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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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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