Journal of the Pediatric Orthopaedic Society of North America
JPOSNA® (the Journal of the Pediatric Orthopaedic Society of North America) is an open access journal focusing on pediatric orthopaedic conditions, treatment, and technology.
The Generational Differences in Growth-Friendly Treatment Utilization for Early-Onset Scoliosis
Background: The development of new growth-friendly techniques for treating early onset scoliosis (EOS) has resulted in a rapidly changing landscape of available treatment strategies. There is no literature revealing how a surgeon’s years in practice (YIP) is related to the EOS techniques they learned in fellowship and how their YIP influences their decision making in selecting EOS constructs. Methods: A 25-question survey was electronically delivered to 144 surgeons who treat EOS, and 87 (60%) responded. Surgeons were divided into two groups: a younger group (YG) with 0-10 YIP and an older group (OG) with ＞10 YIP. Growth-friendly techniques queried included serial casting, traditional growing rods (TGR), Vertical Expandable Prosthetic Titanium Rib (VEPTR), non-VEPTR rib constructs, Magnetically Controlled Growing Rods (MCGR), and SHILLA. A Chi-square analysis was used to determine differences between the YIP groups with regards to which techniques surgeons learned in fellowship and which techniques they use in practice. Results: One-hundred percent (38/38) of the YG surgeons were fellowship trained, vs 87.8% (43/49) of the OG surgeons. More YG vs OG surgeons received fellowship training in serial casting (84.2% vs 38.8%, p<0.001), TGR (94.7% vs 63.3%, p<0.001), VEPTR (65.8% vs 28.6, p<0.001), non-VEPTR rib constructs (55.3% vs 16.3%, p<0.001), and MCGR (47.4% vs 2%, p<0.001). OG surgeons were more likely to use TGR in the last 3 years, with 26% of YG vs 6% of OG surgeons never utilizing TGR, and 5% of YG vs 31% of OG surgeons performing TGR cases > 10 times (p=.004). Regarding treatment preferences, more YG surgeons (84.2% vs 39.6%, p<0.001) preferred to delay intervention until final fusion, rather than use any growth-friendly techniques. Furthermore, YG surgeons see a limited need for growth-friendly constructs other than MCGR. Conclusions: YG surgeons were more likely to learn growth-friendly techniques in fellowship than OG surgeons, though in their practices the groups use growth-friendly techniques at similar rates. Compared to OG surgeons, YG surgeons prefer performing definitive fusions over utilizing any growth-friendly surgical techniques.
Copyright (c) 2023 Journal of the Pediatric Orthopaedic Society of North America https://www.posna.org
Scoliosis Bracing: Details Make the Difference
Effective bracing for idiopathic scoliosis is influenced by factors such as age, skeletal maturity, and curve attributes, with success reliant on patient adherence and engagement. The BrAIST study highlights the merits of full-time bracing (16-23 hours/day) for most curves, though part-time wear, yielding around 70% curve correction, may be suitable for smaller curves. Maintaining communication among the orthopedic surgeon, orthotist, and patient is paramount. Using standardized, effective communication detailing patient data, including radiographic measurements, supports clear communication between all parties. Consistent orthotist visits are important to ensure correct brace fit by evaluating aspects like tightness, comfort, and deformity correction. Monitoring growth metrics like height and weight can signal necessary adjustments. An initial in-brace x-ray facilitates early refinements, with subsequent imaging based on growth stages and brace adherence. Adherence monitors augment treatment by tracking brace-wear patterns. Weaning protocols, aiming to reduce brace wear gradually while curbing curve progression, are influenced by factors such as curve size, brace comfort and skeletal maturity markers. Lastly, psychological aspects cannot be overlooked. Overcoming barriers like physical discomfort and self-consciousness is pivotal for effective treatment. Emphasizing resilience, choice, and emotional support ensures enhanced patient commitment and satisfaction, leading to the best possible outcomes.
On November 1, 2019, POSNA published the inaugural edition of JPOSNA®. Over the last 4 years, our journal has grown in content and importance. We started as a journal exclusively focused on educational content, such as Current Concept Reviews and Surgical Techniques. Two years ago, under the leadership of Deputy Editor JR Cruz, we started accepting, adjudicating, and publishing Original Research. The number of these submissions has risen at a very high rate, and the quality is excellent. Our journal has been a fantastic resource for practicing pediatric orthopaedists, residents, and fellows. In addition to providing a location for publishing great content, our journal was an important revenue stream for our society when the pandemic reduced income from POSNA meetings. The success of JPOSNA® is a POSNA success story. Your passion for educating, performing research, and advancing orthopaedic care for children is YOUR SUCCESS. Recently, POSNA leadership formed a partnership with Elsevier. Together, we will continue to produce the same high-quality content you have come to expect from this journal. Elsevier’s staff and publishing platform will take JPOSNA® to the next level, where we will have a more global impact and where our research will be easily discovered and read through indexing databases. We must recognize and thank our current Associate Editors for their outstanding work to date and appreciate their continued service in the future. We stand in awe and in the shadow of the foundational contribution of Bryan Tompkins who created the original JPOSNA® platform, spending only a few hundred dollars on software. Finally, we thank the POSNA staff, especially Executive Director Teri Stech and Managing Editor Lisa Dushane (who seems to answer emails at all hours of the day). It’s quite remarkable what they have done to facilitate our journal’s rise. The following are answers to concerns/questions that we anticipate many of you may have in this time of transition. No changes to journal ownership or editorial policies Elsevier will provide production, sales, and marketing services for JPOSNA® journals. While this partnership will add considerable resources and expertise to the JPOSNA® publications program, it will not impact ownership or control over decisions impacting JPOSNA®. We will continue to set policies that govern access to content and editorial appointments, for example. Similarly, the partnership will not impact editorial policies or publication decision criteria, which remain the sole purview of journal editors. Information for authors and reviewers At the current moment, we ask authors to hold new submissions to the current JPOSNA® website until the Editorial Manager submission site is available sometime before the end of 2023. Will the submission site change? A new submission site will be created in Editorial Manager (EM) for JPOSNA®, and the details of this will be shared with you as soon as they are ready. Will the Elsevier agreement affect readership and citations of my article? Through posting of JPOSNA® content on ScienceDirect, we expect exposure to your content to grow. In addition, with the help of a new generation of Elsevier platforms and analytical solutions, we expect JPOSNA® content to be discoverable to an even broader pool of researchers and health professionals. Under Elsevier’s open access agreements with countries and institutions, authors from well over 30 organizations will have the opportunity to publish under open access licenses via publish and read funding agreements. Finally, in partnership with Elsevier, JPOSNA® plans to transform into a fully open access journal as of 2024. It is with great excitement that we start a new chapter in the history of JPOSNA® and our mission to improve musculoskeletal health in children. I think we can expect great things as we walk this journey together.
Parental Awareness and Attitudes Towards ACL Injury Prevention Programs in Youth Athletes
Background: The incidence of anterior cruciate ligament (ACL) injuries has steadily increased in young athletes and may have long-term implications for physical function and quality of life. ACL injury prevention programs have been developed and refined over the past several decades and have been shown to reduce the risk of ACL injuries by up to 70%1,2. However, awareness and understanding of these programs among parents of athletes is unknown. This study aims to evaluate knowledge and attitudes towards ACL injury prevention programs for parents of young athletes involved in cutting and pivoting sports at varying levels of competition. Methods: A cross-sectional survey was nationally distributed to a convenience sample of parents of young athletes between the ages of 5 and 18. The survey focused on questions relating to demographic information, history of ACL injury, knowledge of ACL injury prevention programs, and factors influencing program awareness. Descriptive statistics were used to summarize participant characteristics and determine prevalence of program awareness. Results: A total of 244 parents completed the survey with 74% indicating their child’s primary sport was soccer. Seventy-seven percent of these athletes began specializing in their primary sport at an average age of 8 years old (SD = 2.72). Only 18% of parents reported knowledge of ACL injury prevention programs and just 6% reported their child has ever participated in one. Of the 29 (12%) athletes who had experienced an ACL injury, only 17% had ever participated in an ACL injury prevention program. The most common reported barrier of ACL injury prevention program participation was the lack of awareness of where to get such training and it not being readily offered to their child. Sixty-eight percent of all parents would have their child participate in an ACL injury prevention program if offered to them. Conclusion: There is a lack of awareness of ACL injury prevention programs among parents of young athletes involved in high injury-risk sports. However, most parents would be interested in their child utilizing an ACL injury prevention program if it were offered.
Outcomes of Operative Management of Multi-Ligament Knee Injuries in an Adolescent Population: A Retrospective Case Series
Background: The aim of this study was to describe the presentation, surgical management, and patient outcomes following multi-ligament knee injuries in a pediatric and adolescent cohort. Methods: A retrospective case series was conducted involving all patients aged <18 years who underwent surgery for a multi-ligament knee injury at a single institution between March 2005 and January 2015. Outcome questionnaires were administered, including Pediatric version of International Knee Documentation Committee (Pedi-IKDC), Lysholm score, Tegner activity scale, and an internal physical activity questionnaire. Results: Twenty-three knees from 23 patients were included with a mean (SD) age of 16.4 (± 2.3) years at time of injury. The most commonly injured structure requiring reconstruction or repair was the anterior cruciate ligament (91%), the medial collateral ligament (57%), posterior cruciate ligament (22%), posterolateral corner (22%), and lateral collateral ligament (15%). Meniscal procedures were performed concurrently in 65% knees. Subsequent manipulation under anesthesia and arthroscopic lysis of adhesions was performed in five (22%) knees. Examination at final follow-up, occurring at a median of 20.1 months, demonstrated 100% knees could achieve full extension and 87% could achieve full flexion. Questionnaires were returned by 12 patients (52%) at a median of 3.7 years post-operatively. The mean Pedi-IKDC, Lysholm, and Tegner scores were 81.0 18.1, 82.5 15.5, and 8.3, respectively. Conclusions: In this study, multiligament knee injuries in children and adolescents resulted mainly from sports-related injuries. Patients were generally able to achieve good functional outcomes at short term follow-up and return to sport was possible.
Plain Radiographs Have Limited Utility in the Evaluation of Discoid Lateral Meniscus
Background: Debate persists regarding the utility of plain film radiography in the diagnosis of discoid lateral meniscus, especially in children. The purpose of this study was to assess various radiographic measurements between healthy children and those with discoid lateral meniscus while controlling for other patient characteristics. Methods: Plain radiographs of 55 pediatric patients with discoid lateral meniscus were matched by age and sex to 55 controls with healthy knees as verified by magnetic resonance imaging. Each radiograph was evaluated for the following parameters: lateral joint space height (both in the central and medial portions of the compartment), medial joint space height, fibular head height, lateral tibial spine height, femoral inter-epicondylar distance, lateral tibial plateau obliquity, and chordal distance of the femoral condyle (medial and lateral). Results: In univariate analysis, children with discoid lateral meniscus had higher median lateral joint space heights (p<0.001) and lower fibular head height (p=0.001) than controls. No other radiographic measurements were significantly different. When adjusting for covariates in regression analysis, the presence of discoid lateral meniscus was predictive of a higher lateral joint space heights and lower fibular head height, however, age was also significantly predictive in these models. Conclusions: On plain radiographs, lateral joint space heights and fibular head height are associated with discoid lateral meniscus. However, many previously reported measurements were not predictive. The practical utility of these parameters may be complicated by the impact of age. Advanced imaging is recommended to confirm the diagnosis of discoid lateral meniscus.
Outcomes Following Repair of Radial, Mid-Body Tears of the Lateral Meniscus in Adolescents
Background: Radial tears of the lateral meniscus result in increased contact forces and expedite arthritis. Due to the technically difficult repair and poor healing, partial or complete lateral meniscectomy is often performed, even in the young, active patient. There is a surprising paucity of literature regarding clinical outcomes after repair of radial tears of the lateral meniscus. This study aims to evaluate a cohort of adolescent patients who have undergone repair of radial tears of the lateral meniscus body at least 2 years after surgery. Methods: With IRB approval, subjects under the age of 18 who underwent repair of mid-body, lateral meniscus tears were identified at least 2 years out from surgery. Of the 18, eight patients completed patient reported outcome surveys. Results: PROs were collected at mean 55.8 months. Mean 2-year IKDC score was 91.67 ± 10.72, and the mean MARX score was 11.63 ± 3.25. Six of eight (75%) reported performance at same level of sport with one reporting pain during sport. Three respondents of the SPORTS score reported continued participation in organized sport, with one patient participating at the collegiate level. Six knees (33%) had postoperative MRI at mean 14 months postop, with five of the six (83.3%) suggestive of preserved integrity of repair. There were five (27.8%) complications, all requiring subsequent surgical procedures. Four patients had meniscus tears at locations distinct from initial injury requiring partial meniscectomies at mean 13.8 months (range, 7-35 months); however, all radial mid-body tears from index procedures were completely healed under arthroscopic visualization. Conclusions: Repairs of radial mid-body tears in the lateral meniscus may provide a significant benefit in the adolescent population. The majority of patients were able to return to their prior activity levels without complication, with evidence of healing on repeat evaluation.
Evaluating the Etiology of Osteochondritis Dissecans of the Knee: The Role of the Articular-Epiphyseal Cartilage Complex
Introduction: In pathologic form, osteochondritis dissecans (OCD) is a focal end-stage disease of articular cartilage. Comparative anatomy studies have demonstrated that injury to epiphyseal anlage cartilage leads to development of OCD in many species, whereas in humans, the exact etiology is suspected but remains unknown. A potential candidate is the articular-epiphyseal cartilage complex, and our hypothesis is that injury at the junction between the epiphyseal anlage cartilage and the articular cartilage results in childhood OCD. Methods: A retrospective, two-institution assessment of children with magnetic resonance imaging (MRI) of the affected knee before the onset of an OCD lesion was performed. Demographics were recorded, including the history of why each initial pre-OCD MRI (Index-MRI) was obtained. MRI measurements were made on the Index-MRI as well as the subsequent OCD-MRI of the epiphyseal ossification length (Growth), marrow edema, the distance of lesion from physis (Lesion Position), and the distance from articular surface (OCD Depth). Comparisons over time were then calculated. Results: Six children (seven knees) were identified with an Index-MRI (Pre-OCD development) obtained at median age 11.6 years and OCD-MRI obtained at a median of 1.9 years later. ‘Growth’ occurred in at least one dimension for all children (sagittal MRI, p=0.018). As a group, the ‘Lesion Position’ did not change significantly in any plane but two demonstrated continued ossification of the epiphysis and one demonstrated bone necrosis. As a group, the ‘OCD Depth’ was significantly different (coronal plane, p=0.029 and sagittal plane, p=0.026) over time, with all lesions increasing their depth (since none existed on the Index-MRI). Discussion: Even though the articular-epiphyseal cartilage complex appeared to be involved with the etiology of knee OCD in this limited series, we found significant variation in the response to a presumed injury with either halted progression, continued ossification, or even regression of ossification adjacent to the OCD. This variation either indicates that there is a multimodal etiology, or that the articular-epiphyseal cartilage complex inconsistently responds to injury. This may explain the inconsistent response to management and calls for further basic science studies to ascertain the exact location of injury in the human articular-epiphyseal cartilage complex.
Pediatric and Adolescent Medial Collateral Ligament Injuries
Medial collateral ligament injuries are common in pediatric and adolescent patients, yet are frequently overlooked. Published literature has reported on the unique anatomic, biomechanical, and non-surgical and surgical management strategies specific to this age group. A multidisciplinary committee of pediatric orthopaedic sports medicine surgeons and physical therapists from the Pediatric Research in Sports Medicine (PRISM) Knee Ligament Research Interest Group (RIG) produced this current concepts review through critical appraisal of recently published literature on the topic of pediatric knee Medial Collateral Ligament (MCL) injuries. MCL injuries in young athletes have been shown to constitute a high percentage of all sports related injuries with MCL injuries. Injury assessment in this age group must include a comprehensive knee exam evaluating for associated injuries unique to developing patients. Imaging should include a 4 view knee series, stress radiographs, and alignment films to guide and follow treatment. To optimize patient outcomes, a detailed understanding of patient specific factors related to knee anatomy and biomechanics during development are essential, along with appropriate characterization and classification of injury severity. While the majority of MCL injuries in this age group can be managed non-surgically with a thoughtful approach to rehabilitation, some injuries based on clinical and radiographic assessment may benefit from surgical intervention. MCL injuries can present decision making challenges related to primary repair versus reconstruction all while restoring normal anatomy and mechanics to the knee without compromising patient growth and development. Special considerations also apply to the rehabilitation process for both non-operatively and operatively managed MCL injuries in this age group. This current concepts review was assembled by a multidisciplinary committee of pediatric sports medicine specialists to better define anatomic, clinical, and treatment applications unique to the pediatric and adolescent patient with a knee MCL injury. MCL injuries in pediatric and adolescent patients can be managed safely and effectively, but a nuanced approach is required to optimize outcomes in this unique patient population.
Tibial Tubercle Osteotomy in the Adolescent Patient
Patellofemoral instability (PFI) is an increasingly prevalent issue affecting pediatric and adolescent patients. Anatomic factors including lateralization of the tibial tubercle and patella alta can contribute to increased risk of initial and recurrent PFI. Additionally, especially in the case of recurrent PFI, chondral injuries of the patellofemoral compartment can occur. These anatomic pathologies can be surgically addressed using tibial tubercle osteotomy (TTO), adjusting the angle and direction of the osteotomy as needed to achieve the desired correction. We discuss the indications and present our technique for performing TTO, including the modifications that can be made to the procedure to address the specific pathoanatomy of the patient.
Shoulder Reconstruction for Brachial Plexus Birth Injuries: An In-Depth Review and Case-Based Update
Brachial plexus birth injuries can result in significant shoulder dysfunction with limitations in range of motion, decreased strength, and risk of glenohumeral joint deformity. This comprehensive review examines current approaches for management of the shoulder including surgical reconstruction following these injuries. Serial clinical exams and selective imaging are critical to determine optimal timing of surgery based on recovery potential and joint pathology. For nerve reconstruction, biceps recovery is monitored monthly from birth, and if absent by 5-6 months, serves as an indication for nerve reconstruction with nerve grafting, transfers, or both. Glenohumeral contracture, deformity, and dislocation commonly occur in infancy and are assessed by exam, ultrasound, and MRI scan. Procedural intervention is indicated when there is loss of passive external rotation, active motor weakness, and/or glenohumeral deformity/dislocation present. Contracture release and joint reduction to center the humeral head on the glenoid is performed early when there are limitations in passive external rotation not resolved with therapy. Glenoid remodeling can occur when reduction is performed early (6 months to 2-3 years). Surgical options include (1) extra-articular contracture releases (e.g., botox, subscapularis slide) and closed reduction; (2) intra-articular arthroscopic/open release and reduction; and (3) contracture release/joint reduction combined with tendon transfers (latissimus-teres major most common). The lower trapezius transfer is increasingly used for active external rotation as it spares internal rotation strength and has an excellent line of pull reproducing that of the infraspinatus. For advanced joint deformity, humeral/glenoid osteotomies are utilized. A nuanced, individualized approach is required considering the child's deficits, pathoanatomy, and age in a case-based manner. Open communication between providers and families is imperative to optimize care. Overall, this review provides a comprehensive analysis of current shoulder reconstruction approaches following brachial plexus birth injuries.
Triple Fusion in Children and Adolescents
Most foot deformities affecting children and adolescents can be managed nonoperatively or with joint-preserving procedures. Severe fixed deformities often require more comprehensive treatment, and triple fusion remains an option in these situations. Surgical decision-making in electing for a triple fusion in this age group and in these rare conditions can be difficult. The primary goals of treatment are elimination of pain, correction of the deformity, and maintenance of a plantigrade foot. This review aims to outline those situations where triple fusion is warranted and describe our technique.
Physiolysis for Metatarsal Bracketed Epiphysis
Metatarsal bracketed epiphysis is an uncommon disorder that results in the diaphyseal ossification of the tubular bones due to abnormally located/continuous physeal tissue along the diaphysis. This interferes with normal growth by causing progressive shortening and an angular deformity of the affected medially convex bone. This disorder progresses in four stages: (1) lack of ossification along the longitudinal epiphyseal bracket, (2) formation of ossification centers both proximally and distally, (3) unification of ossification centers along the longitudinal diaphysis, (4) complete closure of the bracket. Treatment of this condition is primarily surgical and varies depending on the stage. Our recommendation is treatment with early physiolysis to remove the excess growth plate, a surgical technique which has been documented in the literature by Choo & Mubarak. Due to the rarity of the condition, there are limited case reports documented in the literature. To our knowledge, there are no visual demonstrations of surgical technique. Treatment with early physiolysis gives the greatest potential for correction of longitudinal and angular deformity of the bone as the patient grows it allows for natural growth to counteract the present angulation. This case report reviews the surgical treatment of a skeletally immature, 8-year-old female with stage 3 bracketed epiphysis with central physiolysis, using PMMA to block the regrowth of the bar.
Lapidus Procedure for Adolescent Hallux Valgus
Surgical correction of adolescent hallux valgus (AHV) is accompanied by high rates of recurrence, so surgery in the adolescent age group should only be undertaken in insistent patients with pain refractory to nonoperative measures. A subset of patients with AHV may manifest hypermobility of the 1st tarsometatarsal joint (TMTJ) which may lead to recurrence. The Lapidus or modified Lapidus procedure involves TMTJ fusion and when done properly is a powerful and durable procedure for correcting metatarsus primus varus (MPV) and thus hallux valgus. Furthermore, it can reliably correct pronation of the 1st metatarsal which is likely a contributor to recurrence. However, many pediatric orthopedists may be unfamiliar with this operation. The current paper discusses the patient evaluation and preferred technique for performance of the Lapidus procedure.
Trends in the Management of Femur Fractures in Young Children
Background: Femoral shaft fractures in young children are commonly treated with closed reduction and spica casting; however, there is increasing literature and interest focusing on internal fixation. This study aims to assess trends in the management of femoral shaft fractures in patients under the age of 6. Methods: This is a retrospective study utilizing the Pediatric Health Information System (PHIS) database. We queried for patients aged 1 to 6 years who had an isolated, closed femoral shaft fracture from October 2015 to December 2020. ICD10 procedure codes were used to determine treatment of the injury. Descriptive statistics and tests of trend were utilized in the analysis of this study. Results: We identified 4608 patients with a femoral shaft fracture during the study period. The majority of patients were treated with spica casting (n = 3398, 73.7%) followed by intramedullary fixation (n = 600, 13.0%) and plate osteosynthesis (n = 449, 9.7%). In this cohort, 3236 patients were between the ages of 1-3 years and 1372 patients were between the ages of 4-6 years. There was a significant difference in management between these two age groups with lower rates of spica casting in older patients (92.1% vs. 30.5%) and higher rates of intramedullary fixation (37.3% vs. 2.7%) and plate osteosynthesis (28.2% vs. 1.9%) (p < 0.01). There was a significant correlation with increasing rates of intramedullary fixation and plate osteosynthesis from 2016 to 2020 (p = 0.03 and 0.01, respectively), and a decrease in rate of spica casting over time (p = 0.04). Conclusion: Femur fractures in young children are treated with spica casting, intramedullary nails, and plate osteosynthesis. There is a significant change in management over time, and children between the ages of 4 and 6 are more likely to be treated with intramedullary nails compared to younger children. Additional studies are needed to understand these trends as well as justify the increase in rates of intramedullary nails and plate osteosynthesis in young children.
AI = Appropriate Insight? ChatGPT Appropriately Answers Parents’ Questions for Common Pediatric Orthopaedic Conditions
Background: Artificial intelligence services, such as ChatGPT (generative pretrained transformer), can provide parents with tailored responses to their pediatric orthopaedic concerns. Chatbots are increasingly popular, therefore we undertook a qualitative study to assess the accuracy of the answer provided by ChatGPT in comparison to OrthoKids (“OK”), a patient-facing educational platform governed by the Pediatric Orthopaedic Society of North America (POSNA) for common pediatric orthopedic conditions. Methods: A cross-sectional study was performed on May 26-June 18, 2023. OK website (orthokids.org) was reviewed and 30 existing questions were collected. The corresponding OK and ChatGPT responses were recorded. Two pediatric orthopedic surgeons assessed the answer provided from ChatGPT against the OK response. Answers were graded as: AGREE (accurate information; question addressed in full), NEUTRAL (accurate information; question not answered), DISAGREE (information was inaccurate or could be detrimental to patients’ health). The evaluators’ responses were compiled; discrepancies were adjudicated by a third pediatric orthopedist. Additional chatbot answer characteristics such as unprompted treatment recommendations, bias, and referral to a healthcare provider were recorded. Data was analyzed using descriptive statistics. Results: The chatbot’s answers were agreed upon in 93% of questions. Two responses were felt to be neutral. No responses met disagreement. Unprompted treatment recommendations were included in 55% of its responses (excluding treatment-specific questions). The chatbot encouraged users to “consult with a healthcare professional” in all responses. It was nearly an equal split between recommending a generic provider (46%) in contrast to specifically stating a pediatric orthopedist (54%). The chatbot was inconsistent in related topics in its provider recommendations, such as recommending a pediatric orthopedist in 3 of 5 spine conditions. Conclusion: Questions pertaining to common pediatric orthopedic conditions were accurately represented by a chatbot in comparison to a specialty society-governed website. The knowledge that chatbots deliver appropriate responses is reassuring, however the chatbot frequently offered unsolicited treatment recommendations whilst simultaneously inconsistently recommending an orthopaedic consultation. We urge caution to parents utilizing artificial intelligence without also consulting a healthcare professional.
Delay in Time to Physical Therapy After Orthopaedic Treatment
Introduction: Pediatric patients are often prescribed physical therapy following an orthopaedic diagnosis or surgical procedure; however, many children experience delays which can consequently prolong recovery. The purpose of this study was to identify the factors that delay the patient’s ability to receive timely care after referral to Physical Therapy (PT). Methods: Pediatric patients who were ordered physical therapy after orthopaedic treatment were prospectively recruited to participate in this study. Patients were administered a Pediatric Outcomes Data Collection Instrument (PODCI) (self or parent-reported) at 6 weeks post initial referral. A delay was defined as a wait of 2 weeks or more between the referral and first physical therapy appointment. Results: 100 patients with an orthopaedic etiology were enrolled. 60% (60/100) of patients had government insurance and 40% (40/100) had private insurance. Significant differences were revealed between insurance type (p=0.005), ethnicity (p=0.01), and site of injury in time to first appointment (p=0.03). Patients with government insurance were 3.4 times more likely than patients with private insurance to experience a delay to physical therapy (95% CI: 1.5, 8.2). Only 27% (11/40) of patients with private insurance experienced a delay as compared to 57% (34/60) of patients with government insurance. Of the patients with public insurance who experienced a delay, 10% (6/60) were never able to see a physical therapist. All privately insured patients were ultimately seen in PT. More than half (59/100) of participants completed a PODCI; however, there was no correlation was found between PODCI score and delay in therapy (p>0.28). Conclusion: Patients with government insurance were over three times more likely to experience a delay to attend a physical therapy appointment than patients with private insurance. 10% of patients with public insurance were never able to see a physical therapist. These findings demonstrate a marked inequality in access to care based on insurance type.
POSNA-POGO Scholars Research Initiative: Capacity and Needs
Background: The POSNA Pediatric Orthopaedic Global Outreach (POGO) Committee was established with its core mission of advancing children’s musculoskeletal care around the world, with recent expansion of its scope toward furthering scientific research. POSNA sponsors international surgeons (POGO Scholars) to visit North America as part of the mutual outreach effort. Research results from North America may not be generalizable to other regions, where surgeons may see pathologies that are unique to the area. The purpose of the study was to identify the challenges and needs of the POGO Scholars when pursuing scientific research. Methods: An online survey questionnaire composed of nine questions was disseminated via email to all POGO Scholars from year 2007-2020. The survey was anonymous but the Scholars could voluntarily disclose their names and countries of practice. Descriptive statistics were performed. Results: Thirty-four out of 76 identified Scholars responded to the survey, encompassing five continents and at least 15 countries worldwide. The major barriers of performing research were lack of funding (82.4%), insufficient training in research (70.6%) and issues relevant to study execution (64.7%). Most Scholars preferred to publish their results in international indexed journals (58.8%), followed by presentation at international conferences (17.6%), while the need of statistical assistance (56.3%), prohibitive publication costs and difficulty with manuscript revisions (50% each) were the major challenges. POSNA could help the most in the areas of funding (64.7%), research writing support (55.9%), statistics support (52.9%) and research mentorship (50%). Conclusions: The challenges the Scholars face are similar to those encountered by academic surgeons in North America, but amplified by a limited resource environment. Mutually-beneficial involvement including sharing POSNA resources in funding, networking and a platform for research mentoring and equitable collaboration, can synergize the surgeons’ efforts internationally as well as further the development of Scholar-centered local research program while fostering long-lasting relationships. The POGO committee will use the results of this survey in the ongoing efforts to support research that improves global orthopaedic care for children.
The Impact of Institutional Clinical Care Guidelines on Treatment Outcomes in Pediatric Musculoskeletal Infection: A Systematic Review
Background: Pediatric musculoskeletal infections (MSKIs) are complicated to manage, and inconsistent approaches to care within an institution can negatively affect patient recovery. The aim of this systematic review is to assess the impact of implementing institutional clinical care guidelines (CCGs) on treatment outcomes in pediatric MSKIs. Methods: The authors carried out a systematic review of medical literature using the databases Embase and Medline. Ten comparative studies assessing quantitative treatment outcomes of pediatric patients with MSKIs before and after implementation of a CCG were included. Studies in adult populations and those lacking comparative analysis were excluded. Results: Implementing CCGs led to improvements in patient care and clinical outcomes. Outcomes assessed across papers varied. Implementation of CCGs for the management of pediatric patients with MSKIs was shown to shorten patients’ length of stay, duration of IV and/or oral antibiotic therapy, and duration of clinical symptoms associated with MSKIs. There was also evidence of reduced financial costs, which was determined by cost-effective analysis in one study. Additionally, improved access to magnetic resonance imaging and better coordination between disciplines was discussed in some studies to benefit patients’ outcomes by providing an earlier diagnosis and the ability to image concerns throughout treatment. Conclusions: CCGs for pediatric patients with MSKIs improve outcomes by decreasing length of stay and inpatient costs, promoting earlier transition from IV to oral antibiotics, decreasing central line use, encouraging coordination between disciplines, and prioritizing earlier access to MRI and surgery. Further research across existing literature regarding the impact of early access to MRI is of interest for the future.
Appropriate Antibiotic Duration in Pediatric Bone and Joint Infection: A Systematic Review
Background: Optimal duration of antibiotic therapy for childhood bone and joint infection (BJI) remains controversial, despite recent literature in support of shorter courses and early oral switch. We have reviewed the literature to summarise current evidence for reduced duration of antibiotic therapy with particular attention to regional variation in pathogen type and treatment success. Methods: Systematic review was undertaken over the period Jan 1980 - Dec 2022 for children aged up to 18 years. Cohort studies, systematic reviews, randomised controlled trials, and prospective studies were analysed for data on treatment success rates and time of therapy. Results: A total of 34 studies met inclusion criteria reporting treatment duration for 8337 cases of BJI. There were five prospective studies, 21 cohort studies, six randomised controlled trials, and three systematic reviews. Conclusions: There is moderate evidence for shortened duration of therapy with early switch to oral antibiotics in select patients. Studies reporting good success for reduced therapy included healthy patients with uncomplicated disease. Regional disease variation and study protocol heterogeneity limits widespread adoption of short-course treatment. The experience of BJI is diverse. Although the majority of children respond well to treatment there is subset who demonstrate acute or chronically complicated disease. Further research is needed to define patient and disease factors that contribute to treatment failure.
Fasted or Not: Anesthesia-Related Pulmonary Complications in Pediatric Orthopaedic Emergencies Are Rare: A Pilot Study
Background: The American Society of Anesthesiologists (ASA) recommends fasting before surgery: clear liquids (2 hrs), breast milk (4 hrs), light meal (6 hrs), and fried foods/fatty foods/meat (> 8 hrs). In emergencies, guidelines are bypassed for timely surgical intervention. Pediatric post-anesthesia complications caused by violating fasting guidelines remain controversial. The aim of this study was to compare the risk of post-anesthetic complications in patients who met and did not meet ASA fasting guidelines for pediatric orthopaedic emergency procedures. Methods: Patients were retrospectively identified who had emergent procedures at a level 1 pediatric trauma center from 2010 to 2020. Patients were divided into two groups: those meeting current ASA fasting criteria of fasting and those who did not. Charts were reviewed for complications of gastric content aspiration during or following anesthesia. Results: There were 321 patients who met inclusion criteria for emergency orthopaedic surgeries. Of these, 264 (82%) met fasting guidelines, and 57 (18%) did not. One patient who met preoperative fasting status needed postoperative supplemental oxygen and met criteria to be reported as an adverse event. Of the 57 patients not meeting fasting guidelines, there were no anesthesia-reported adverse events. Conclusions: No increased risk was found with anesthesia in nonfasted patients with orthopaedic emergencies undergoing general anesthesia during the perioperative period. No respiratory complications (pulmonary aspiration, intraoperative or postoperative emesis, or postoperative respiratory support) were reported in patients who did not meet fasting guidelines. The authors believe this is a valuable starting point for further research into fasting criteria in pediatric trauma patients.
FDA Device Approval–What You Were Not Taught in Training
Medical devices are ubiquitous in the practice of pediatric orthopaedic surgery, but few surgeons receive any formal training or education on the process of bringing a medical device to market for pediatric orthopaedic patients. Innovation in the field of medical devices has led to significant improvement in the care of pediatric orthopaedic patients. Understanding the history, structure, and pathways to market approval is critical to encouraging innovation of novel devices and techniques and improving the care of pediatric orthopaedic patients. Orthopaedists should have a command of the concepts of adverse event reporting as well as an understanding of the on and off-label uses of medical devices as this is helpful for discussion of care and informed consent for the use of such devices. Due to the relative rarity of the diseases addressed, pediatric orthopaedists should understand the framework of the humanitarian device exemption as well. These concepts can be synergized into some successful improvement in care for pediatric orthopaedic patients. One such success story in recent history was the introduction of the vertical expandable titanium prosthetic rib (VEPTR) system by Dr. Robert Campell. The American Academy of Orthopaedic Surgeons (AAOS) and Pediatric Orthopaedic Society of North America (POSNA) recognize the importance of making innovative medical devices available to pediatric patients and have made advocacy an important aspect of their mission and relationship with industry and governmental regulatory organizations.
Discriminatory Patient Behavior Towards Minority Healthcare Providers: Prevalence, Consequences, and Coping Strategies
In recent years, waves of civil unrest precipitated a national reckoning on the topics of racial injustice, diversity, equity, inclusion and belonging. Despite playing an essential role in society, minority healthcare personnel are not immune to experiencing discriminatory patient behavior in the clinical setting. As the U.S. healthcare workforce becomes more racially and ethnically diverse, the frequency of negative encounters between patients/families and healthcare providers of varying social identities will likely increase. For minority healthcare personnel, patients’ discriminatory behavior can be emotionally challenging, painful, degrading, and could cause feelings of distress, potentially leading to burnout. Patients/families who demean healthcare providers based on their social identity pose multiple clinical obstacles and ethical dilemmas to care, which unfortunately can elicit a significant psychological toll on healthcare providers. A stable therapeutic bond between provider and patient is built on mutual trust, respect, and understanding. This is the basis of a mutually fulfilling physician-patient relationship and efficacious patient care. In contrast, an incongruous therapeutic alliance poses challenges to achieve optimal patient and provider outcomes. We will discuss the prevalence of discriminatory patient behavior against minority health providers and explore the impact of these potentially distressing experiences. We will present coping strategies and resources for healthcare providers when directly facing negatively biased patient behavior. Finally, we will offer guidance and a framework that physicians, bystanders, and institutions that encounter racially motivated behavior from patients and/or their families can use to respond to these difficult situations.
Necrotizing fasciitis (NF) is a rapidly progressing bacterial infection of the subcutaneous tissue that can be life threatening. Without prompt diagnosis and treatment, it can lead to septic shock, organ failure and death. Due to the rarity of this disease in the pediatric population and the fact that initial symptoms are frequently nonspecific, NF in children is often misdiagnosed as cellulitis, which delays the correct treatment. Physicians must maintain a high index of suspicion and keep NF in mind because rapid surgical debridement is necessary to reduce morbidity and mortality. The purpose of this article is to better characterize what is currently known about NF within the pediatric population. In this article, the microbiology, pathophysiology, clinical manifestations, diagnosis, and treatment of pediatric NF are reviewed, and key differences between adult and pediatric NF are highlighted.
A New Look on the Epidemiology of Slipped Capital Femoral Epiphysis: A Topic Revisited
Background: Slipped capital femoral epiphysis (SCFE) is a common hip pathology affecting adolescents mostly in the rapid growth phase. Previous studies have presented epidemiological data to inform practitioners of its etiology to improve diagnosis, treatment, and prevention. However, in recent years, national databases have been redesigned, which may change previously published information on SCFEs. The purpose of this study is to evaluate SCFE epidemiology using the Healthcare Cost and Utilization Project (HCUP) and Kids’ Inpatient Database in conjunction with U.S. Census Data. Methods: The Kids’ Inpatient Database reflects data on 5.9 million pediatric discharges in 2019 and was combined with U.S. Census data to produce epidemiologic data regarding SCFEs in the pediatric population. KID regional data was then overlayed with National Oceanographic and Atmospheric Administration (NOAA) data to assess the associations between climate patterns and UV indices with SCFE incidence. Results: Overall incidence of SCFE in the U.S. was 2.66/100,000 children 9-16 years of age. The average age at presentation with SCFE was 12.3 years with males being older at presentation (12.8 vs. 11.6 years; P<.001; r=0.34). Males were significantly more likely to develop a SCFE than females (OR 1.73; 95% CI, 1.51-1.97). Black patients were significantly more likely to present with a SCFE than all other races (OR 1.66; 95% CI, 1.40 to 2.97). Obesity (23.2%) was the most common metabolic and endocrine comorbidity followed by severe obesity (7.5%). Geographical regions with colder temperatures and lower UV indexes had higher SCFE rates, while regions with higher temperatures and higher UV indexes had lower SCFE rates. Conclusion: This study determined a lower SCFE incidence rate than previously reported but shows similar distributions of SCFEs amongst different races. Age of onset was increased compared to previous studies. The rate of obesity also continues to increase while the incidence of SCFEs has experienced a gradual decrease over time. It is plausible that environmental factors and race (skin tone) may have a more influential effect on the development of this pathology.