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> en-US posna@posna.org (POSNA Staff) posna@posna.org (POSNA Staff) Mon, 01 Feb 2021 00:00:00 -0700 OJS 3.1.2.4 http://blogs.law.harvard.edu/tech/rss 60 Editor's Note https://jposna.org/ojs/index.php/jposna/article/view/238 <p>Welcome to the first installment of JPOSNA’s third volume.</p> <p>Our Editorial Team endeavors to represent all of pediatric orthopaedics and all of our Society. We open the doors for information from established names and faces, we promote the expertise of rising stars who can teach older dogs (like me) new tricks, and we welcome anyone who wants to provide a better way to care for our patients and families. Pediatric orthopaedics is diverse, which is why we love it, and JPOSNA presents content that is both individual and synergistic. As an example, we are fortunate to present three different but relatable papers that review management of acute pain, strategies to manage chronic pain, and a QSVI initiative for narcotic disposal. JPOSNA is the only source for Pediatric Orthopaedic QSVI publications. In this edition, you can read a QSVI paper on how to start a halo traction program for severe spinal deformity, spend some time on an excellent review on cervical spine instrumentation, and settle in and watch a Master’s correction of Scheuermann’s Kyphosis.</p> <p>We are pleased to present some very well-done Surgical Technique articles/videos and Surgical Tips. Matt Oetgen and Nick Fletcher plan at least two contributions each edition, and all of these will flow to POSNAcademy which is fast becoming the go-to source for Pediatric Orthopaedic Education. This edition contains a number of individual, group, and committee generated Current Concept Reviews. We are especially pleased to continue the JPOSNA Tutorial on the Management of Gait in CP with Wade Shrader’s excellent review of Instrumented Gait Analysis. Subsequent editions will apply these concepts to actual case examples with panel discussions.</p> <p>New to JPOSNA is the Coding Corner. Under Ryan Muchow’s leadership, we plan to present practical information in subsequent editions on how to bill accurately and effectively in this ever-changing environment. We hope this will provide real value to all of us who seek to appropriately maximize our clinical returns.</p> <p>“If I have seen further,” Isaac Newton wrote in 1675, “it is by standing on the shoulders of giants.” In pediatric orthopaedics we do what we do because of and in honor of those who have mentored us and developed systems of pediatric orthopaedic care. At JPOSNA, one of our goals is to provide context to our profession—by understanding the past, we can treasure the present and be motivated to contribute to the future. In this edition, we are fortunate to have a beautifully written history of the Shrine System by Peter Armstrong and George Thompson. I believe it’s fair to say that our practices have been affected by the Shrine System of care and the world is a better place because of this venerable organization.</p> <p>Enjoy this Edition. It’s yours.</p> <p>Ken Noonan</p> Kenneth Noonan Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/238 Mon, 01 Feb 2021 13:20:24 -0700 Message from the President https://jposna.org/ojs/index.php/jposna/article/view/239 <p>Welcome to Volume 3 of our <em>JPOSNA</em>.</p> <p>This continues to impress in every regard. As you read through this exciting edition, you will see that <em>JPOSNA</em> offers something for everyone. From updates around practice management issues like coding to overviews of pain management and gait analysis to cutting edge multimedia “Masters Techniques” to important communication about efforts to improve quality in our field, <em>JPOSNA</em> is YOUR Journal.</p> <p>And speaking of quality improvement in our field, kudos to Kevin Shea and the QSVI council for launching our Pediatric Safe Surgery Program (PSSP) which is about to go live in its beta version. I will let him share some of the details, but congratulations to the team for persistence in this effort to make care better for kids with orthopaedic problems!</p> <p>See you in Dallas in May!</p> <p><strong>POSNA Safe Surgery Program 2021 </strong></p> <p>The POSNA Safe Surgery Program (PSSP) does not seek to rank individual centers with respect to other centers–the logistical, operational, and statistical obstacles to this approach are significant. Practice assessment and risk factor adjustment are major obstacles to ranking. Furthermore, we do not believe that formal program ranking is the optimal way to drive quality and performance improvement amongst POSNA member surgeons and affiliated health systems. Our goal is to develop a program that supports all POSNA members and affiliated health systems on their path to ideal care–the right treatment for each patient, the best possible outcome, with zero harm.&nbsp;</p> <p>After greater than 2 years of development work, the POSNA Safe Surgery Program (PSSP) will enter a 2-year Demonstration Period. In order to refine the program, we begin an evaluation phase where the program will be available to POSNA BOD members and QSVI Committee Chairs. Our primary goals include:</p> <ol> <li>To focus upon patients and their families as we improve outcomes</li> <li>To engage the physician expertise of POSNA members to develop, implement, and evaluate the impact of quality metrics</li> <li>To provide expert clinicians a framework to decide best practices which optimize outcomes in different subspecialties</li> </ol> <p>At this stage, 24 metrics have been developed with input from small, medium, and large centers as well as private independent groups and major academic centers in the following subspecialties: Spine, Sports, Hip/Lower Extremity, Hand/Upper Extremity, and Trauma. These metrics will be available on the POSNA website, and beta testing sites will answer questions and provide detailed responses to these metrics. We expect that different programs will solve clinical challenges with unique and effective approaches. Regular progress reports will be provided to the Quality Safety Value Council and the BOD. We will modify our metrics as appropriate, and we will provide updates to the POSNA membership going forward. We intend to use this information to develop a “learning collective” in which information is shared freely and to create quality performance improvement opportunities across centers. We strive not just for high reliability but also effectiveness and efficiency of care. We seek to become a HERO–<strong>H</strong>ighly <strong>E</strong>ffective and <strong>R</strong>eliable <strong>O</strong>rganizations.</p> <p>The POSNA Safe Surgery Program recognizes that healthcare is provided in a highly matrixed, complex care environment that requires a large team. While individual surgeons play a major role in the leadership of the care team, we are dependent upon our health system to provide the resources necessary to provide optimal care to our patients and families.&nbsp; As such, many of the metrics emphasize the importance of health system commitment and provision of appropriate resources to provide ideal care. These metrics will provide POSNA members a framework upon which to build administrative, operational teams in their ambulatory and surgical environments.</p> <p>We look forward to your feedback on the POSNA Safe Surgery Program.</p> <p>&nbsp;</p> Michael Vitale Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/239 Mon, 01 Feb 2021 13:20:07 -0700 Surgical Treatment of Scheuermann's Kyphosis https://jposna.org/ojs/index.php/jposna/article/view/222 <p>Severe Scheuermann’s kyphosis can be associated with pain and a lifetime of progression. Operative treatment in carefully selected patients has been shown to improve radiographic outcomes, pain, and satisfaction compared to non-operative treatment. Historically, combined anterior disc releases and fusion with posterior instrumentation and fusion was the preferred method of treatment. However, more recently with improvements in spinal instrumentation and use of posterior osteotomies anterior surgery is rarely indicated. This paper outlines the process of a posterior spinal fusion with posterior column osteotomies for Scheuermann’s kyphosis.</p> Kira Skaggs, Kenneth Kato, Kenneth Illingworth, Lindsay Andras, David Skaggs Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/222 Mon, 01 Feb 2021 13:25:42 -0700 Surgical Treatment of Trigger Thumb and Trigger Finger https://jposna.org/ojs/index.php/jposna/article/view/229 <p>Trigger thumb and trigger finger in children both can result in a painful “triggering” or fixed contracture of the digit. Although they clinically present in a similar fashion, they have quite different treatment methods. Trigger thumb is an acquired condition, with observation for spontaneous resolution as the initial treatment. If trigger thumb fails to resolve with observation, then surgical treatment involves release of the A1 pulley. Conversely, trigger finger is usually due to a congenital difference in the finger flexor anatomy but can be due to metabolic, inflammatory and other conditions. Initial treatment of trigger finger involves extension splinting, but in cases requiring surgical treatment A1 pulley release and excision of a slip of the flexor digitorum superficialis tendon is typically needed. It is crucial for the treating provider to understand these differences in diagnosis and treatment to ensure the best outcome of these similar but unique conditions.</p> Suzanne Steinman Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/229 Mon, 01 Feb 2021 13:23:32 -0700 Radiographic Hip Screening In Cerebral Palsy: Developing POSNA Wide Consensus https://jposna.org/ojs/index.php/jposna/article/view/231 <p>Population based studies have found that approximately 33% of children with cerebral palsy are at risk for progressive lateral hip displacement/subluxation during childhood. There is growing evidence supporting the practice of hip surveillance for children with cerebral palsy and many developed countries have established national and state surveillance programs. However, across POSNA there is a lack of consensus regarding a radiographic hip screening protocol for children with cerebral palsy. Therefore, the purpose of this quality initiative was to develop a POSNA-wide radiographic hip screening schedule using a Modified Delphi technique. A group of 24 pediatric orthopedic surgeons participated in the Modified Delphi technique to achieve consensus regarding a hip radiographic screening protocol. The development of a POSNA - wide radiographic hip screening protocol has the potential to standardize screening practices across our society, decrease practice variation and ultimately improve the quality of health care delivery for children with cerebral palsy and other neuromuscular conditions. &nbsp;</p> Benjamin Shore, Kishore Mulpuri, Wade Shrader Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/231 Mon, 01 Feb 2021 13:22:51 -0700 Pathway for Implementation of Halo-Gravity Traction for the Treatment of Severe Spinal Deformities at a New Institution https://jposna.org/ojs/index.php/jposna/article/view/227 <p><strong>Background:&nbsp; </strong>Halo-Gravity Traction (HGT) is an adjunct technique for treating severe spinal deformity that has received increasing interest.&nbsp; Hospitals unfamiliar with these techniques may find implementation difficult due to the need for specialized equipment and coordination involving many healthcare providers. We aim to discuss critical steps for the implementation of HGT technique at new hospitals.</p> <p><strong>Methods: </strong>HGT was instituted in 2019 at a single, tertiary academic center under the direction and planning of multiple pediatric orthopedic spine surgeons, each experienced in HGT through work at other centers. After successful implementation and continued process review, the required components to create and execute a HGT program were reviewed and detailed.</p> <p><strong>Results: </strong>HGT initiation first requires equipment purchasing and modification. While surgeon knowledge drives clinical protocols, they must be developed in coordination with a multidisciplinary team. A sustainable HGT program requires plans for equipment maintenance as well as regular review and improvement of clinical protocols. Total institutional costs will vary but should generally be affordable to interested centers.</p> <p><strong>Conclusions: </strong>Safe and efficient implementation of HGT is achievable for orthopedists across most practice settings.</p> Gabriel Li, Keith Compson, Joseph Stone, James Sanders, Craig Louer Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/227 Mon, 01 Feb 2021 13:24:41 -0700 Disposal of Unused Opioids Using an At-home Disposal Method https://jposna.org/ojs/index.php/jposna/article/view/150 <p><strong>Introduction: </strong>At-home opioid disposal systems have been shown to increase proper opioid disposal following cessation of acute post-operative pain. As part of our Opioid Stewardship Initiative, we sought to improve proper opioid disposal by providing an at-home medication disposal product to all patients prescribed opioids for at home use.</p> <p><strong>Methods: </strong>From May 2019 to May 2020, patients prescribed opioids for acute at-home post-operative pain were given a packet of an at-home disposal product and an educational flyer describing safe at-home storage and disposal methods. Instructions regarding disposal were further iterated by an anesthesiologist during the preoperative. Families with unused opioids at the conclusion of the first post-operative meeting were encouraged to dispose of these opioids and given a reminder call two weeks after following up on opioid disposal.</p> <p><strong>Results: </strong>452 packets of the at-home disposal product were distributed. There were 355 encounters with unused opioids who were followed up. Of these 338 (95%) ultimately disposed of their unused opioid. All but 10 families used the at-home disposal product (328, 92%) as provided. A total of 97 were excluded from final analysis due to surgery cancellation (20), failure to follow-up (39), never filled prescription (21) and used all of the prescribed medication (17).</p> <p><strong>Discussion and Conclusion: </strong>Providing an at-home disposal product is a viable method of ensuring proper disposal of unused opioids. The combined cost of the disposal packet plus the instructional flyer was $1.90 per patient. Additional efforts are being undertaken to evaluate whether follow-up reminder calls at 2 weeks can be simplified to be included in the post-operative follow-up call to increase parent/guardian adherence.</p> De-An Zhang, Marilan Luong, Emmanuel Barragan , Frederic Bushnell, Robert Cho, Selina Poon Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/150 Mon, 01 Feb 2021 13:29:30 -0700 Shriners Hospitals for Children Past, Present and Future https://jposna.org/ojs/index.php/jposna/article/view/228 <p>Shriners Hospitals for Children (SHC), previously Shriners Hospitals for Crippled Children, from its beginning in 1922, has provided care to over 1.4 million children.&nbsp; The history of this great organization, from its inception to the present is an intriguing story.</p> Peter Armstrong, George Thompson Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/228 Mon, 01 Feb 2021 13:24:11 -0700 2021 Changes in E/M Codes for Office-Based Practice https://jposna.org/ojs/index.php/jposna/article/view/226 <p>In this first installment of the JPOSNA Coding Corner, we hope to demystify the 2021 changes for an easier transition to the new coding requirements for E/M billing. Future JPOSNA Coding Corner topics will have a subspecialty focus on billing for different procedures.</p> <p>Beginning January 1, 2021, changes to the CPT guide-lines for new and established outpatient evaluation and management (E/M) codes take effect. Impacting codes in the ranges 99202-99215 (new and established office or other outpatient categories), the modifications will alter documentation requirements and will affect E/M code selection for pediatric orthopaedic surgeons.</p> Ryan Muchow, Sarah Wiskerchen Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/226 Mon, 01 Feb 2021 13:23:49 -0700 Innovations in Pediatric Prosthetics https://jposna.org/ojs/index.php/jposna/article/view/221 <p>Although many of the surgical and technological advances for prosthetics have emerged from caring for adults, the pediatric patient with limb differences continues to provide unique challenges and demands appropriate, pediatric-specific innovation. Not only do children test the current technology with their size, weight, and potential growth, but also with their chosen activities, energy-level and drive to explore varied environments. This article explores the recent advances within the broader realm of prosthetics, primarily based on research in adult patients.&nbsp; It identifies technologies that have already been translated to pediatric populations and points out areas for potential pediatric applications. This review also highlights numerous needs and gaps in the currently available resources and tools for these patients, including surgical techniques, prosthetic componentry, and rehabilitation strategies. Further innovation and research are needed for pediatric patients to maximize their functional potential while using a prosthesis.</p> Michelle Hall, Rosanna Wustrack, Donald Cummings, Richard Welling Jr., Mary Kaleta, Kevin Koenig Jr., Jennifer Laine, Sara Morgan Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/221 Mon, 01 Feb 2021 13:25:59 -0700 A Primer on Statistics https://jposna.org/ojs/index.php/jposna/article/view/219 <p>Statistics describe the major findings of every paper we read and are often the basis of the decisions we make every day taking care of patients in the clinic and the OR.&nbsp; This article serves as a review of common statistical terms in a “case-based” format. We will explain Standard Deviation, P-value, Number Needed to Treat, Confidence Interval, Sensitivity, Specificity, Negative and Positive Predictive Value.&nbsp;</p> Sara Davis, Neeraj Patel, Ifeoma Inneh, Raymond Guo, Justin Mistovich, Tracey Bastrom, Scott McKay Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/219 Mon, 01 Feb 2021 13:26:40 -0700 Coping Skills in Children https://jposna.org/ojs/index.php/jposna/article/view/211 <p>Pain management is a significant challenge for both families and physicians following major orthopaedic surgery in children. A variety of psychosocial factors have all been documented to affect post-operative pain, including anxiety, catastrophizing and self-efficacy. Unfortunately, interventions attempting to address these different variables have been limited across pediatric orthopaedics. &nbsp;In this article we review the psychosocial constructs that impact a child’s ability to manage pain while recovering from pediatric orthopaedic surgery. Additionally, we will highlight some promising coping skills and resilience interventions to date as well as what the ‘ideal’ psychosocial intervention might encompass. By familiarizing our colleagues with the evidence behind each of these concepts, we hope to improve surgeon confidence in managing psychosocial issues and catalyze efforts aimed at addressing this important knowledge gap.</p> Alex Gornitzky, Mohammad Diab Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/211 Mon, 01 Feb 2021 13:28:55 -0700 Platelet Dysfunction in Major Pediatric Scoliosis Surgery: A Cause of Common Surgical Bleeding Phenotypes https://jposna.org/ojs/index.php/jposna/article/view/216 <p><strong>Objectives:</strong> <br>Spinal fusion is often complicated by high blood loss and the clinically observed phenomenon of increased bleeding times throughout the case. Although the pathophysiology of this phenomenon involves hyperfibrinolysis and occurs to a lesser extent in the presence of antifibrinolytics (e.g. TXA), we hypothesize that perioperative changes in platelet function also contribute to this continued observation.</p> <p><strong>Methods:</strong> <br>Blood samples were acquired from patients undergoing posterior spinal fusion for correcting scoliosis (5 neuromuscular, 3 idiopathic ). Samples were obtained immediately before the procedure, at 2, 4, and 6 hours post-incision, and the subsequent morning (POD1). Platelet activation in response to stimulation with an intravascular agonist, thrombin, and an extravascular agonist, convulxin, was measured by flow cytometry. Activation of the fibrin-binding integrin glycoprotein IIb/IIIa (GpIIb/IIIa) was reported by PAC-1 binding and expression of the alpha-granule component P-selectin was reported by CD62p binding. CBCs and Thromboelastography (TEG) were performed on samples in parallel. Estimated blood loss (EBL) was calculated using a hematocrit-based analysis of red cell mass.</p> <p><strong>Results:<br></strong>All 5 neuromuscular patients exhibited a marked and progressive decline in platelet count and activity throughout surgery and early postoperative period. Reductions were most notable for thrombin-stimulated GpIIb/IIIa activation (Th PAC1) at 4 hrs (mean 41.7%, p=0.0056) and 6 hrs (50.9%, p=0.0096). Similar trends in mean reductions were observed for thrombin stimulated P- selectin expression (Th P-Selectin) at 6 hrs (22.5%, p=0.0112) and on POD1 (39.2%, p=0.0274). Patients with idiopathic scoliosis demonstrated significant reductions in convulxin-stimulated GpIIb/IIIa activation (32.8%, p=0.0087) and P-selectin expression (35.1%, p=0.0147) at 2 hrs, which recovered to or increased beyond baseline thereafter.</p> <p>These trends also manifested on TEG for all neuromuscular patients as the average time to maximum clot strength increased by 48.8% at 6 hrs (p=0.0058).</p> <p>Furthermore, platelet activity correlated with the calculated EBL for all 8 patients (Th PAC1 at 4 hrs R= -0.673, p=0.146 and 6 hrs: R= -0.623, p=0.099; Th P-Selectin at 6 hrs: R= -0.694 p = 0.056 and POD1: R= -0.713, p=0.047). EBL also significantly correlated with reductions in platelet count at 6 hrs (R= -0.919, p=0.010) and absolute platelet count on POD1 (R= -0.858, p=0.006).</p> <p><strong>Conclusions:</strong> <br>We have observed a progressive reduction in platelet activation and fibrin-dependent clot formation throughout scoliosis surgery, particularly in patients with neuromuscular disease. High endothelial injury related to achieving surgical exposure may account for the early drop in response to the extravascular collagen receptor agonist, convulxin. Measures associated with secondary hemostasis, such as the thrombin-stimulated platelet activation and time to maximum clot strength, both demonstrated exhaustion towards the post-operative period. These data suggest that surgically-induced disruption in platelet function may be a key component of the coagulopathic phenomenon described and closely associated with blood loss.</p> Lydia McKeithan, Matthew Duvernay, Vaibhav Tadepalli, Stephanie N. Moore-Lotridge, Breanne Gibson, Alexandra Borst, Jonathan Schoenecker Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/216 Mon, 01 Feb 2021 13:27:34 -0700 Comparison of Long vs. Short Leg Casts for Distal Third Tibial Shaft Fractures in Children https://jposna.org/ojs/index.php/jposna/article/view/215 <p><strong>Background/Purpose:<br></strong>Long leg casts (LLC) with delayed weight-bearing is an established treatment for pediatric tibial shaft fractures including fractures involving the distal third. There is a paucity of literature assessing the use of SLC for tibial shaft fractures. The purpose of this study was to determine if SLC and early weight-bearing was as effective as LLC with delayed weight-bearing for the treatment of pediatric distal third tibial shaft fractures.</p> <p><strong>Methods:</strong><br>A retrospective review was conducted on consecutive distal third tibial shaft fractures treated at a tertiary pediatric hospital from 2015 to 2018. Exclusion criteria included midshaft and proximal fractures of the tibia, distal fractures that violated the tibial physis or plafond, and pathologic fractures. We compared primary outcomes of time to weight-bearing, time to union, and final angulation between LLC and SLC groups.</p> <p><strong>Results:<br></strong>Eighty-five patients aged 5 to 17 years (mean age 9.2±3.2 years) met inclusion criteria, including 50 LLC and 35 SLC patients. Fracture type (p=0.14), presence of associated fibula fracture (p=0.49), open fracture (p=0.46), and injury mechanism (p=0.18) were similar between the two groups. Time to weight-bearing for SLC (3.3±0.6 weeks) was shorter compared to LLC (6.4±0.7 weeks, p&lt;0.0001). Overall, fractures treated with SLC had a shorter time to union (7.4±0.9 weeks) compared to LLC (9.0±0.9 weeks, p=0.026) without differences in final angulation (p=0.54). There was a higher percentage of cast complications in the LLC treatment group (12%) compared to SLC (6%).</p> <p><strong>Conclusion:</strong><br>SLC with early weight-bearing demonstrated earlier time to weight-bearing and shorter time to fracture union when compared to LLC. Surgeons should consider SLC and early weight-bearing for the treatment of distal third tibial shaft fractures in children.</p> Scott A. Barnett, Michael J. Heffernan, Bailli Fontenot, Sagar Shah, Claudia Leonardi, Joseph Gonzales, Dominic Gargiulo Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/215 Mon, 01 Feb 2021 13:27:51 -0700 Developmental Dysplasia of the Hip: Quantifying if Patients Read, Understand, and Act on Online Resources? https://jposna.org/ojs/index.php/jposna/article/view/214 <p><strong>Introduction: <br></strong>Parents often access online resources to educate themselves when a child is diagnosed with developmental dysplasia of the hip (DDH). In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding DDH would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). It was additionally hypothesized that the readability, understandability, and actionability would not correlate with search rank.</p> <p><strong>Methods: <br></strong>Patient education materials were identified utilizing two independent online searches of the term “DDH” utilizing a commonly used search ending. From the top 50 search results, websites were included if directed at educating patients/parents regarding DDH. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to DDH were excluded. The readability of included resources was quantified using the Flesch-Kincaid Grade Level Index. The Patient Education Materials Assessment Tool (PEMAT) was used to assess understandability and actionability using a 0-100% scale for both measures of interest. Spearman’s rho was used to examine the association between a website’s average search rank (from first to last) and its readability, understandability, and actionability. Statistical significance was defined as p&lt;0.05.</p> <p><strong>Results: <br></strong>From 60 unique websites, 37 websites met inclusion criteria. The mean reading grade level (Flesch-Kincaid) was 12.54±2.72, with no websites having a reading level ≤ 6. No readability statistics were statistically associated with search rank (lowest three p-values: 0.80, 0.83, 0.85).</p> <p>Mean understandability and actionability scores were 55.19± 13.96 and 16.58±21.69, respectively. Among understandability criteria, only 27.03% (10/37) resources made their purpose evident and only 10.81% (4/37) included summaries. Among actionability categories, 40.54% (15/37) of websites identified ≥1 action for readers, but only 5.41% (2/37) studies broke down actions into explicit, easy to understand steps. The order of search results was not associated with understandability (rho: -0.21, p=0.22) or actionability (rho: 0.0878, p=0.61).</p> <p><strong>Conclusion: <br></strong>Overall, the online DDH patient/parent educational materials that were assessed scored poorly with respect to readability, understandability, and actionability. Currently, search rank for DDH materials is not associated with the readability, understandability, or actionability of these resources. In the era of shared decision-making and readily available information, patients often turn to the internet for additional insight into the diagnosis, management, and outcomes of DDH.</p> <p>Therefore, future efforts should be made by medical professionals to improve the readability, understandability, and actionability of online resources in order to optimize parental understanding and facilitate informed decision-making.</p> Holly K. Conger, Stuart Weinstein, Burke Gao, Trevor Gulbrandsen, Alan Shamrock, Mary-Kate Skalitzky, Joshua Holt Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/214 Mon, 01 Feb 2021 13:28:10 -0700 Rate of Concomitant Cellulitis and Osteoarticular Infections in a Pediatric Population https://jposna.org/ojs/index.php/jposna/article/view/213 <p><strong>Purpose: <br></strong>Concern for infection is a common presentation in pediatric emergency departments with cellulitis being one of the most common infections encountered. Cellulitis is frequently treated with antibiotics alone with the rare need for surgical intervention. This is in comparison to pediatric musculoskeletal infections. These common occurrences have the potential to cause rapid destruction and long term sequelae if not treated promptly and appropriately. Advanced imaging prior to surgical intervention is frequently used in the treatment of deep infections. Within our institution, we have noted that clinical signs consistent with cellulitis commonly lead to a work up for deep musculoskeletal infections despite a lack of evidence to suggest that the two entities commonly co-exist. The aim of this study is to identify the rate of concomitant cellulitis with osteomyelitis or septic arthritis.</p> <p><strong>Methods: <br></strong>A retrospective study was performed of 482 patients at a single, tertiary care institution undergoing MRI to evaluate for deep infection from January 2008 to December 2018. Charts were reviewed for clinical signs of cellulitis as documented in the admission history and physical exam note. MRI reports were then examined and findings of cellulitis and/or deep musculoskeletal infections were recorded. The data was analyzed to determine the incidence of concomitant cellulitis with deep infection.</p> <p><strong>Results:<br></strong>Of the 482 patients undergoing MRI, 238 had documented signs of cellulitis. Of these, 52 cases (10.8%) were found to have both cellulitis upon clinical presentation and an associated deep musculoskeletal infection on MRI. On the basis of location, 92.3% were found to be involving bone in the subcutaneous location of the hand and wrist or the foot and ankle (GROUP 1). There were 116 cases in Group 1 with 48 cases (41.4%) of concomitant cellulitis and deep infection. The remaining skeletal sites (Group 2) consisted of 122 cases with 4 cases (3.3%) of concurrent cellulitis and deep musculoskeletal involvement. A significant difference in the rate of concomitant cellulitis and deep osteoarticular infections were found based on location (p&lt;0.0001).</p> <p><strong>Conclusion: <br></strong>When cellulitis is seen in the areas of the hand and wrist as well as the foot and ankle, there Is a greater than 40% chance of a deep musculoskeletal infection. This is compared to the remaining skeletal sites in which a rate of just over 3% of concomitant cellulitis and deep osteoarticular infection was found. The index of suspicion for additional deep involvement of the musculoskeletal system should be high when cellulitis is seen in the distal extremities. Yet, when found on the other areas of the body, a low likelihood of deep infection is present and advanced imaging may not be indicated at initial presentation.</p> Claire Ryan, Matthew Ellington, Christopher Souder Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/213 Mon, 01 Feb 2021 13:28:24 -0700 Non-Accidental Trauma in Pediatric Elbow Fractures — Beware of Non-Ambulatory Elbow Fractures https://jposna.org/ojs/index.php/jposna/article/view/212 <p><strong>Background/Purpose: <br></strong>Non-accidental trauma (NAT) remains a major cause of morbidity and mortality in childhood, with fractures serving as the second most common presenting sign of abuse. Conventionally, elbow fractures are more frequently associated with accidental trauma than NAT. We hypothesized that elbow fractures in non-early ambulatory children are at risk of a NAT mechanism.</p> <p><strong>Methods:<br></strong>Patients were identified using an institutional database of pediatric elbow fractures at a large, tertiary pediatric hospital between 2007 and 2017. A diagnosis of NAT was established if a physician specializing in Child Abuse Pediatrics confirmed that the trauma was the result of NAT by their clinical judgement, if custody of the child was altered as a result of the case, or if legal documentation of criminal investigation secondary to the case was found.</p> <p><strong>Results:<br></strong>Of 4,608 elbow fractures in the database, 21 were confirmed to be caused by NAT. Fifteen (71%) of the patients were male with a median age of 0.7 years-old and a range between 0.1 and 10.4 years (Table 1). Of the 21 elbow fractures associated with NAT, there were 11 supracondylar (further subclassified as 3 Gartland I, 3 Gartland II, 1 Gartland IIIa, 1 Metaphyseal-Diaphyseal Junction fracture and 3 unspecified), 5 lateral condyle, 4 humeral shaft fractures involving the elbow and 1 radial head fracture. Of the 21 patients identified, 12 (57%) were found to have bruising inconsistent with the mechanism given or unrelated to the injury, while 11 (52%) had additional fractures or healing fractures identified. Seventeen (81%) injuries were determined to be inconsistent with mechanism of injury described or did not specify mechanism. Among all the patients presenting with an elbow fracture under the age of 1 over a 10-year span, 33% were determined to have suffered NAT (12/36). Patients between 1 and 2 and older than 2 presenting with elbow fractures had injuries caused by NAT 1% (3/221) and 0.1% (6/4350) of the time respectively.</p> <p><strong>Conclusion:<br></strong>While elbow fractures are rarely considered a result of NAT in most age groups, a high degree of clinical suspicion should be maintained for elbow fractures in children under one. For comparison, in children under one year presenting with femur fractures, widely considered to be pathognomonic of child abuse, 16-35% are the result of NAT. An overwhelming majority of patients with elbow fractures resulting from NAT presented with additional bruising and injuries. However, a minority did not, and suspicion is only raised as a result of the mechanism provided. Thus, it is imperative that medical personal who encounter pediatric injuries understand the natural history of these injuries and vigilantly evaluate for their common signs in order to identify possible NAT.</p> Vaibhav Tadepalli, Stephanie N. Moore-Lotridge, Jonathan Schoenecker, Andrew B. Rees, Jacob Schultz, Lucas Wollenman Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/212 Mon, 01 Feb 2021 13:28:37 -0700 “RAMBO” Lesions: Radiographic Anomalies Missed by Orthopaedists https://jposna.org/ojs/index.php/jposna/article/view/233 <p><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SpellingErrorHighlight SCXW167256572 BCX4">Orthop</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SpellingErrorHighlight SCXW167256572 BCX4">a</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SpellingErrorHighlight SCXW167256572 BCX4">edists</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> are typically skilled diagnosticians as orthopedic training involves frequent evaluation of radiographs</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">,</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> but</span></span> <span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">even a seasoned orthopedist has the potential to miss certain anomalies on </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">radiographic</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> images</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">.</span></span> <span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">Misdiagnosis can lead to morbidity, malunion, increased need for surgical procedures, or osteonecrosis of a large joint. </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">“RAMBO” lesions, or radiographic </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">anomalies missed by </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">orthop</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">a</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">edists</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">,</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> are a subset of traumatic pediatric injuries that can be missed by an </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">orthop</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">a</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">edist</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">. </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">T</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">hese include </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">t</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">ransphyseal</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> fracture of the distal humerus, </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">Monteggia</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> injury, entrapped medial epicondyle fracture of the elbow, hip dislocation with incongruous hip after reduction, and lower extremity ipsilateral second fractures</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">. </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">Radiographs of skeletally immature </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">patients </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">offer additional challenges in interpretation as many providers may be unfamiliar with the radiographic anatomy of younger patients. Understanding the characteristics of pediatric radiographs and a high index of clinical suspicion help prevent missing certain subtleties on radiographs. </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">The purpose of this article is to review a few key traumatic pediatric radiographic anomalies missed by </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">orthop</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">a</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">edists</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">, deemed RAMBO lesions</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">,</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> with the aim</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">s</span></span> <span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">of</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> further educat</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">ing</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> highly skilled </span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">orthop</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">a</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SpellingErrorV2 SCXW167256572 BCX4">edic</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> surgeons and prevent</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4">ing</span></span><span class="TextRun SCXW167256572 BCX4" lang="EN-US" xml:lang="EN-US" data-contrast="auto"><span class="NormalTextRun SCXW167256572 BCX4"> radiographic anomalies from being missed.&nbsp;&nbsp;</span></span></p> Anna Rambo, Trevor McGee, David Spence, Benjamin Sheffer, Derek Kelly, James Beaty Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/233 Mon, 01 Feb 2021 13:22:31 -0700 Antibiotic Considerations in the Management of Pediatric Open Fractures https://jposna.org/ojs/index.php/jposna/article/view/225 <p>Open fractures represent 2–9% of all pediatric fractures. Standard treatment in the Emergency Department (ED) includes prompt administration of intravenous antibiotics and tetanus prophylaxis, bedside irrigation, and reduction or immobilization based on the fracture pattern. Recommendations for management of open fractures in the pediatric population are mostly based on a 1989 landmark study by Patzakis et al. which analyzed factors influencing infection rates in adults and ultimately concluded that Cefazolin was superior to fluroquinolones or no antibiotics. Subsequent studies regarding antibiotic administration in the pediatric population have been less evidence-based, often choosing antibiotic protocols based on physician discretion and institutional practice patterns. To our knowledge, there is no consensus regarding optimal antibiotic treatment protocols for pediatric open fractures. To that end, we set out to review the literature for current trends in antibiotic management of open pediatric fractures. We specifically reviewed antibiotic choice, length of treatment, and subsequent infection rates.</p> <p>Based on our review of the literature we found that Gustilo and Anderson Type I pediatric open fractures are generally managed with the administration of a first-generation cephalosporin (e.g. Cefazolin) within three hours of injury, bedside irrigation, and fracture stabilization in the emergency department. Types II &amp; III fractures may be similarly managed with a first-generation cephalosporin and provisional bedside irrigation, and fracture stabilization; however, these fracture types require further debridement and fracture stabilization in the operating room. Additional gram-negative coverage (e.g. Gentamicin) is frequently added for Type 3 fractures, and in cases of farm injuries, anti-clostridial drugs such as penicillin may be added; the evidence supporting these practices, however, is lacking. Overall, we found a paucity of high-quality evidence regarding antibiotic management of open pediatric fractures.</p> Edgar Garcia-Lopez, Emil Stefan Vutescu, Sebastian Orman, Jonathan Schiller, Craig P. Eberson, Aristides I. Cruz Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/225 Mon, 01 Feb 2021 13:25:01 -0700 Pain Management in Acute Fracture Care https://jposna.org/ojs/index.php/jposna/article/view/220 <p>The management of pediatric and adolescent pain continues to evolve.&nbsp; Pain, as in the adult population, is a complex process modulated by both physiologic and psychological factors. It is essential for the orthopedic clinician who manages pain in the acute setting to not only understand the medical aspects of pain control, but also the larger context in which the injury is taking place. &nbsp;The opioid crisis has changed the manner in which pain management is delivered, and an understanding of pediatric physiology is critical for delivering analgesia.&nbsp; This is particularly important in the setting of acute fracture management.&nbsp; Utilization of anti-inflammatory medications, diversion techniques, and regional anesthesia are integral to management in the emergency room, pre-operatively, intra-operatively, and post-operatively. A multi-faceted, holistic approach is essential to achieve successful clinical outcomes.</p> Ishaan Swarup, Nirav Pandya Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/220 Mon, 01 Feb 2021 13:26:22 -0700 Pearls and Pitfalls of Forearm Nailing https://jposna.org/ojs/index.php/jposna/article/view/218 <p>Pediatric forearm fractures are one of the most common injuries that pediatric orthopaedic surgeons manage. Unstable fractures that have failed closed reduction and casting require surgical intervention in order to correct length, alignment, and rotation to optimize forearm range of motion and function. Flexible intramedullary nailing (FIN) is a powerful technique that has garnered widespread popularity and adaptation for this purpose. Surgeons must become familiar with the technical pearls and pitfalls associated with this technique in an effort to prevent complications.</p> Sreeharsha Nandyala, Benjamin Shore, Grant Hogue Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/218 Mon, 01 Feb 2021 13:26:56 -0700 Pediatric Cervical Spine Instrumentation https://jposna.org/ojs/index.php/jposna/article/view/235 <p>Pediatric cervical spine fixation can be challenging to place as it must accommodate small and often abnormal anatomy. However, multiple safe options exist. Halo-vest orthosis is a useful adjuvant technique to modern rigid implants. Occipital plates, C1 lateral mass screws, multiple C2 trajectories, and subaxial lateral mass screws all have proven efficacy in young children. Anterior approach for decompression and anterior column support is possible, with creative implant and graft solutions in the smallest children. While complications are reported, modern rigid implants can be used safely in pediatric spine with careful pre-operative anatomic understanding and planning.</p> Jennifer M. Bauer, Douglas L. Brockmeyer, Josh M. Pahys, Burt Yaszay, Daniel J. Hedequist Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/235 Mon, 01 Feb 2021 13:21:59 -0700 Pneumatic Powered Kerrison Rongeur in Spine Surgery Can Benefit Patient and Surgeon https://jposna.org/ojs/index.php/jposna/article/view/230 <p>Spinal deformity surgeons are at increased risk of overuse injuries. The use of power instruments has been incorporated to reduce the rate of occupational injuries and increase efficiency of surgery without increasing risk to the patient. The pneumatic powered Kerrison rongeur minimizes the force a surgeon must apply and theoretically may increase precision. The purpose of this paper is to review the technique and safety of the pneumatic Kerrison in pediatric spine deformity surgery.</p> Kyle Obana, Kenneth Kato, Kenneth Illingworth, Lindsay Andras, David Skaggs Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/230 Mon, 01 Feb 2021 13:23:18 -0700 The Contemporary Role for Hip Arthrodesis in Adolescents and Young Adults https://jposna.org/ojs/index.php/jposna/article/view/171 <p>There are two modes of surgical treatment for end stage arthritis in the young patient. Hip arthrodesis and arthroplasty are historically proven options.&nbsp; Currently, patient and surgeon related factors influence choice of treatment. Arthrodesis relieves arthritic pain and enables modified function with expected eventual transition to arthroplasty. Advances in arthroplasty implants have increased component survivorship but studies are still needed to determine outcomes using modern implants. Conversion arthroplasty following arthrodesis provides good outcomes with significant functional gain. Primary total hip arthroplasty for young patients is increasingly accepted due to improvements and consistency of implantation and more patient-expected natural levels of function. &nbsp;Data supporting arthrodesis or arthroplasty for young patients with end stage hip arthritis requires further study. This article summarizes the dilemma, provides current data in order to help guide decision-making.</p> Radomir Dimovski, Ira Zaltz Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/171 Mon, 01 Feb 2021 13:29:13 -0700 Expanded Indications for Guided Growth in Pediatric Extremities https://jposna.org/ojs/index.php/jposna/article/view/217 <p>Guided growth for coronal plane knee deformity has successfully historically been utilized for knee valgus, and knee varus. More recent use of this technique has expanded its indications to correct other lower and upper extremity deformities such as hallux valgus, hindfoot calcaneus, ankle valgus and equinus, rotational abnormalities of the lower extremity, knee flexion, coxa valga, and distal radius deformity. &nbsp;Guiding the growth of the extremity can be successful and is a low morbidity method for correcting deformity and should be considered early in the treatment of these conditions, when the child has a minimum of 2 years of growth remaining. Further expansion of the application of this concept in the treatment of pediatric limb deformities should be considered</p> Teresa Cappello Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/217 Mon, 01 Feb 2021 13:27:16 -0700 Instrumented Gait Analysis in the Care of Children with Cerebral Palsy https://jposna.org/ojs/index.php/jposna/article/view/237 <p>Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation.&nbsp;&nbsp; Children with cerebral palsy often have significant gait impairments that negatively impact their ambulation, activity in society, and their quality of life.&nbsp;&nbsp; Instrumented gait analysis, with motion capture, can provide significant data to help the surgeon better understand specific pathophysiology and to plan surgical correction.&nbsp;&nbsp; Modern instrumented gait analysis is comprised of many components, including kinematics, kinetics, electromyography, pedobarography, and metabolic assessment. Newer technology allows for wearable measurement devices in the community to provide information about environmental activity, such as step counts, that augment information traditionally measured in gait laboratories. The synthesis of data from these components allow for the team to accurately assess individual components of pathological gait and systematically plan surgical procedures to address the significant impairments.&nbsp;&nbsp; Literature suggests that the use of instrumented gait analysis can be effective in the treatment and care of children with cerebral palsy. Following surgical recommendations from gait analysis can lead to changes in surgical plans derived from physical exam alone, overall less surgical procedures, and possibly improved outcomes.&nbsp;&nbsp;</p> Wade Shrader, Celestine Shih, Tyler McDonald Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/237 Mon, 01 Feb 2021 13:21:22 -0700 Adolescent Bunions: Treatment Options and Technical Pearls for the Distal Percutaneous Osteotomy https://jposna.org/ojs/index.php/jposna/article/view/224 <p>Juvenile hallux valgus is a complex condition that is associated with multiple forefoot abnormalities and can be accompanied by a flexible flat foot. Initial treatment remains conservative with large toe box shoes, pain control, stretching, taping, or spacers. When indicated, surgical treatment is controversial because of the greater than 100 described surgical procedures and a historically high prevalence of recurrence. However, more recent reviews of surgical techniques for juvenile bunions show less recurrence than previously reported. The percutaneous distal metatarsal osteotomy is one procedure that offers many advantages to correcting adolescent hallux valgus deformities including minimal scar, immediate weight bearing, and effectiveness at correcting the deformity in a reproducible manner. The purpose of this paper is to review the management of juvenile/adolescent bunions and share technical pearls for the successful treatment with a percutaneous distal metatarsal osteotomy.</p> <ul> <li>Juvenile bunions are complex deformities that are not “younger” versions of adult bunions because of an increased dysplastic metatarsal articular angle.</li> <li>Lesser toe deformities may accompany the obvious hallux valgus deformity.</li> <li>Historically high rates of recurrence for surgical treatment are decreasing with improved techniques such as percutaneous distal metatarsal osteotomy.</li> </ul> <p><strong>&nbsp;</strong></p> Louise Reid Nichols, Kathryn Ritacco, Marie Gdalevitch Copyright (c) 2021 JPOSNA https://jposna.org/ojs/index.php/jposna/article/view/224 Mon, 01 Feb 2021 13:25:20 -0700