JPOSNA https://jposna.org/ojs/index.php/jposna <p><strong>JPOSNA</strong> (the <strong>Journal of the Pediatric Orthopaedic Society of North America)</strong> is an open access online journal focusing on pediatric orthopedic conditions, treatment and technology.</p> POSNA en-US JPOSNA Editor's Note https://jposna.org/ojs/index.php/jposna/article/view/291 <p><strong>Leaders and Leadership.</strong></p> <p>According to Google Search, in the year 2020, there were 1246 books published with “leadership” in the title. Last year in healthcare, there were 6220 “leadership” papers cited in PubMed. A great number of these described leadership in the midst of the COVID-19 pandemic.</p> <p>Who are leaders? What and how do they do it? How do you describe leadership; how do we deliver it? Ernest Shackleton, Mary McLeod Bethune, John Kennedy, Ruth Bader Ginsburg naturally come to mind. Justice Potter Stewart once used the term for a less honorable vocation, “I know it when I see it.” For POSNA members, we clearly see leadership in our Society, and we can see it in ourselves.</p> <p>We are on the eve of our first Annual Meeting in two years and we are not resuming where we left off, but rather we build on the growth our Society has had over the last year despite COVID-19. All of our committees have conducted business as usual—accepting and reviewing grants and awarding research dollars. Our educational, advocacy, and service committees are in full throttle. All of this was facilitated and stimulated by President Vitale and the POSNA BOD while they worked to keep us afloat in the COVID-19 tempest. Leaders listen and inform as did ours via multiple communications and Town Hall meetings. Leaders adapt as Jeff Martus and the POSNA program committee nimbly pulled off a fantastic virtual 2020 meeting in under two months. Leaders relish broad critical thinking; when Todd Milbrandt and the IPOS team recommended against a virtual IPOS, the Board listened. There is nothing “remote” about the hands-on personalized instruction and mentorship that flows through an IPOS meeting. A virtual IPOS is not IPOS. Leaders evaluate the landscape and make courageous decisions; ours read the recent increase trajectory of immunization and decreasing infections. As a result, Woody Sankar and his program committee will guide POSNA to be one of the first to have an in-person meeting with robust safety and social distancing precautions.</p> <p>Our Society is full of leaders, they are the authors and the contributors to your JPOSNA presented here. They are also the readers of this journal and the worldwide providers of pediatric orthopaedic care. A leader gets up every day, puts aside personal risk, provides for their family, selflessly works to care for their patients, making the world better while providing optimism and hope. When I see a leader . . . I see you.</p> <p>Ken Noonan </p> Ken Noonan Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Message from the President https://jposna.org/ojs/index.php/jposna/article/view/290 <p>Welcome to the next edition of our spectacular <em>JPOSNA</em>!</p> <p>It has been an amazing thrill seeing <em>JPOSNA</em> first launch and now continue to evolve under the tremendous leadership of Ken Noonan and our <em>JPOSNA</em> editorial board. Some years ago, the POSNA BOD recognized the need to have more autonomy over content, style, and cadence of publications and communications with our members.&nbsp; We approached this in several ways. While we continue to examine our relationship with the publisher of <em>JPO</em> (and so much appreciate many years of loyal and steadfast service that Drs. Hensinger and Thompson need to be lauded for), we also saw the need for our own separate publication. <em>JPOSNA</em> was born of the need to be nimble in the online publication space and to have autonomy with regard to what&nbsp;<em>“our journal”&nbsp;</em>is<em>.&nbsp;</em><u>And this is&nbsp;<em>our journal</em>!&nbsp;&nbsp;</u>To ensure that we continue to excel, we have hired Lisa DuShane, who brings tremendous capability and experience in this space to help continue to support this important effort.</p> <p>As I wind down my Presidential year, <em>JPOSNA</em> stands as one of the real highlights of what we together have created. I cannot wait to see it continue to grow up and evolve under the continued leadership of Ken, the editorial team, the BOD, and our incoming president, Min Kocher.</p> Michael Vitale Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Placement of Hexapod External Fixator for Deformity Correction https://jposna.org/ojs/index.php/jposna/article/view/278 <p>Hexapod circular external fixators provide a powerful technique for correcting limb deformity.&nbsp; The ability to correct multi-planar deformity sequentially or simultaneous in a gradual manner is unique to this method.&nbsp; This article provides a review of the pertinent pre-operative, intra-operative and post-operative details that will help the surgeon achieve a successful outcome with hexapod circular external fixators.</p> Christopher Iobst Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Proximal Femur Guided Growth for the Management of Hip Dysplasia in Children with Cerebral Palsy https://jposna.org/ojs/index.php/jposna/article/view/245 <p>&nbsp;Proximal femoral deformity associated with neuromuscular hip dysplasia in children with cerebral palsy (CP) is characterized by increased anteversion, coxa valga, and caput valgum.&nbsp; Guided growth of the proximal femur (PFGG) utilizes a screw to tether the medial portion of the physis to achieve progressive varus alignment of the femoral head and neck with subsequent growth.&nbsp; This procedure has been shown to decrease the head shaft angle and Reimer’s migration percentage (RMP); and decrease the need for subsequent skeletal hip reconstructive surgery.&nbsp; The indications, surgical technique, post-operative management, potential pitfalls of this relatively new procedure are reviewed.</p> Jon Davids Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Using Data-Driven, Principled Negotiation with a Clinician-Integrated Approach to Achieve Best Values on Spinal Implants https://jposna.org/ojs/index.php/jposna/article/view/263 <p><strong>Objectives:</strong> In many health systems, the costs of surgical implants are one of the largest components for surgical budgets, and economies of scale in purchasing agreements do not always provide increased value due to lack of data transparency and administrative complexity. The purpose of the study was to determine if clinician-informed, well-defined negotiation strategies informed by market-based pricing and volume data from supply chain experts within the health system could achieve lower pricing levels for spinal implants and reduce the number of vendors.&nbsp;</p> <p><strong>Methods:</strong> Market data based upon pricing levels for implants were reviewed from an industry implant price database, and utilized by surgeon clinicians and supply chain management (SCM) to select benchmark pricing levels for common spine implants used at our institution.</p> <p><strong>Results:</strong> Benchmark modeling to the 25<sup>th</sup> percentile among comparable institutions was used in the request for proposal (RFP) sent to all vendors. After three rounds of structured negotiation involving SCM and surgeon leaders, 20% savings over the previous year’s total spend was achieved, with a total savings upward of one million dollars; 8 of 22 vendors were excluded from the system.</p> <p><strong>Conclusion:</strong> Negotiation tactics included utilizing benchmark pricing data, “economies of scale” principles, game theory principles, and strong internal communication strategies between supply chain, physician leadership, and actively practicing surgeons. These findings demonstrate that there is significant opportunity for healthcare SCM to further negotiate contracts and achieve favorable pricing on items such as spinal implants with surgeon collaboration and utilization of benchmark data.</p> Kelly H. McFarlane Eli M. Cahan Amanda Chawla James Lee Ly Nguyen Vignesh Rajagopalan Serena S. Hu John K. Ratliff John S. Vorhies Meghan N. Imrie Lawrence A. Rinksy Steven L. Frick James K. Wall Kevin G. Shea Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Levels of Evidence Are Not the Whole Story https://jposna.org/ojs/index.php/jposna/article/view/274 <p>Levels of evidence (LOE) are classification systems that use a hierarchal structure to indicate where the research in question may fall in regard to the strength of the recommendations. They have been used in some form in medical literature since the 1970s and have continued to be refined for ease of use by the practicing physician.&nbsp;</p> <p>The purpose of this article is to define LOE as commonly used in the orthopaedic literature and to highlight that LOE alone is not always sufficient for assessing the quality of the evidence presented. Examples of research at different LOE are presented and discussed, highlighting the importance of critical appraisal when using these guidelines.</p> Susan Nelson Unni Narayanan Matthew Schmitz Scott McKay Tracey Bastrom Arvindera Ghag Joseph Janicki Judson Karlen Indranil Kushare Ronald Lewis Justin Mistovich Neeraj Patel William Phillips Jeffrey Sawyer Kelly Vanderhave Maegen Wallace Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 The Ponseti Method - Stay True to It! https://jposna.org/ojs/index.php/jposna/article/view/258 <p>The Ponseti method has, over the last 25 years, become the international gold standard for clubfoot management because of its proven efficacy, safety, and universality. It is an exacting method that requires specific training and ongoing practice. It also requires a commitment to applying it without modification to ensure the highest rate of success. This perspective article provides 1) an historical background of the method, 2) evidence for an apparent shift by providers away from dedication to strict application of the method, 3) reasons why that may be occurring, and 4) justifications for staying true to the method.&nbsp;</p> Vincent Mosca Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Mihran O. Tachdjian, MD https://jposna.org/ojs/index.php/jposna/article/view/270 <p>The Tachdjian name floats through the subconscious history of our society and our specialty, and because his professional background is foundational to our present; it’s important to have a feel for the man as well as his achievements. Because of Myke’s inexplicable ability to not only educate within the field but also his ability to impact so many lives on a personal level, he was able to develop many life-long relationships around the world which in turn fostered further growth in the field.</p> Alvin Crawford Charles Price Dayna Phillips Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 JPOSNA Coding Corner: Fracture Clinic https://jposna.org/ojs/index.php/jposna/article/view/288 <p>A certainty every spring is that warmer weather brings green grass, blooming flowers, monkey bars, trampolines and —pediatric fractures! With our trauma clinics starting to fill up, the aim of this installment of the JPOSNA “Coding Corner” is to equip you with the most up-to-date knowledge regarding fracture documentation and billing.</p> Ryan Muchow Stephanie Holmes Sarah Wiskerchen Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Orthopaedic Management in Down Syndrome https://jposna.org/ojs/index.php/jposna/article/view/283 <p>Down syndrome is the most common chromosomal disorder and typically results from a maternal duplication of chromosome 21 yielding trisomy 21. General features include a flat facial profile, short stature, oblique palpebral fissures, epicanthal folds, and associated medical conditions such as congenital heart disease, vision problems, and hearing loss.&nbsp; Most musculoskeletal manifestations of Down syndrome are related to generalized ligamentous laxity, joint hypermobility, and hypotonia which can lead to atlantoaxial instability, atlanto-occipital instability, scoliosis, spondylolisthesis, hip dysplasia / instability, patellar instability, pes planus, and hallux valgus.&nbsp; Importantly, the orthopaedist may also be the first to discover systemic conditions such as hypothyroidism associated with slipped capital femoral epiphysis (SCFE) or leukemia or inflammatory arthritis leading to musculoskeletal pain .&nbsp; The purpose of this review is to summarize what the orthopaedist needs to remember when evaluating and treating their patients with Down Syndrome.</p> Kyle Rako Sheena Ranade Abigail Allen Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Skeletal Dysplasia Quiz https://jposna.org/ojs/index.php/jposna/article/view/292 <p>This Skeletal Dysplasia Quiz represents an interactive session where POSNA members are able to work through 9 clinical scenarios to challenge how they would address these problems.&nbsp; Associated with each scenario is an OITE-style question and multiple choice options that seek the most preferred answer.&nbsp; In addition to the answer and follow-up radiographs, we have enlisted the opinions of&nbsp; POSNA experts in skeletal dysplasia to provide an evidenced-based approach to thinking through each problem.&nbsp;</p> William Mackenzie Klane White Matt Bernstein Samantha Spencer Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Pediatric Acute Compartment Syndrome https://jposna.org/ojs/index.php/jposna/article/view/252 <p>Pediatric acute compartment syndrome (PACS) is a rare but potentially limb threatening entity. The prompt recognition and emergent treatment of developing compartment syndrome is imperative to prevent lifelong disability. The anxiety and age of the pediatric population make it difficult to accurately diagnose PACS. This article seeks to provide an overview on how to appropriately diagnose and treat PACS providing various tips and tricks.</p> Christopher Souder Scott Yang Dustin Greenhill Phillip McClure Matthew Ellington Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Early Onset Scoliosis Series Announcement https://jposna.org/ojs/index.php/jposna/article/view/286 <p>We would like to introduce an initiative on early onset scoliosis (EOS) within <em>JPOSNA</em>. The initial idea for this project was born from Pediatric Spine Study Group (PSSG) meetings during the COVID-19 pandemic, and was initially championed by founding PSSG member, Dr. Behrooz Akbarnia. Contributors in this series are PSSG members across many generations of pediatric spine practice. Our goal is to create a repository of information that is easily accessible for learners in all stages. Each decision in the care of an EOS patient is steeped in decades of experience, triumph, and failure. This history not only shapes our current practice, but informs the future of EOS care.</p> <p>Over the course of 3 editions we will explore greater than 50 years of EOS experience, technique, and research. Each offering will have Current Concept Reviews with a coupled educational video. In this first edition we present reviews on the first generation of care in EOS, and on the evolution of casting in the EOS patient.&nbsp; The casting review is accompanied by an exceptional master technique video.&nbsp; In future editions we will explore thoracic insufficiency syndrome, instrumentation in the early onset scoliosis patient, refining/redefining our research efforts for this population, and finally a long-range view of what the future holds in EOS.</p> <p>Great thanks and appreciation to Ken Noonan, Jennifer Bauer and the <em>JPOSNA</em> editorial staff for their expertise and support in this endeavor. The electronic nature of <em>JPOSNA</em> allows for greater depth of education and understanding than is conceivable in the traditional journal experience. We hope to augment an already incredible journal with our EOS initiative.</p> Grant Hogue Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 The First Generation of Early Onset Scoliosis Care https://jposna.org/ojs/index.php/jposna/article/view/281 <p>Reports of the prevalence and natural history of spinal deformity in younger pediatric patients became part of the orthopaedic literature in the middle of twentieth century. Formal use of the term “Early Onset Scoliosis” to describe a wide range of spinal pathology based on age of onset did not gain popularity until much later. Early reviews of the natural history of these deformities detailed which patients were at risk of progression, and which patients may benefit from intervention rather than simple observation. However, long-term follow-up of the application of adult spine deformity management principles in skeletally immature patients demonstrated a significant risk of both spinal and associated pulmonary complications over time. Reports of efforts to alter the natural history of these conditions through surgical treatment that attempted to control the deformity, while still allowing spinal growth, emerged in the late 1970s and 1980s.</p> Robert Murphy James Mooney Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 The Evolution of EDF Casting https://jposna.org/ojs/index.php/jposna/article/view/282 <p>Casting for scoliosis has evolved significantly since it was first reported 150 years ago. Earlier techniques focused on temporizing scoliosis, loosening up curves prior to surgery and facilitating fusions after surgery. Modern techniques have evolved to address the three dimensional nature of the deformity and to harness the power of growth in younger children to provide a lasting correction. Its current iteration, elongation derotation flexion casting, has been successfully applied in multiple patient populations. It has been shown to cure anywhere from 35-69% of patients with infantile idiopathic scoliosis and will palliate many more. It can delay surgical intervention two or more years in patients with congenital, syndromic or neuromuscular scoliosis. It is not without its limitations including rashes, pressure sores, rib deformity and the potential long-term impact of repetitive anesthesia. Additionally, there continues to be variable outcomes in part due to the heterogeneous patient population and variability in casting techniques. However, the technique continues to improve as it evolves and it is the only treatment that can potentially cure scoliosis. Here we aim to discuss the evolution of casting, its application in different patient populations, and the tips and tricks of our preferred casting technique.</p> Michelle Welborn James Sanders Jacques D'Astous Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Is a CT Scan Needed for Pedicle Screws Crossing the Midline? https://jposna.org/ojs/index.php/jposna/article/view/234 <p>Posterior spinal fusion (PSF) is an effective and safe treatment for various spinal deformities in the pediatric population, including Scheuermann’s Kyphosis. Several studies have evaluated the variations in pedicle anatomy, parameters to detect pedicle breach, and need for postoperative computerized tomography scan (CT scan). The purpose of this case study is to present an example of PSF in a relatively large male patient with Scheuermann’s Kyphosis. The surgery was uneventful and relatively long pedicle screws were used. Postoperative X Rays showed pedicle screws crossing the midline at several levels. Further work up with CT did not demonstrate any medial breaches. In conclusion, long pedicle screws are not necessarily malpositioned if they cross the midline.</p> Jestin Williams Peter D'Amore Manaf Younis Andrew King Carter Clement Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Pitfalls of Pediatric and Adolescent Sports Specialization https://jposna.org/ojs/index.php/jposna/article/view/268 <p>Engagement in athletic participation is critical for the physical and emotional well-being of pediatric and adolescent youth. Yet, changing patterns of sports participation have created multiple consequences for those involved.&nbsp; A trend toward single sport specialization and club sports at the expense of unstructured, recreational play has led to these changes.&nbsp; Youth are subject to increased injury risk as well as compromised mental health. Furthermore, disparities in access to sports are created for many who cannot afford to play, leaving many communities without access to physical activity.&nbsp; This drive toward sports specialization (and privatization) has been driven by the fallacy that it will lead to subsequent athletic success at the collegiate and professional level, a notion that health care providers must help to dispel.</p> Nirav Pandaya Pamela Lang Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Fat Pads as a Cause of Adolescent Anterior Knee Pain https://jposna.org/ojs/index.php/jposna/article/view/264 <p>Anterior knee pain is one of the most frequently encountered symptoms in pediatric sports medicine. The fat pad is a structure with mounting evidence supporting its dynamic involvement in many pathological states in the anterior knee. There are three peripatellar fat pads that occupy much of the extra-synovial space of the knee. This review explores the anatomy, innervation, vasculature, function, imaging, and pathology of these fat pads. Fat pad pathology is likely underestimated given the limited literature on such disease in the pediatric population. In particular, the prefemoral fat pad is the least described of the fat pads with only a few reports detailing chronic pathological processes. To highlight the relevance of the fat pad, particularly in the pediatric population, we describe an atypical case of a self-limiting acute prefemoral fat pad impingement due to a hyperextension injury in a young athlete.</p> Mitchell G. Foster Jerry Dwek James D. Bomar Andrew Pennock Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Traumatic Physeal Arrests at the Wrist https://jposna.org/ojs/index.php/jposna/article/view/265 <p>Fractures involving the physes of the distal forearm are exceedingly common in children, representing upwards of 1/3 of all pediatric fractures. These injuries are often amenable to closed treatment, but physeal injury can lead to premature arrest and significant related long-term sequela. Common practice guidelines have not been established amongst the pediatric orthopaedic community for radiographic monitoring, need for 3-dimensional imaging, and treatment algorithms in these injuries. This review seeks to outline the literature and share the perspective and methods of a panel of leading pediatric upper extremity experts in hopes of providing a framework for better understanding these injuries and treating their growth-related sequelae.</p> Laura Bellaire Carley Vuillermin Suzanne Steinman Walter Truong Donald Bae C. Douglas Wallace Christine Ho Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2 Pediatric Femoral Head Osteonecrosis Secondary to Trauma, Sickle Cell Disease, and Corticosteroid Therapy https://jposna.org/ojs/index.php/jposna/article/view/285 <p>Management of pediatric femoral head osteonecrosis (FHO) due to various etiologies remains a clinical challenge due to delayed diagnosis, limited evidence to guide treatment decision making, and a lack of consensus on treatments to prevent the femoral head deformity. &nbsp;Since many review articles have been written on Legg-Calve-Perthes disease, this review focuses on pediatric FHO secondary to trauma, sickle cell disease, and corticosteroid therapy. Post-Traumatic FHO is a serious complication that can occur following femoral neck fractures and traumatic hip dislocations in children. Sickle cell disease is the most common inherited blood disorder in the US and is a common cause of multi-focal osteonecrosis in patients of African descent and from the sub-Saharan Africa, the Mediterranean, the Persian Gulf, and the Indian subcontinent.&nbsp; Corticosteroid induced osteonecrosis in patients with acute lymphocytic leukemia is of particular interest since acute lymphocytic leukemia is prevalent in the pediatric population.&nbsp; The goal of this review is to educate the clinician on the epidemiology, pathophysiology, natural history, evaluation, and treatment considerations for pediatric FHO secondary to these conditions.</p> Harry Kim William Morris Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Osteochondral Allograft Transplantation of the Femoral Head Through an Open Surgical Hip Dislocation https://jposna.org/ojs/index.php/jposna/article/view/287 <p>Young patients with avascular necrosis (AVN) of the femoral head have limited options for the management of their severe pain.&nbsp; The most common treatments include activity modification, core decompression, proximal femoral osteotomies, nonvascularized or vascularized bone grafting, and total hip arthroplasty. &nbsp;Although osteochondral allograft transplantation (OAT) is commonly used to treat cartilage defects in the knee, few studies report osteochondral allograft transplantation in the hip.&nbsp; OAT of the femoral head is an emerging technique that may be an effective option to preserve the hip in young patients with AVN.&nbsp; The manuscript and video review the indications and describes the technique of OAT of the femoral head through an open surgical hip dislocation.&nbsp; &nbsp;</p> William Baumgartner Trevor Shelton Carter White Brian Haus Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Jump Gait in Spastic Diplegia: An Expert Panel Case Review https://jposna.org/ojs/index.php/jposna/article/view/276 <p>A detailed, thoughtful examination of a patient’s gait is an important aspect of the care of most patients in orthopaedics.&nbsp;&nbsp;Many times, an appropriate visual inspection of gait can reveal the most important pathologies seen in a general pediatric orthopaedic practice.&nbsp;&nbsp; However, some conditions, such as cerebral palsy (CP), often present with significant gait complexities and multiple impairments that negatively affect patient mobility.&nbsp;&nbsp; The use of advanced instrumented gait and motion analysis has become an essential piece of high-quality care of children with CP.&nbsp; In this edition, we discuss evaluation and management of jump-gait.&nbsp;In this series, a group of gait experts will be presenting principles and tips to help us all improve in the evaluation of gait in patients with CP.&nbsp; This case will include clinical information, physical examination data, pertinent radiographs, links to gait videos, and motion analysis data.&nbsp;&nbsp;</p> Wade Shrader Benjamin Shore David Scher Robert Kay Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 The Orthopaedic Management of Arthrogryposis Multiplex Congenita https://jposna.org/ojs/index.php/jposna/article/view/277 <p>Arthrogryposis multiplex congenita (AMC) is a term that describes at least 400 different conditions that result in a baby born with multiple joint contractures. The underlying similarity of these causative conditions is that the developing baby experiences fetal akinesia. The most common forms of AMC are Amyoplasia, or “classic arthrogryposis”, and the different kinds of distal arthrogryposis. Over the past two decades, the orthopaedic treatment of children with arthrogryposis multiplex congenita has steadily evolved steadily, with a better appreciation of the functional potential of persons with arthrogryposis. The development of newer procedures specific for the arthrogrypotic deformities have improved surgical treatment, and outcomes studies that provide understanding of the overall capabilities of adults with arthrogryposis continue to help determine which treatments were the most beneficial. The outcome studies indicate that most adults with arthrogryposis are ambulatory, but less than half are fully independent in self-care, most are limited by upper extremity dysfunction. Pain in adulthood, both chronic and episodic, is frequent, particularly of the foot and back, limiting ambulation and standing. To improve independence, upper extremity treatments have advanced to improve elbow motion, and wrist and thumb positioning. In the lower extremities, attempts to improve the ambulatory ability and decrease future pain include correction of hip and knee contractures, and emphasizing casting treatments of foot deformities. &nbsp;Pediatric patients with arthrogryposis require a careful evaluation, with both a physical examination and an assessment of needs to direct their treatment. Further outcomes studies are needed to continue to refine procedures and define the appropriate candidates.</p> Harold van Bosse Dan Zlotolow Copyright (c) 2021 JPOSNA 2021-04-25 2021-04-25 3 2 Unicameral Bone Cysts: Treatment Rationale and Approach https://jposna.org/ojs/index.php/jposna/article/view/267 <p>Unicameral bone cyst (UBC) is a benign cystic lesion, most commonly diagnosed in the proximal aspects of the humerus and femur of growing children. Medullary venous obstruction is the leading pathogenesis theory, resulting in fluid accumulation, bone resorption, and cortical thinning. Most UBCs are asymptomatic and likely go undiagnosed, while the most common presentation is a pathologic fracture, either complete or insufficiency/stress. Younger children tend to present with active lesions, which are uniloculated, abut the physis, and have a higher recurrence or persistence rate after treatment. Lesions in older children tend to migrate away from the growth plate (latent), and might become multiloculated, especially if they recur after treatment. Radiographs are often diagnostic and reveal a centrally-located, lucent metaphyseal lesion with cortical thinning, although advanced imaging is also helpful is some cases. Most UBCs do not need treatment and are amenable to observation alone. Management ranges from aspiration and steroid injection to decompression, curettage, grafting, and internal fixation. Percutaneous or open surgical approaches are acceptable, and often yield good results, although high recurrence rates should be expected, especially in younger children with active lesions.</p> Soroush Baghdadi Alexandre Arkader Copyright (c) 2021-04-23 2021-04-23 3 2 Medical Mission to Ambato, Ecuador https://jposna.org/ojs/index.php/jposna/article/view/275 <p>Medical Mission Ecuador is a not for profit group comprised of 70+ volunteers who provide medical care for children in Ambato, Ecuador. This is a travel diary for the February 2020 trip focused on the experience of the Pediatric Orthopaedic Surgeons experience.&nbsp;</p> Michael Horan Kevin Williams Henry Iwinski Vishwas Talwalkar Scott Riley Copyright (c) 2021 JPOSNA 2021-04-24 2021-04-24 3 2