Journal of the Pediatric Orthopaedic Society of North America <p><em><strong>JPOSNA</strong></em><strong>®</strong> (the <strong>Journal of the <a href="">Pediatric Orthopaedic Society of North America</a>)</strong> is an open access journal focusing on pediatric orthopaedic conditions, treatment, and technology.</p> <p><a href=""><img style="width: 100%; height: auto;" src="" alt="Pre-Course Supplement" width="1200" height="400" /></a></p> POSNA en-US Journal of the Pediatric Orthopaedic Society of North America 2768-2765 Editor's Note <p>In the early 1950s, the United States was mired in a highly emotional public health debate regarding the safety and efficacy of seatbelt use in automobiles. Post-World War II automobiles were outfitted with interiors that were not designed to protect passengers and, in many cases, could lead to severe injury. Many advocated for improvements in safety, yet others argued an infringement on personal rights, and disinformation was promoted to argue that seat belts were dangerous: “If a car burst into flames or if submerged, the driver would not be able to escape.” The <em>Wisconsin State Journal </em>wrote, “The value of seat belts had yet to be proved, especially in cases of keeping people from ‘being thrown out of the car.’”</p> <p>This is where research, medicine, and innovation helped to focus discussion and the financial implications that eventually led to meaningful safety improvements. Based upon research, the AMA and the American College of Surgeons, in 1954 and 1955, demanded that car manufacturers provide seatbelts. In 1959, Volvo engineer Nils Bohlin patented the three-point restraint which Volvo gave to all manufacturers—for <em>free</em>. Finally, in 1989, Transportation Secretary Elizabeth Dole made car companies decide between mandatory airbags and automatic restraints (expensive) or three-point restraints (cheaper). Thus, data informed society on the scope and scale of the problem. The discussion pivoted to a public health issue, and innovation led to options that those with economic interests became motivated to facilitate change.</p> <p>Today, our country is in a contentious debate over why firearms are the number one cause of pediatric mortality. From 1999 to 2017, 26,000 children died from firearms. Over that same time period, the Department of Defense reported 26,945 deaths in U.S. service members, of whom less than 20% died in combat.<sup>1</sup> While the above facts are indisputable, the reasons why and what to do about it are embroiled in a passionate national conversation. Each voice represents an agenda that is rooted in ideological, economic, and social perspectives that may not be based on good data. As the volume of the discussion increases, passion and bias tend to drown out what we know and what can be learned.</p> <p>Prior work has studied the role that medical organizations have done in response to pediatric mortality from firearms. In 2022, Lillvis published in the <em>Journal of Pediatric Surgery </em>that while there has been a dramatic increase in public statements by physician professional associations, the announcements have been reactionary as opposed to keeping gun violence against children continuously on their agenda. The authors conclude that “…the issue of gun violence…fits within the realm of their professional expertise and experiences, declaring that #ThisIsOurLane.”2</p> <p>What can pediatric orthopaedic surgeons and organizations such as POSNA and AAOS do? We can stay true to our missions of research, education, and quality care in order to promote optimal musculoskeletal health for all children. In the past, when an orthopaedic issue has been fully vetted, we have also provided informed advocacy. Examples include avoiding hip swaddling, guiding safe ATV use, and highlighting the risk of trampolines. While other organizations have focused on mortality, can we do similar work on the lifetime <em>morbidity </em>and the societal <em>cost </em>of musculoskeletal injury to children from firearms?</p> <p>In this edition of <em>JPOSNA</em><sup>®</sup>, Villegas and Whitaker present a thorough review of the management of pediatric firearm injuries, which will help us manage the current problem that we face. Can we do more than study optimal methods to treat these injuries and their complications and sequelae? What are some public health questions we can help answer through research?</p> <ol> <li>What are the annual numbers of pediatric orthopaedic firearm injuries in the U.S.?</li> <li>What are the annual numbers of pediatric orthopaedic firearm injuries in each state?</li> <li>What are the annual costs to the nation and the states to manage acute musculoskeletal firearm injuries? <br />a. How do these costs compare to federally funded research in firearm injury?</li> <li>What are the societal costs for a child to be permanently disabled from a musculoskeletal firearm injury?<br />a. While this question seems daunting, can we mirror methodology from a prior <em style="font-size: 0.875rem;">JPOSNA</em><sup>®</sup><span style="font-size: 0.875rem;"> study by Koenig et al. 2020? In this study, the authors quantified the lifetime </span><em style="font-size: 0.875rem;">Financial Impact of Surgical Care for Scoliosis, Developmental Hip Dysplasia, and Slipped Capital Femoral Epiphysis in Children.</em><sup>3</sup></li> <li>Do the number of injuries correlate with different legislation on gun safety?<br />a. We know that those states that mandate safer gun storage with child access prevention (CAP) laws have lower rates of suicide, unintentional, and overall firearm-related deaths.<sup>4-10</sup><span style="font-size: 0.875rem;"> Does more stringent gun storage legislation translate into decreased rates of musculoskeletal injury and the attendant acute cost and potential lifetime cost?</span></li> </ol> <p>With the above data and other approaches, we can help educate society on the impact of orthopaedic firearm injuries and where possible, inform strategies to prevent these injuries. Pediatric orthopaedists have the respect of our patients, families, and our society. Similar to our predecessors who framed automobile safety as a public health crisis, don’t we have a role in performing research and objectively presenting the data to society and policymakers?</p> <p><strong>References</strong></p> <ol> <li>American War and Military Operations Casualties: Lists and Statistics. Congressional Research Service. Available at: <a href=";rct=j&amp;q&amp;esrc=s&amp;source=web&amp;cd&amp;cad=rja&amp;uact=8&amp;ved=2ahUKEwi0wJSLyPD_AhX7lIkEHRl1DgYQFnoECBIQAQ&amp;url=https%3A%2F%2Fsgp"></a> <a href=";rct=j&amp;q&amp;esrc=s&amp;source=web&amp;cd&amp;cad=rja&amp;uact=8&amp;ved=2ahUKEwi0wJSLyPD_AhX7lIkEHRl1DgYQFnoECBIQAQ&amp;url=https%3A%2F%2Fsgp">url?sa=t&amp;rct=j&amp;q=&amp;esrc=s&amp;source=web&amp;cd=&amp;cad=rja&amp;uact=8&amp;ved=2ahUKEwi0wJSLyPD_AhX7lIkEHRl1DgYQFnoECBIQAQ&amp;url=https%3A%2F%2Fsgp.</a>org%2Fcrs%2Fnatsec%2FRL32492.pdf&amp;usg=AOvVaw20dqdEbLPMGb3truJZniyX&amp;opi=89978449.</li> <li>Lillvis D, White J, Cooper M, et al. An analysis of American physician professional statements about gun violence against children. <em>J Pediatr Surg</em>. 2022;57(1):130-134.</li> <li>Koenig L, Nguyen JT, Hamlett EG, et al. Financial impact of surgical care for scoliosis, developmental hip dysplasia, and slipped capital femoral epiphysis in children. <em>J Pediatr Orthop Soc N Am. </em>2020;2.</li> <li>Hamilton EC, Miller CC, Cox CS, et al. Variability of child access prevention laws and pediatric firearm injuries. <em>J Trauma Acute Care Surg. </em>2018;84(4):613e619.</li> <li>Azad HA, Monuteaux MC, Rees CA, et al. Child access prevention firearm laws and firearm fatalities among children aged 0 to 14 Years, 1991-2016. <em>JAMA Pediatr</em>. 2020;174(5):463e469.</li> <li>Anestis MD, Houtsma C. The association between gun ownership and statewide overall suicide rates. <em>Suicide Life Threat Behav</em>. 2018;48(2):204e217.</li> <li>Resnick S, Smith RN, Beard JH, et al. Firearm deaths in America: can we learn from 462,000 lives lost? <em>Ann Surg</em>. 2017;266(3):432e440.</li> <li>Anestis MD, Anestis JC, Butterworth SE. Handgun legislation and changes in statewide overall suicide rates. <em>Am J Public Health</em>. 2017;107(4):579e581.</li> <li>Ghiani M, Hawkins SS, Baum CF. Associations between gun laws and suicides. <em>Am J Epidemiol</em>. 2019;188(7):1254e1261.</li> <li>Madhavan S, Taylor JS, Chandler JM, et al. Firearm legislation stringency and firearm-related fatalities among children in the United States. <em>J Am Coll Surg</em>. 2019;229(2):150e157.</li> </ol> Ken Noonan Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-759 Message from the President Daniel J. Sucato Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-760 Management and Outcomes of Femur Fractures in Patients with Duchenne Muscular Dystrophy <p><strong>Background: </strong> Duchenne muscular dystrophy (DMD) is a severe, progressive X-linked recessive neuromuscular disorder characterized by muscle weakness and atrophy. Additionally, patients with DMD have significant reductions in bone mineral density compared to age-matched controls, which is exacerbated by concomitant steroid use. These findings dramatically increase fracture risk, which may irreparably decrease functional status. The aim of this case series is to examine outcomes of operative versus nonoperative management of femur fractures in this patient population.</p> <p><strong>Methods: </strong> An IRB-approved retrospective chart review was completed for patients with DMD treated at a single institution for a femur fracture between 2013-2022. Patients were excluded for incomplete documentation, treatment initiation at an outside hospital, or diagnosis of a different muscular dystrophy. Demographic variables, treatment information, functional status, and adverse events were collected for each patient. Descriptive statistics were used to summarize demographic and outcome variables.</p> <p><strong>Results:</strong> A total of 10 patients with 11 femur fractures were included for analysis. All patients were male with an average age of 12.7 years and clinical follow-up of 286 days. Five fractures in five patients underwent operative fixation (<strong>Group A</strong>) and six fractures in five patients underwent nonoperative management (<strong>Group B</strong>). In Group A, three patients were short-distance ambulators prior to injury, and all patients regained a similar functional status postoperatively. All three patients were treated with a locked intramedullary nail. One patient in Group B was a short-distance ambulator prior to injury, the remainder were nonambulatory; all patients in Group B were primary wheelchair users at final follow-up. There were no adverse events as a result of treatment in either group.</p> <p><strong>Conclusion:</strong> Nonoperative management with cast immobilization remains an acceptable option for nonambulatory patients and those with minimally-displaced fractures not amenable to surgical intervention. Surgical intervention is recommended for higher-functioning patients with the goal of restoring ambulatory status. Regardless of treatment modality, patients should receive aggressive physical therapy directed at early weight-bearing, range of motion, and mobilization to preserve strength, muscle mass, and mobility.</p> Christopher R. Gajewski Kevin Y. Chen Eric Chang Doug Levine Jennifer Wallace Valdes Rachel M. Thompson Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-664 Decreasing Radiation Exposure in the Treatment of Pediatric Long Bone Fractures Using a DXA Scan: A Proof of Concept <p><strong>Background:</strong> Fractures are typically evaluated and monitored using plain radiographs, but in the pediatric population the goal is always to reduce radiation exposure when possible. Dual energy x-ray absorptiometry (DEXA) is an imaging modality that uses less radiation. The evaluation of upper and lower extremity fractures in the pediatric population using DEXA imaging has not yet been studied.</p> <p><strong>Method:</strong> Radiographs of 19 patients treated for forearm or tibia fractures were compared to images taken with a DEXA machine. The angulation and translation of the fractures were measured twice each by two independent observers. Correlation of these values between plain radiographs and DEXA scans along with intra and inter-observer reliability was calculated.</p> <p><strong>Results:</strong> A total of 19 patients with a forearm or tibia fracture were enrolled in the study. Correlation with conventional radiographs for angulation was r=0.77, p&lt;0.001, while for translation it was r=0.76, p&lt;0.001. The mean difference between the methods was 0.5 degrees (range of -6.7 to 7.7) for angulation and 4% (range of -28% to 37%) for translation. For plain radiographs the inter-rater reliability was 0.90 (95% confidence interval of 0.84-0.93) for angulation and 0.89 (0.68-0.95) for translation. The inter-rater reliability for DEXA imaging was 0.77 (0.69-0.83) for angulation and 0.76(0.41-0.88) for translation.</p> <p><strong>Conclusion:</strong> Our study showed that DEXA imaging correlates well with plain radiographs when measuring angulation and translation of forearm and tibia fractures in the pediatric population. This study is a proof of concept that DEXA, a low-dose radiation alternative to plain radiographs, may be useful in the management of pediatric fractures.</p> Jared Nowell Ryan S. Murray Matthew E. Oetgen Benjamin D. Martin Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-564 Early Failure of Locking Compression Plates in Pediatric Proximal Femoral Fracture <p><strong>Background:</strong> Although proximal femoral locking compression plates (PF-LCP) have been used with increasing frequency in the fixation of proximal femoral fractures in the pediatric population, there is a lack of literature regarding their use. The purpose of this study was to examine the failure rates of PF-LCP fixation in comparison to other accepted fixation methods within a pediatric population.</p> <p><strong>Methods:</strong> Retrospective review identified consecutive children treated for proximal femoral fractures from September, 2008 to February, 2019, who had a minimum follow-up of 12 weeks. Patient charts and radiographs were reviewed, and demographic information was compiled. In the case of failures, timing and method of failure were documented.</p> <p><strong>Results: </strong>Sixty-four proximal femoral fractures (61 children) were studied. The average age at the time of presentation was 10.4 years. Twenty-six fractures were treated with PF-LCPs and 38 with other fixation methods (compression hip screws, rigid locked intramedullary nailing, cannulated screws, or a combination of hip screw side plate and intramedullary nailing). Failure occurred in four of the 26 fractures treated with locking compression plating (15.4%), compared to none of the 38 treated with other fixation types (p&lt;0.05).</p> <p><strong>Conclusions: </strong>This study demonstrates an increased risk of failure in proximal femoral fractures treated with locking compression plates (12.9%) compared to 0% other fixation methods (no failures). As a result of this study, we no longer use locked plating systems for pediatric femoral neck fractures at our institution.</p> Seth R. Cope Matthew Wideman Benjamin W. Sheffer Jeffrey R. Sawyer James H. Beaty William C. Warner Jr. David D. Spence Derek M. Kelly Copyright (c) 2022 JPOSNA® 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-436 Validation of a Novel Radiographic View for Evaluating Proximal Humerus Fractures: The Clear View <p><strong>Background: </strong>Orthogonal radiographs of the proximal humerus are challenging to obtain because the patient’s body mass can impede a quality lateral view and positioning of the shoulder can cause fracture displacement and patient discomfort. We describe a novel radiograph, the clear view (CL), taken 90° to the scapular Y (SY), developed with the goal to minimize pain and reduce radiation exposure. Evaluate the ability to accurately evaluate proximal humerus fracture displacement utilizing the CL in comparison to the standard available x-rays and assess pain score when obtaining the CL.</p> <p><strong>Methods: </strong>Eleven independent observers at different levels of experience evaluated angulation and translation of three proximal humerus fractures: two cadaveric fractures and a third fracture in a 15-year-old to determine intra-observer correlation (ICC). Each fracture underwent the traditional radiographic series of anteroposterior (AP) in internal rotation (IR), AP in external rotation (ER), true axillary lateral (AX), SY, and transthoracic lateral (TRANS) plus computed tomography (CT). CL was obtained on the two cadaver fractures. Pain scores based on the Wong-Baker FACES Pain Scale were assessed for individual radiographic projections in thirteen patients with proximal humerus fractures.</p> <p><strong>Results: </strong>ICC was &gt;0.6 for all measures. True fracture angulation was underestimated a majority (&gt;75%) of the time in all radiographic views, TRANS (p&lt;0.001) and AX (p&lt;0.049) views had the least amount of error. Moreover, measures of translation were both underestimated and overestimated in all views, but the most accurate measures of translation were obtained with IR, ER, and CL views. Pain scores ranged from 0-1.2 when the CL was obtained.</p> <p><strong>Conclusions: </strong>Our study demonstrates that proximal humerus fracture angulation is often underestimated and translation is difficult to measure regardless of view utilized. However, the clear view, when combined with the AP view offers an orthogonal, reproducible, valid measure of displacement and causes minimal patient discomfort. </p> Liane Chun Amirhossein Misaghi Krishna R. Cidambi Natalie P. McNeil Christine L. Farnsworth Eric W. Edmonds Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-633 Opioid Prescription Trends for Isolated Diaphyseal Femur Fractures in Pediatric Patients <p><strong>Purpose: </strong>Despite the ongoing opioid epidemic, there is a lack of research on narcotic prescribing in the pediatric orthopaedic population. The Pediatric Orthopaedic Society of North America (POSNA) therefore published a survey on pain management to provide recommendations for opioid dosing. The goal of this study was to characterize opioid prescribing patterns for pediatric femur fractures in the context of the opioid epidemic and emerging national studies/guidelines. </p> <p><strong>Methods: </strong>A retrospective review of 128 pediatric patients (age &lt; 16) with isolated diaphyseal femur fractures was conducted between 2003-2019 at a level I pediatric trauma center. Comparison groups included before distribution of the POSNA survey (pre-POSNA = 01/01/2016 or earlier, N = 85) and after the survey (post-POSNA, N = 43).</p> <p><strong>Results: </strong>Median total hospital post-operative opioids prescribed was 27.2 morphine milligram equivalents (MME). The two groups differed in: age (pre-POSNA = 9.0 years, post-POSNA =3.7 years, P =0.0381), hospital length of stay (LOS) (pre-POSNA = 2 days, post-POSNA =1 day, P &lt; 0.0001), and procedural incision required for fracture reduction (pre-POSNA = 28.3%, post-POSNA = 58.1%, P = 0.0019). Adjusted post-operative opioid dosing was significantly lower post-POSNA (median reduction of 18.351 MME per year, P = 0.0408).</p> <p><strong>Conclusions: </strong>The period following the POSNA survey was associated with a significant decline in post-operative narcotic prescriptions for pediatric femur fractures. The timing of the survey likely represents an increased concern for pediatric opioid use and a shift in clinical practice. Further work is needed to optimize injury and patient-specific narcotic prescribing.</p> Jennifer Grauberger Dirk Larson Anthony A. Stans William J. Shaughnessy A. Noelle Larson Todd A. Milbrandt Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-663 A Quality Improvement Initiative to Reduce Opioid Prescriptions Following Surgical Treatment of Supracondylar Humerus Fractures in Children <p><strong>Background: </strong>Opioid abuse and overdose are in epidemic range in the United States and medical prescriptions, including those for postoperative analgesia, are a large contributing source to this misuse. Our quality improvement initiative aimed to reduce the opioid prescribing of pediatric orthopaedic surgeons in the postoperative setting. The aim was to decrease the percentage of children with surgically treated supracondylar humerus (SCH) fractures who are prescribed opioid medications at discharge from a baseline of 40% to 10% within 6 months.</p> <p><strong>Setting/Local Problem: </strong>The study took place at an urban level 1 trauma center at a children’s hospital. The orthopaedic team completed closed reduction and percutaneous pinning for SCH fractures over a 14-month baseline period. Forty percent of these patients were discharged with an opioid prescription. After assessing baseline prescription rates, a multidisciplinary team of health professionals developed a key driver diagram.</p> <p><strong>Interventions: </strong>Primary interventions included orthopedic department-wide pain management education, reporting of prescription rates during monthly conferences, and provider-specific feedback. The primary measure was the percentage of patients prescribed opioids upon discharge following closed reduction and percutaneous pinning of Type II and III SCH fractures. As a balancing measure, we tracked the use of a 24-hour nurse triage line for pain-related follow-up in the intervention period. We used statistical process control to examine changes in measures over time.</p> <p><strong>Results: </strong>The percentage of patients receiving opioid prescriptions upon discharge following surgically treated SCH fractures decreased from 40% to 8% over 5 months and sustained for an additional 16 months.</p> <p><strong>Conclusions: </strong>Through provider education, feedback, and regular reporting, we decreased the number of pediatric patients with surgically treated SCH fractures that were discharged with any opioid prescription by 80% over 5 months while ensuring clinically adequate pain control.</p> Garrett E. Rupp Joanna L. Langner Claire E. Manhard Amy Bryl Vidyadhar V. Upasani Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-696 Best Practices for Orthopaedic Treatment of Pediatric Gunshot Injuries <p style="font-weight: 400;">Gun injuries are now the leading cause of death in children. This arises from increased access to guns across the U.S. More firearm injuries are presenting to emergency departments and non-trauma centers. We identified 52,414 children with firearm injuries, including 19,583 extremities. Most were treated with antibiotics, bedside I&amp;D, and non-operative stabilization for simple wounds of &lt;1 cm without contamination and stable fracture patterns. More complex injuries with larger soft tissue defects usually caused by high-velocity weapons with contamination, bone loss, operative fracture patterns, intraarticular projectiles, vascular injuries, compartment syndromes, and nerve injuries warrant further treatment in the operating room and IV antibiotics. Only 28% of nerve injuries regained function. Loss to follow-up was high (43%). Growth arrest and lead toxicity are long-term sequelae that must be monitored, especially given the decrease in acceptable blood lead levels to &lt;3.5 mg/dL by the CDC in 2020. Evaluation of the child’s environment and access to guns and education is important for preventing future injuries on an individual level, however, research and legislation are needed to decrease this epidemic of gun violence injuring and killing children today.</p> Alex Villegas Amanda Whitaker Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-06-13 2023-06-13 5 3 10.55275/JPOSNA-2023-683 Minimally Invasive Methods for Adolescent Intraarticular Distal Humerus Fractures with an Intact Column <p>Intraarticular distal humerus fractures occur in adolescents and represent a unique morphology that is amenable to different surgical techniques than distal humerus fractures in adults or younger children, especially when one column remains intact. Despite articular involvement, a minimally invasive approach utilizing the intact periosteum and opposing intact column of bone can often achieve successful reduction and fixation. Here, we present an operative technique for these fractures along with four cases successfully treated with percutaneous lag screws.</p> Austin J. Broussard Julia S. Sanders William Accousti R. Carter Clement Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-716 The Reliability of Measurements for Tibial Torsion: A Comparison of CT, MRI, Biplanar Radiography, and 3D Reconstructions With and Without Standardized Measurement Training <p><strong>Background: </strong>Accurate and reliable assessment of tibial torsional is critical for the identification and treatment of tibial rotation malalignment, however the ideal rotational measurement modality and technique are controversial. This study compares rotational measurements between computed tomography (CT), magnetic resonance imaging (MRI), biplanar erect radiograph (BER) reconstructions and three-dimensional (3D) reconstructed CT before and after standardized training to evaluate measurement reliability.</p> <p><strong>Methods: </strong>Eight adult cadaveric specimens underwent CT, MRI, and BER imaging. Tibial torsion was measured by three independent observers (one resident and two experienced orthopedic surgeons) both before and after standardized measurement instruction. Reliability for inter-observer measurement was evaluated using the Intraclass Correlation Coefficient (ICC). Measurement values for CT, MRI, and BER reconstructions were compared to 3D CT reconstructions analyzed using custom software to align and measure tibial torsion (used as the reference standard).</p> <p><strong>Results: </strong>Before training, there was poor inter-observer reliability for CT (ICC=0.492, p=0.014) and moderate inter-observer reliability for MRI (ICC=0.633, p=0.002). There was no inter-method reliability between 3D CT and MRI for 2 of the 3 surgeons, and moderate to good reliability between 3D CT and CT. After training, the inter-observer reliability for CT improved to 0.536 and the inter-observer reliability for MRI improved to 0.701. The BER measurements (no observer involvement) had moderate reliability compared to the 3D CT reconstructions (ICC=0.69, p = 0.026). Measurement error was 4˚ for CT pre- training and 7˚ post- training), and 7˚ for MRI pre-training and 8˚ post-training.</p> <p><strong>Conclusions: </strong>A standardized training regimen for MRI measurements improved both inter-observer and intra-observer reliability. Inter-method reliability between CT, MRI and BER compared to reference 3D CT reconstructions demonstrated that all imaging modalities are a valid means to measure tibial rotation, but that they differ in reliability from moderate to good. When assessing tibial torsional deformities, it is important to consider these variations from true rotation and feel comfortable using them for pre-operative planning purposes.</p> Eric W. Edmonds Kevin C. Parvaresh Mason J. Price Christine L. Farnsworth James D. Bomar Jessica L. Hughes Vidyadhar V. Upasani Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-661 The Evolution of Guided Growth for Lower Extremity Angular Correction <p style="font-weight: 400;">Guided growth is one of the most utilized surgical techniques for managing limb deformity in skeletally immature patients. Our understanding of this technique and the types of implants utilized have evolved over the past century. Many of the known risks of this surgery, such as over-correction, under-correction, and rebound deformity, are the same risks initially described when hemiephysiodesis and guided growth techniques were first published. The staple has been a powerful tool for deformity correction but its high rates of implant backout and breakage as well as unpredictable rates of premature physeal closure after removal have contributed to this implant being used less frequently today. Many studies on percutaneous transepiphyseal screws (PETS) are promising but have little follow-up so the risks of this technique with regard to premature physeal closure are not well understood. Tension band plating is currently the most utilized method. However, in specific patient subgroups, the perioperative complication and failure of correction rates are high. Despite the abundance of literature on these techniques, our understanding of guided growth is still quite limited as most studies are small and do not follow patients to skeletal maturity. Guided growth surgery also can restore the mechanical axis of the limb while leaving patients with significant residual diaphyseal or peri-articular deformity and the implications of these secondary deformities have not been studied.</p> Elizabeth W. Hubbard Alexander Cherkashin Mikhail Samchukov David Podeszwa Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-738 Identifying Risk Factors for Appointment No-Shows in a Pediatric Orthopaedic Surgery Clinic <p><strong>Background:</strong> Appointment non-adherence in pediatric orthopaedic clinics negatively affects patient outcomes. While previous studies have examined risk factors for missed appointments, there is a lack of such research in pediatric orthopaedics. This study tests the hypothesis that pediatric orthopaedic patients with greater socioeconomic risk are more likely to miss appointments. Our objective<strong> </strong>is to identify risk factors contributing to missed appointments.</p> <p><strong>Methods:</strong> A retrospective chart review was conducted of all visits in an outpatient pediatric orthopaedic clinic and affiliated Midwest level 1 academic hospital in 2019. Possible covariates with appointment attendance collected included sociodemographic information such as age, gender (male/female), race/ethnicity (non-Hispanic White, Black, Hispanic/Latinx, Other), and insurance (Commercial, Medicaid, Medicaid HMO, Other). The main study outcome was appointment status, defined as either “No-Show” or “Attended/Completed.” Using census data, the Area Deprivation Index (ADI) was determined for a matched case (“No-Show”) control sample to quantify socioeconomic risk. Factors associated with appointment non-adherence were analyzed with a logistic regression model.</p> <p><strong>Results: </strong>Out of 10,078 total encounters included in the study, there was a no-show rate of 6.61%. Significant predictors of “No-Show” included race (p&lt;0.001), insurance type (p&lt;0.001), and lag days between appointment scheduling and completion (p&lt;0.001). In a matched case-control sub-study, ADI was positively associated with increased odds of “No-Show” (p&lt;0.001), making this model unique from other studies. </p> <p><strong>Conclusions: </strong>This data informs pediatric orthopaedic providers of risk factors for appointment non-adherence in order to individualize patient care plans based on specific socioeconomic needs. Efforts to improve appointment adherence may reduce the rate of poor health outcomes and health disparities in underserved areas. Next steps include qualitative assessments to articulate the experience of families who miss appointments to develop a greater standard for more accessible patient-centered care.</p> <p> </p> Meghan Malloy Sergey Tarima Bethany Canales David Nelson Jessica Hanley Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-695 Differentiating Between Septic Arthritis and Lyme Arthritis in the Pediatric Population <p>Septic arthritis and Lyme arthritis are two conditions that can present with similar symptoms, making it challenging to differentiate between them in a clinical setting. While septic arthritis often requires immediate surgical intervention, Lyme arthritis can often be managed effectively with antibiotic therapy alone. However, given the dangerous nature of untreated septic arthritis, accurate diagnosis and timely intervention is crucial in managing the condition, especially in the pediatric population. Efforts to distinguish between the two conditions include the use of laboratory tests, history &amp; physical exam findings, and MRI imaging. The authors aim to explore the causes, presentation, and treatment of septic versus Lyme arthritis, as well as to provide a summary of the evolving research in this area and propose an algorithm that can aid in diagnosis. By synthesizing the proposed algorithm in diagnosis, clinicians will be better equipped to manage septic versus Lyme arthritis effectively while avoiding invasive procedures such as joint aspiration.</p> Carlos D. Ortiz James Barsi Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-706 Z-plasties for the Pediatric Orthopaedic Surgeon <p>Z-plasty refers to a local soft-tissue transposition using interdigitating triangular flaps and is a simple but powerful surgical technique to transpose skin, lengthen scars, and shift topography. There are a host of applications of this technique within pediatric orthopaedics, given the spectrum of traumatic, post-traumatic, and congenital differences affecting the growing child. The purpose of this Master’s Surgical Technique supplement is to describe the principles and common applications of z-plasties in pediatric orthopaedic surgery.</p> Donald S. Bae Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-700 “A Little Skin in the Game”: Full Thickness Skin Grafting in Pediatric Orthopaedic Surgery <p>Congenital orthopaedic anomalies and acquired pediatric wounds of the extremities frequently require reconstruction of the soft tissue envelope. In many of these circumstances, full-thickness skin grafting (FTSG) is a reliable and appropriate reconstructive option. However, FTSG harvest is rarely discussed in the orthopaedic literature. We present a reliable and reproducible method of full-thickness skin grafting that is easily performed. In this technique, we harvest a full-thickness skin graft from the lower abdomen using a symmetric transverse midline suprapubic incision (i.e., Pfannenstiel incision). This donor site allows for abundant skin graft harvest while providing a concealed location and the potential for additional graft harvest. Finally, we discuss the critical importance of postoperative recipient site dressings to optimize skin graft take.</p> Pradeep K. Attaluri Ellen C. Shaffrey Peter J. Wirth Natalie Gaio Michael L. Bentz Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-744 Dr. Robert Bruce Salter: Memories from His Mentees <p>An argument could be made that the most recognized name in the history of pediatric orthopaedics belongs to Dr. Robert Salter. Every medical student in the last 50 years has at least heard of his classification of growth plate injuries and most have been tested on it. His innovations and contributions to pediatric orthopaedics are numerous and have stood the test of time. In 2020, the <em>Journal of Orthopaedics</em> listed the most impactful pediatric orthopaedic literature, and Dr. Salter’s name is cited in 56 of the top 100 referenced papers.</p> <p>As time passes, the name and the impact made remain. Yet who was this man? What made him a legend and such an impactful figure? How did he educate, nurture, and raise the grandparents of our current pediatric orthopaedic family? The editorial staff is indebted to Drs. Heather Kong, Cheryl Lawing, and Sarah B. Nossov, from the POSNA History and Archives Committee, and to friends and colleagues Drs. Baxter Willis, George Thompson, and Peter Armstrong for shedding light on this remarkable man.</p> Baxter Willis George Thompson Peter Armstrong Heather Kong Cheryl Lawing Sarah B. Nossov POSNA History & Archives Committee Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-746 Variations in Duration of Clinical Follow-up After Spinal Fusion for Adolescent Idiopathic Scoliosis: A Survey of POSNA and SRS Membership <p><strong>Background: </strong>There are currently no evidence-based guidelines addressing the duration of follow-up after spinal fusion. Despite the safety and efficacy of posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS), long-term complications exist, including infection, pseudoarthrosis, adjacent segment disease, deformity progression, persistent pain, and junctional deformities. The objective of this study was to describe practice variation existing among surgeons regarding duration of follow-up after surgical treatment of AIS.</p> <p><strong>Methods: </strong>An anonymous online survey was created and subsequently distributed to members of POSNA and SRS to assess practice demographics and surgeon opinions surrounding long-term surveillance following surgery for AIS. Only surgeons who treated at least 5 operative AIS cases within the past year were included. Descriptive statistics and comparative sub-analyses are presented.</p> <p><strong>Results: </strong>Forty-nine participants met inclusion criteria. Respondents were mainly Pediatric Orthopaedic Surgeons (92%) in practice for 21-50 years (49%) who performed approximately 21-50 operative AIS cases per year (49%). 48% of providers had an age limit in their practice and 52% regularly followed operative AIS patients over 18 years of age. 62% of surgeons followed operative AIS patients for 2-5 years post-operatively whereas only 4% followed for more than 10 years. The most cited factors impacting follow-up recommendations were junctional deformities, adjacent segment disease, and symptomatic implants. There were no significant associations between years in practice, operative volume and, for long-term follow-up after routine operative AIS cases.</p> <p><strong>Conclusions: </strong>Significant variability in long-term follow-up after PSF for AIS exists. Although most patients are clinically followed for 2 years after surgery, only a small percentage of providers follow AIS patients for more than 10 years post-operatively. Numerous AIS revisions occur more than 5 years after the index surgery. Further investigations to determine the benefits of long-term surveillance following PSF for AIS should be conducted.</p> Taylor R. Johnson Nicole A. Segovia Xochitl Bryson Meghan Imrie John Vorhies Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-645 An Effective and Safe Surgical Technique for Salvage of Postoperative Proximal Junctional Failure in Pediatric Patients—A Case Series <p><strong>Background:</strong> Proximal junctional failure (PJF) is a known complication following posterior spinal fusion surgery and can be defined simply as proximal junctional kyphosis that requires surgical revision of the proximal instrumentation. PJF can be associated with pain, decreased neurologic function, infection, and increased morbidity. There is little literature on this topic in children and especially on specific surgical techniques for revision surgery.</p> <p><strong>Methods:</strong> The revision technique involves extending the spine instrumentation proximally with paired sets of sublaminar bands used as anchors. Posterior osteotomies are typically required at the level of the kyphosis. The bands are gradually and sequentially tightened, bringing the spine into a corrected sagittal position. Patients who underwent this procedure and had at least 1 year of follow-up were identified. Demographic and clinical data, as well as plain radiographic and CT sagittal spine parameters, were analyzed before the surgery and at the most recent follow-up.</p> <p><strong>Results:</strong> Eight children, average age 14 years, 10 months, were included in the study with an average follow-up time of 31 months. Revision surgery occurred approximately 3 years following the initial surgery. There was 20 degrees (ranging from an increase of 18° to a decrease of 46 degrees) mean kyphotic angle correction at the site of the failure and 16 degrees (ranging from an increase of 24 degrees to a decrease of 78 degrees) mean cervical lordosis correction, using an average of 6 sublaminar bands. Before revision, all patients reported neck/upper back pain, with upper rod prominence. At the most recent post-revision visit, pain was markedly reduced, and rod prominence had resolved. One patient reported increased satisfaction with appearance, and another noted that maintaining horizontal gaze was easier.</p> <p><strong>Conclusion:</strong> Children who received this surgical technique for their PJF experienced resolution of pain and upper rod prominence and improved cervical spine sagittal radiographic parameters that was maintained at least 1 year after revision surgery.</p> Mason A. Fawcett Richard M. Schwend Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-560 Factors Associated with Presentation of Severe Adolescent Idiopathic Scoliosis <p><strong>Background: </strong>Adolescent idiopathic scoliosis (AIS) is a common referral to pediatric orthopaedic surgeons. Timely treatment with appropriate bracing decreases the risk of curve progression and need for surgical intervention. Despite pediatrician screening, patients still present to orthopaedic surgeons with curve magnitudes too significant for appropriate nonoperative bracing.</p> <p><strong>Methods:</strong> This retrospective cross-sectional study included patients aged 10 to 18 years diagnosed with AIS between 2011-2021 at a major metropolitan tertiary care center. Patients were excluded if initial radiographs were obtained more than 1 week after clinical diagnosis. Scoliosis severity was classified based on initial radiographs. Sociodemographic factors were recorded, including patient addresses, which were cross-referenced with the Child Opportunity Index (COI) database, which analyzes the quality of resources in a geographic area.</p> <p><strong>Results: </strong>Gender, health insurance provider, race/ethnicity, and COI were all found to have a statistically significant relationship with CA and age at initial presentation. The odds of presenting with severe (versus mild and moderate) scoliosis was 2.3 times higher for patients who identified as black/African American compared to those who identified as white. Additionally, the odds of initially presenting with severe scoliosis were almost 40% higher in females compared to males. Furthermore, each stepwise increase in COI was associated with a 17%-19% decrease in odds of presenting with severe scoliosis, depending on standardization.</p> <p><strong>Conclusions:</strong> There are sociodemographic disparities in the identification and initiation of treatment for AIS. Specifically, the odds of presenting with severe scoliosis are increased in patients who identify as black/African American or female and/or come from areas with lower access to resources (as defined by COI). Appropriate and timely referral to a pediatric orthopaedic surgeon for AIS treatment thus requires 1) educating primary care providers, pediatricians, and scoliosis screeners on how to appropriately identify scoliosis and the risks associated with late identification/referral and 2) public health initiatives to address access to care for patients at risk for late scoliosis identification.</p> Ian P. Erkkila Christopher A. Reynolds Joshua P. Weissman Oscar P. Levine Hunter Aronson Justin M. Knoll Jill E. Larson Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-651 Retrospective Review of 181 Patients with Pathologic Vertebral Compression Fractures <p><strong>Background: </strong>Compression fractures are often associated with lower energy trauma and may occur in the setting of abnormal bone health associated with genetic disorders and endocrine disorders, neoplastic disease, infection, and inflammatory disorders. There is no significant series in the literature describing the prevalence or etiology of pathologic pediatric compression fractures.</p> <p><strong>Methods: </strong>IRB approved retrospective study was performed at a tertiary children’s hospital from 2012-2022. Patients &lt;18 years old diagnosed with atraumatic vertebral compression fractures were included and reviewed for demographics, underlying diagnosis/comorbidity, presentation, mobility, deformities, imaging data, treatments, and outcomes.&nbsp;&nbsp;</p> <p><strong>Results: </strong>181 patients (54% Male) were included with mean age 14.17 years and follow up of 20 months. A compression fracture was the presenting symptom of an underlying diagnosis in 32% of patients. Primary osteoporosis was the cause in 15%, and secondary osteoporosis was in 65% of patients; primarily due to immunosuppressants (46%) and ALL (10%). Primary lesions were the etiology in 20% of patients. There was a median of 3 fractures per patient, mostly of the midthoracic (82%) and thoracolumbar spine (51%). Radiographs revealed wedge fractures in 82% and vertebra plana in 11%. Patients were managed with careful observation or bracing (78%) and only 6% received an operation. By last follow-up, more patients developed scoliosis and were wheelchair bound. Overall, there was a 16% mortality rate which was mostly associated with cancer.&nbsp;</p> <p><strong>Conclusion</strong>: About 32% of patients presented with a compression fracture as the presenting symptom of an underlying disease. Pathologic vertebral compression fractures in children frequently occurred due to immunosuppressants, ALL, and metastatic disease. The fractures are often wedge or non-structural in the thoracolumbar and mid-thoracic regions of the spine. MRI’s may be useful for distinguishing between benign fractures and malignancy. Most children were treated by observation, but bracing for kyphosis was often necessary.</p> Tristen N. Taylor Callie S. Bridges Lauren E. Pupa Beatrice A. Morrow Brian G. Smith Nicole I. Montgomery Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-697 Proximal Femoral Growth Alterations Can Be Seen Prior to Treatment of Developmental Dysplasia of the Hip: A Multicenter Cohort Study <p><strong>Background:</strong> Avascular necrosis (AVN), better considered proximal femoral growth disturbance (PFGD), following treatment for developmental dysplasia of the hip (DDH) remains poorly defined. In addition to limited reliability, it has been our experience that some radiographic features attributed to AVN/PFGD may be present prior to surgery. Our purpose was to determine the baseline prevalence of radiographic features suggestive of PFGD in a diverse population with surgically-treated DDH.</p> <p><strong>Methods: </strong>The prospectively collected database for an international multicenter study group was retrospectively queried for patients undergoing surgery for DDH with minimum one-year radiographic and clinical follow-up. <em>Preoperative</em> radiographs were evaluated for findings typically used to define PFGD at follow-up. Development of actual AVN/PFGD was determined by consensus review of follow-up radiographs by three experts separate from this study.</p> <p><strong>Results: </strong>145 patients were evaluated, with median preoperative age of 16.8 months (IQR:10.7-25.60). The proportion of patients with initial IHDI grades of 2, 3, or 4 was 18%, 32%, and 50%, respectively. Prior to surgery, 20 hips (14%) had a heterogenous or “fragmented” epiphysis. Eight of the 145 epiphyses (6%) were significantly ellipsoid in shape. Depending on the definition, between 5-10% of hips had a wider neck at baseline compared to the contralateral, normal hip.&nbsp; At final follow-up, 42% of the hips were determined to have PFGD based on consensus review. Of all the patients that were considered to have PFGD at follow-up, 59% of patients had one feature of PFGD at baseline, and 20% had two or more.</p> <p><strong>Conclusions: </strong>The current study suggests that several factors used to define the development of PFGD following DDH surgery may be present prior to surgical intervention.&nbsp; Our data demonstrates that 20% of the patients who develop AVN have at least two markers of PFGD, per Salter criteria, prior to receiving any treatment. This suggests that some of these hips may not be morphologically “normal” at baseline and adds to the mounting body of evidence about the limitations of the Salter classification for AVN.</p> Patrick England Emily Schaeffer Charles Price Kishore Mulpuri Global Hip Dysplasia Registry (GHDR) Wudbhav N. Sankar Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-669 Management of Atypical Slipped Capital Femoral Epiphysis <p>Atypical slipped capital femoral epiphyseal (SCFE) is associated with endocrine or metabolic disorders and radiation therapy. In this review, we discuss the clinical presentation for endocrinopathies, such as hyperparathyroidism, hypothyroidism, and growth hormone deficiency as well as renal osteodystrophy, radiation-induced, and valgus SCFE, with pertinent case examples. Routine laboratory screening of all patients with SCFE is likely not cost-effective. Patients with atypical SCFE are often short in stature, underweight, and present either older or younger than the typical age range (10-16 years old) of idiopathic SCFE. Patient’s fitting these criteria should undergo an endocrine workup. While uncommon, prompt recognition of atypical SCFE is crucial as coordinated care with pediatric subspecialists is necessary. In situ fixation with cannulated screws is the most common fixation method and bilateral fixation is recommended.</p> Amelia M. Lindgren Alexander M. Lieber Suken A. Shah Mihir M. Thacker Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-727 How Reliable is a J-sign Severity Scale When Assessing Lateral Patellar Instability? <p><strong>Background: </strong>Patellar instability is a common cause of anterior knee pain and can limit function and sports participation. To help assess patellar instability, the clinical J-sign test consists of observing the patella translate laterally in the shape of an inverted J over the anterolateral femur proximal to the trochlear groove during active knee extension. Only positive or negative categorization of the J-sign test has typically been used without rating the severity. The purpose of this study was to assess the inter- and intra-observer reliability of a proposed grading/severity scale of the J-sign test.</p> <p><strong>Methods: </strong>A scale for J-sign severity was developed as follows: grade 0: ≤1 quadrant of translation; grade 1: &gt;1quadrant of translation; grade 2: &gt;2 quadrants of translation; grade 3: complete patellofemoral dislocation; grade 4: unable to complete J-sign due to pain or apprehension. This retrospective cross-sectional study assessed J-sign ratings (0 to 4) from videos of patients undergoing evaluation for patellar instability. Six healthcare professionals rated the severity of the J-sign using the proposed scale, two different times, for all knees presented in random order. Inter- and intra-observer reliability were calculated using a Fleiss Kappa, k.</p> <p><strong>Results: </strong>Forty-four patients (87 knees) ages 10-18 were included in this study. Both knees were rated, including unaffected knees to serve as a control. The proposed standardized grading scale for the J-sign had fair agreement for inter-observer reliability, k = 0.31, and moderate agreement for intra-observer reliability, k = 0.58.</p> <p><strong>Conclusion: </strong>The proposed scale for determining J-sign severity yielded fair inter-observer reliability moderate intra-observer reliability, similar to the Kappa scores evaluating only the presence or absence of the J-sign. Further study into developing a standardized scale for J-sign severity grading might improve clinical descriptors of the test, and expand on other factors including clarity of knee extension ability, video standardization, and training materials.</p> Oksana Klimenko Ted C. Sousa Ryan Baker Jacob Carl Shelley Mader Kristopher Holden Mark L. McMulkin Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-630 Reviewer Profile <p>The goal of the&nbsp;<em>JPOSNA®</em>&nbsp;Reviewer Profile Series is to periodically recognize an outstanding member of our volunteer&nbsp;<em>JPOSNA®</em>&nbsp;peer reviewer board. We aim to highlight the exceptional work these individuals do for our Journal, without whom&nbsp;<em>JPOSNA®</em> would not be possible.</p> Laura Bellaire Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-740 Presidential Address <p>Good morning. It gives me great pleasure to stand here before you as the 39<sup>th</sup> President of POSNA. POSNA is a tremendous, all-volunteer organization with many amazing things happening. In the next few minutes, I would like to share with you some of the highlights of the past year. The theme I chose for my year after Min Kocher’s, “Back on Our Feet,” was “Lean and Meaningful.” The goal of “Lean and Meaningful” was to critically assess the structure of POSNA to reduce complexity and increase efficiency in the post-COVID environment, keeping the things that were working well and leaving behind things that were not so we could make room for new opportunities and growth. </p> <p>With over 1500 members, POSNA is a growing and thriving organization. IPOS® and our Annual Meeting in Nashville had record attendance. <em>JPOSNA</em><em>®</em>, our journal, was made independent of Wolters Kluwer and is growing as well. As we looked for new publishing partnerships, <em>JPOSNA</em><em>®</em>, at one point, was called “an unproven start-up” and a “very exciting young journal” by the publishing industry. This year we were able to secure over $350,000 in research grants. Led by our JEDI Committee, our organization continues to place emphasis on diversity, equity, and inclusion.</p> <p>I would like to thank the 2020-2023 Board of Directors for all of its hard work (Figure 1). This is an energetic, highly engaged board that really made some tough decisions to drive this organization forward and make it better. I would like to thank the committee chairs and all the members of the committees. This is an all-volunteer organization, and much of the committee work happens on nights and during weekends. We are grateful to all of you for that.</p> <p>When I became president in May of 2022, in Vancouver, there were six areas that I wanted POSNA to focus on, including technology, workforce, strategic planning, committee structure, finance, and industry relations, while still maintaining our cultural values and diversity. I would like to take a minute to comment on each of these goals.</p> <p><strong>Technology</strong>: I truly believe that technology is the most important aspect for POSNA today. Technology drives everything we do, from our robust educational platforms to our journal, meetings, and podcasts. Our podcasts have been tremendously successful and have been an unexpected revenue stream. Listening to these podcasts is a great way to get to know your fellow POSNA members better, and I encourage you to use this new digital platform. Because technology is vitally important to our organization, I have asked several Board of Director members, led by Todd Milbrandt, MD, to put together a “10-year technology timeline” to critically assess where we are in 2023 and what our needs might be in the future. As part of this, we have engaged a consulting firm to evaluate our current technology infrastructure as well as to assist in its design and future growth. Technology will only become more important to POSNA in the future.</p> <p><strong>Workforce Assessment</strong>: As I mentioned, POSNA is a growing and diverse organization. For this reason, it is important that we understand the makeup of our current workforce and make plans for future growth. Our last Workforce Assessment was published in 2014 and was based on data that is now 10 years old. The medical landscape, pediatric orthopaedic healthcare, and our organization have changed dramatically in the past decade. The Workforce Task Force, led by Woody Sankar, MD, was developed to create models of workforce assessment that not only will be used now but, in the future, as well. We will be presenting very interesting early data at this meeting that will be valuable in helping us plan for the needs of our future workforce and allow trainees to critically assess their future employment opportunities in pediatric orthopaedics.</p> <p><strong>Strategic Plan:</strong> Our strategic plan is solid; however, it only covers 2020 through 2024, and many of the original goals have already been or will soon be accomplished. Please keep in mind that this plan was developed pre-COVID. As we know, healthcare and the macroenvironment in which POSNA operates have changed dramatically since that time, so we must reevaluate our strategic plan and update it as necessary. As POSNA becomes larger and more complex, it will be very important to link our board and committee activities to the strategic plan to make the best use of finite finances and resources.</p> <p><strong>Committee Structure</strong>: As POSNA has grown, our committee structure also has grown, with new committees and charges to those committees being added. Although well-intentioned, it has led to increased complexity and redundancy, and some committees are no longer as relevant as they were when they were started. This has also made the Committee Application Process (CAP), of which over 160 members participated this past year, more complex. We have undertaken an initiative, led by Dan Sucato, MD, to review our committee and council structures to eliminate redundancy, increase efficiency, and provide room for growth, adding committees as needs dictate. This is much like pruning a tree—cutting limbs that are no longer producing to allow for new growth.</p> <p><strong>Finances:</strong> This past year has been very challenging in terms of the financial environment, with an impending recession, increasing inflation, and changing workforce demographics. We are also now under self-management, which has provided flexibility and opportunities but at the cost of staffing and maintaining an operational budget as well as office space. We know that meetings are only becoming more involved and more expensive, and this is expected to continue in the future. We need to balance the financial responsibility of the organization with the need for education, which is at the heart of what we do. Industry partners who are important to the financial health of POSNA also are critically evaluating the structure and value of meetings. Lastly, we want to ensure that our financial activities and dues structure are relevant and provide maximal member value.</p> <p>I would like to come back to meetings for a moment. Meetings make up a significant portion of our revenue stream, but also a significant portion of our expenses. Changes have been made to our meeting programming structure that will allow us to be more competitive and negotiate better hotel and convention center contracts going forward. This is being done through the Long-Range Planning Committee. These changes will benefit POSNA as we move into the second half of this decade.</p> <p><strong>Culture:</strong> People and culture are the “secret sauce” in POSNA. As I mentioned we are a volunteer, mission-driven organization. We also are a diverse organization, the most diverse by far in orthopaedic surgery; however, there is still more work to be done. The healthiest and strongest organizations are those that are built on diversity. We must invest in our people and cultivate the next generation of POSNA leaders. Recently, the first POSNA Leadership Program was launched, a 1-year course on all aspects of leadership, led by Peter Waters, MD. </p> <p>Before I conclude, I would like to thank Teri Stech, our Executive Director, for all that she does and has done for us over the past 25 years. This is her 25<sup>th</sup> year with POSNA (Figure 2). Thank you, Teri, for your service and for being my friend. To the POSNA staff, thank you for all the incredible things that you have done to make this organization better. We have an incredible staff. If you have not had the pleasure of meeting these individuals, please take some time to introduce yourself and say hello.</p> <p>I would like to thank my Campbell Clinic Partners for allowing me the opportunity to serve in the Presidential Line. I have been able to do this with full confidence knowing that you were doing an amazing job taking care of patients at home while I was working for POSNA. They say that you are most like the five people with whom you surround yourself in life, and in terms of my work life, I am grateful that you, my partners, are those people. You truly make me better. There are three giants in my career who deserve special thanks: Dr. James Beaty, Dr. William Warner, and Dr. Denis Drummond. All of you have given your time and energy and have invested in me. I am grateful for your mentorship and, more importantly, your friendship over many years.</p> <p>To my wife, Julie, and my three sons Lucas, Zac, and Jake, I cannot thank you enough for allowing me to have this opportunity (Figure 3). You all have been so supportive of me. You give me energy on those tough days and truly remind me of what is important in life. I am so proud of all of you and grateful that you could be here today to share this with me. I could not have done it without you.</p> <p>In summary, POSNA is an amazing, growing, diverse organization with many exciting opportunities ahead. By getting “Lean and Meaningful,” we will be able to keep the things that are working and provide value to us and leave behind the things that are not working in order to be poised to take advantage of the new opportunities that may come our way. I am also excited to say that POSNA will continue on this amazing trajectory under the guidance of Dan Sucato, MD, your 40<sup>th</sup> POSNA President.</p> <p> </p> <p> </p> <p> </p> Jeffrey R. Sawyer Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-761 A Rapid MRI Protocol for Acute Pediatric Musculoskeletal Infection Eliminates Contrast, Decreases Sedation, Scan and Interpretation Time, Hospital Length of Stay, and Charges <p><strong>Introduction:</strong> Acute musculoskeletal infections (MSKi) affect &gt;1:6000 children in the United States annually, which could lead to arthritis, chronic infection, limb deformity, and even death. MRI is the gold standard for MSKi diagnosis but traditionally requires contrast and anesthesia, delaying results and slowing treatment decision-making. A rapid MRI protocol is an unsedated MRI with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to help identify abscesses. The objective of this study was to compare MRI access, timing, treatment, length of stay, and charges between the traditional and rapid MRI protocols among pediatric patients undergoing MSKi evaluation.&nbsp;<br><br><strong>Methods:</strong> A single-center retrospective study was conducted among 128 patients undergoing MSKi evaluation before (“Traditional cohort” [TC] of 60 patients admitted in Jan-Dec 2019) and after implementation of the Rapid MRI protocol (“Rapid cohort” [RC] of 68 patients admitted in Jun 2021-Jul 2022). Demographic, clinical, and charge data were extracted from electronic health records. Mann-Whitney U tests were performed to compare the two groups.<br><br><strong>Results:</strong> Demographics and diagnoses were similar, while rates of sedation and contrast administration were significantly different (53% and 88% in TC versus 4% and 0% in RC). The median time to MRI after ordering was 6.5 hours (IQR=3.2-12.2) in TC and 2.2 hours (IQR=1.1-4.5) in RC (P&lt;0.01). The median duration of MRI was 63.2 minutes (IQR=52.4-85.3) in TC and 24.0 minutes (IQR=18.5-41.1) in RC (P&lt;0.01). The median time between ordering and receiving the MRI final interpretation was 13.5 hours (IQR=2.35-66.3) in TC and 7.0 hours (IQR=1.25- 41.7) in RC (P&lt;0.01). The median hospital length of stay was 5.3 days (IQR=2.7-7.9) in TC and 3.7 days (IQR=1.0-5.8) in RC (P&lt;0.01). The median charges for the entire hospital stay were $48,015 (IQR=$28,086-$88,496) in TC and $33,532 (IQR=$13,622, $54,710) in RC (P&lt;0.01). While 10/68 of Rapid MRIs were canceled or aborted due to patient motion or pain, only 6/68 required repeat MRI with sedation. No infection diagnoses were missed on Rapid imaging.<br><br><strong>Conclusion:</strong> In patients being evaluated for MSKi, the Rapid MRI protocol eliminated contrast and nearly eliminated sedation while leading to improved MRI access, scan and interpretation times, and significant decreases in hospital length of stay and charges. Future steps include continuing quality control, studying interobserver reliability between protocols, and multicenter program expansion.<br><br><strong>Significance:</strong> Pediatric MSKi carry a large treatment burden, and this Rapid MRI protocol improves imaging access while eliminating contrast, decreasing sedation, scan time, length of stay, and hospital charges, with a &lt;10% rescan rate and without missing actionable diagnoses.<br><br></p> Kyle S. Chan Daniel McBride Jacob Wild Soyang Kwon Jonathan Samet Romie F. Gibly Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-731 Non-Operative Treatment of Tibial Tubercle Fractures: Who is at Risk for Failure? <p><strong>Introduction:</strong> Given the relative rarity of tibial tubercle fractures and the high proportion that undergo surgical treatment, there is little data on non-operative management of these injuries. Some patients that are initially treated non-surgically may ultimately require operative intervention. The purpose of this study was to identify risk factors for failed non-operative management of tibial tubercle fractures.</p> <p><strong>Methods:</strong> This retrospective comparative study included patients younger than 18 years that underwent initial non-operative treatment of a tibial tubercle fracture at six tertiary children’s hospitals. Those that underwent primary surgical intervention were excluded. Demographic, radiographic, and clinical data were reviewed. Conversion to surgical fixation was considered a failure of non-operative treatment. Univariable analysis was followed by multivariate regression to adjust for confounders.<br><br><strong>Results:</strong> A total of 136 patients were included, of which 19.1% failed non-operative treatment and subsequently underwent surgery. The median age of patients that ultimately required surgery was 14.0 y [IQR (interquartile range) 2.5 y] compared to 12.0 y (IQR 2.0 y) for those that were successfully managed without surgery. Non-operative treatment failed in 7.8% of Ogden type I fractures, 66.7% of type II, 81.8% of type III, 35.7% of type IV, and 7.1% of type V (p&lt;0.001). After adjusting for confounders, including weight and initial weight-bearing status, each year of increasing age raised the odds of failure by 1.9 (95% CI 1.2-3.0, p=0.006). Additionally, Ogden type II fractures had 23.4 times higher odds than type I (95% CI 2.1-260.8, p=0.01). Ogden type III fractures had 36.3 times higher odds of failing non-operative treatment than type I (95% CI 4.2-315.4, p=0.001).<br><br><strong>Conclusion:</strong> In this study of patients with a tibial tubercle fracture initially treated non-operatively, 19.1% ultimately underwent surgery. Increasing age and Ogden type II and III fracture classification were associated with failure of non-operative management. These results may help guide decision-making regarding surgical versus non-surgical treatment.<br><br><strong>Significance:</strong> There is little data on non-operative treatment of tibial tubercle fractures. This study identifies risk factors for failure of non-operative treatment and may aid clinical decision-making.</p> Lauren Spirov Konstantin Brnjoš Neil Kaushal Folorunsho Edobor-Osula Alexander Griffith John Blanco Clare Kehoe John Schlechter Evelyn Thomas Lindsay Crawford Abhi Rashiwala Dustin Greenhill Haley Tornberg Brendan Williams Kevin Huang Neeraj Patel Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-732 Like a Lizard: Repair of Perthes Disease Occurs Through Recapitulation of Development of the Proximal Femoral Epiphysis <p><strong>Introduction: </strong>Legg-Calve-Perthes Disease (LCPD) is a complex condition with limited understanding about its healing process. The healing mechanism of LCPD is believed to differ significantly from adult hip avascular necrosis (AVN), thus necessitating an exploration into alternative mechanisms. Our research focused on understanding these mechanisms using a review of histologic specimens, a thorough literature review, and translational basic science studies. </p> <p><strong>Methods: </strong>Histologic Review: IRB-approved biopsies from five Stage 2 LCPD cases undergoing hinged abduction were analyzed to confirm the presence of cartilage in areas of fragmentation. Literature Search: A comprehensive literature review was performed, scrutinizing publications on the role of cartilage during Stage 2 of LCPD from Perthes’ original observations to subsequent studies. Mouse Model: A mouse hip model, chosen for its resemblance to Stage 2 LCPD, was used to study chondrocyte-derived VEGF’s role in angiogenesis and ossification. VEGF blockade was employed to confirm its function. </p> <p><strong>Results: </strong>Histologic Review: All five biopsies of Stage 2 LCPD cases showed robust cartilage presence in areas of fragmentation (Figure 1). Histological analysis confirmed cartilage leading to new bone formation areas, akin to the physis’ zone of ossification. Literature Search: Our literature review identified consistent documentation of cartilage presence during Stage 2 of LCPD in past studies dating back to Perthes, but the role of this cartilage in the healing process was previously not clearly defined. Mouse Model: Chondrocytes were observed to produce a significant amount of VEGF right before vascularization of the hip. Blockade of VEGF production halted both vascularization and ossification. These findings point towards a role for chondrocyte-derived VEGF in promoting angiogenesis and ossification of the femoral head. <strong> </strong></p> <p><strong>Conclusion: </strong>These findings support the theory that <em>chondrification </em>during Stage 2 of LCPD is part of the unique reparative process of LCPD. The production of VEGF by chondrocytes appears to be integral for vascularization and ossification of the femoral head. We propose that the healing mechanism of LCPD is not a superior form of creeping substitution, but rather an endochondral mediated mechanism of vascularization and ossification, much like a lizard regrowing its tail. </p> <p><strong>Significance: </strong>These findings clarify the healing process of LCPD and can inform future treatment protocols. Treatment protocols should consider these biological processes to optimize outcomes in LCPD. Further studies are required to fully elucidate this process and its implications on the management of LCPD. Specifically, it emphasizes the importance of supporting chondrification and the production of VEGF rather than focusing solely on anti-resorptive and osteogenics. </p> Jonathan G. Schoenecker Rachel McKee Courtney Baker Hernan Correa Stephanie N. Moore-Lotridge Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America 2023-08-01 2023-08-01 5 3 10.55275/JPOSNA-2023-730