrained. However, the Nautilus and Diono were found to have both the lowest HIC36 and chest acceleration values, suggesting casted children may not need specially designed seats. Additionally, review of the video of the EZ-On Vest appears to demonstrate that the vest may expose the casted child to additional facial and extremity injuries compared to systems that allow the child to sit upright.</p> <p><strong>Significance:</strong> Parents should not assume a restraint system is automatically appropriate for use with their child. While there were differences in the performances of the tested restraint systems, each child is unique and a trained healthcare provider should be consulted to ensure the child is properly restrained.</p> Jeffrey Peck, Angela Collins, Sean Caskey, Theresa Atkinson, Norman Walter, Patrick Atkinson Copyright (c) 2019 JPOSNA Wed, 06 Nov 2019 04:43:05 -0700 POSNA 2019 Annual Meeting: Best E-Poster <p><strong>Purpose:</strong> Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the proximal femoral epiphysis. Interestingly, even in milder cases of Perthes, the anterior epiphysis collapses most reliably rather than the more weight-bearing lateral quadrant. The purpose of this study is to investigate whether there is a vascular or microstructural predisposition for anterior femoral epiphyseal collapse in Legg-Calve-Perthes Disease.<br><br><strong>Methods:</strong> 32 cadaveric proximal femoral epiphyses from 17 subjects (age 4-14 years old) underwent microcomputed tomography at 10-micron resolution. Specimens were divided into anterior, posterior, medial, and lateral quadrants. Vascular channels entering near the posterolateral epiphyseal tubercle (from the medial femoral circumflex artery) and at the ligamentum teres footprint (from the ligamentum teres vessels) were identified by correlating surface topography with cross-sectional imaging. Each quadrant was then analyzed for four surrogate markers of trabecular bone strength: Bone Volume/Total Volume (BV/TV), Trabecular Thickness, Trabecular Separation, and Trabecular Number.</p> <p><strong>Results:</strong> One-way ANOVA revealed a significant difference between the quadrants in trabecular microstructure and vascular patterns (p&lt;0.001). The medial quadrant had the lowest BV/TV, trabecular number, and the greatest trabecular separation (p&lt;0.01 for each), consistent with the fact that the medial quadrant is the least weightbearing. However, there was no significant difference between the anterior and lateral quadrants for any of the four surrogate markers of bone strength. 32/32 (100%) specimens demonstrated vascular channels from the medial femoral circumflex artery penetrating the posterior aspect of the lateral quadrant. Ligamentum teres vascular channels were visualized in the medial epiphysis in 26/32 (81%) specimens overall and 11/16 (68%) subjects aged 4-8 years. Paired samples t test revealed that the posterior half of the epiphysis had significantly more vascular channels than the anterior half (8.7±4.0 vs 3.4±3.1 vascular channels, p&lt;0.001). Vascular channel mapping illustrated the predominance of vessels in the posterior half of the epiphysis with both the ligamentum teres (medial quadrant) and the medial femoral circumflex vessels (lateral quadrant) entering the epiphysis at the 4 and 8 o’clock positions, respectively.<br><br><strong>Conclusions:</strong> The lack of microstructural differences between the anterior and lateral quadrants, and the predominance of vascular channels in the posterior half of the epiphysis suggest that the anterior femoral epiphysis may be a relative vascular watershed region which predisposes it to collapse after the vascular insult of Legg-Calve-Perthes.<br><br><strong>Significance:</strong> This is the first study to utilize micro-computed tomography to examine trabecular microarchitecture and map vascular channels in the developing human femoral epiphysis.</p> William Morris, Raymond Liu, Elena Chen, Harry Kim Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 16:40:19 -0700 POSNA 2019 Annual Meeting: Best Poster <p><strong>Purpose: </strong>Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of remodeling via the distal radius physis present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures.</p> <p><strong>Methods: </strong>A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2006-2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling.</p> <p><strong>Results: </strong>36 patients with distal radius fractures with a mean age of 7.93 years (range 4 to 12 years) at time of injury were identified. The mean rate of remodeling from maximum angulation to final follow-up was 2.30°per month in the coronal plane. The median peak angulation in the coronal plane was 17°(range 12.4°to 30.4°). At final follow- up, the median coronal angulation was 3.35°(range 0.24°to 14.0°). At the 95% confidence level, remodeling rates ranged from 2.00°per month to 2.59°per month. The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 26.36 weeks and ranged from 10 weeks to 34.86 weeks.</p> <p><strong>Conclusion: </strong>Distal radius fractures have a large capacity to remodel in the coronal plane in the pediatric population. This remodeling occurs in a predictable and reliable fashion. These injuries should be expected to remodel at a rate of 2°per month. Repeat manipulation is not indicated in patients where the maximum coronal angulation is less than 24°, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year following fracture.</p> <p><strong>Significance: </strong>These findings provide a standard for acceptable coronal plane angulation, which should reduce treatment variability among orthopaedic surgeons and limit the number of surgical interventions that likely are not necessary given the distal radius’ ability to remodel.</p> Kyle Lynch, Teresa Cappello Copyright (c) 2019 JPOSNA Sun, 03 Nov 2019 16:08:07 -0700