Pediatric Orthopaedic Society Of North America Research Articles

Current Trends and Variations in the Treatment of Unicameral Bone Cysts of the Humerus: A Survey of EPOS and POSNA Members.

A variety of treatment methods have so far been described for unicameral bone cysts (UBC). However, to the best of our knowledge, no particular consensus has yet been reached on when to operatively treat a patient with a humeral UBC. Therefore, members of the European Pediatric Orthopedic Society (EPOS) and Pediatric Orthopedic Society of North America (POSNA) were surveyed to characterize current treatment preferences. An online electronic questionnaire was sent out to all registered EPOS and POSNA members. The survey comprised 45 questions related to the diagnosis, treatment, and follow-up characteristics of patients with UBCs of the humerus. Particular questions related to the nonoperative or surgical treatment of pathologic proximal humerus and humeral shaft fractures were also included. In total, 444 participants (132 EPOS and 292 POSNA members) responded, of whom 400 were actively involved in UBC treatment. The preferred diagnostic modalities to confirm the diagnosis of a UBC in the humerus were radiographs (88%), MRI in cases of questionable diagnosis (58%) or CT scan (8%). For painless UBCs 67% prefer no treatment at all except when the fracture risk is deemed high (then 53% recommend surgery); 71% of respondents would treat painful UBCs with surgery. Most common surgical techniques comprise curettage (45%), artificial bone substitutes (37%), corticosteroid injection (29%), or intramedullary stabilization (eg, rodding; 24%).Fractured, nondisplaced and mildly displaced proximal humerus UBCs and mildly displaced pathologic humerus shaft fractures are all preferably treated nonoperatively (94%, 91%, 83%, respectively). Severely displaced pathologic proximal humerus fractures are treated less often conservatively (36%) than surgically (40%), and severely displaced humerus shaft fractures are preferably treated surgically (63%) by intramedullary stabilization (60%). There is great variation among EPOS and POSNA members with regards to the diagnosis and treatment of UBCs in the humerus. Although some consensus on general treatment principles is seen, specific surgical treatment indications vary.Prospective randomized-controlled studies are needed to evaluate the outcomes of the different surgical approaches compared with nonoperative strategies. Level V-expert opinion.

Evaluation of Spanish Language Proficiency and Resources Available in Academic Pediatric Orthopaedic Centers.

Given the rapidly increasing population of Spanish-speaking patients in the United States, medical providers must have the capability to effectively communicate both with pediatric patients and their caregivers. The purpose of this study was to query the Spanish language proficiency of pediatric orthopaedic surgeons, assess the educational resources available to Spanish-speaking patients and their families, and identify the barriers to care at academic pediatric orthopaedic centers. The Web sites of medical centers within the United States that have pediatric orthopaedic surgery fellowships recognized by the Pediatric Orthopaedic Society of North America (POSNA) were accessed. Web sites were investigated for a health library as well as the availability of interpreter services. Profiles of attending surgeons within each Pediatric Orthopaedic Department were evaluated for evidence of Spanish proficiency as well as educational qualifications. Centers were contacted by phone to determine if the resources and physicians who could converse in Spanish were different than what was readily available online and if automated instructions in Spanish or a person who could converse in Spanish were available. Forty-six centers with 44 fellowship programs were identified. The profiles of 12 of 334 (3.6%) surgeons who completed pediatric orthopaedic fellowships indicated Spanish proficiency. Seventeen physicians (5.1%) were identified as proficient in Spanish after phone calls. Thirty-eight pediatric orthopaedic centers (82.6%) noted interpreter service availability online, although services varied from around-the-clock availability of live interpreters to interpreter phones. When contacted by phone, 45 of 46 centers (97.8%) confirmed the availability of any interpreter service for both inpatient and outpatient settings. Sixteen centers (34.8%) had online information on orthopaedic conditions or surgical care translated into Spanish. Twenty centers (43.5%) did not have automated phone messages in Spanish or live operators that spoke Spanish. There is a scarcity of surgical providers in pediatric orthopaedic centers proficient in Spanish, demonstrating a large discrepancy with the growing Hispanic population. Interpreter services are widely available, although there is variability in the services provided. Considerable barriers exist to Spanish-speaking patients who attempt to access care by phone or online.

Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership.

PurposeThe therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR).MethodsAn email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied.ResultsIn all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR.ConclusionCurrent practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome.Level of EvidenceII

Pediatric Orthopaedists Are Not Immune: Characterizing Self-reported Burnout Rates Among POSNA Members.

There are no published data characterizing burnout rates for pediatric orthopaedic surgeons. The primary purpose of this study was to identify the rates of self-reported personal and team burnout among members of the Pediatric Orthopaedic Society of North America (POSNA). A secondary aim was to determine whether specific demographic variables were more likely to be associated with self-reported burnout. During its 2018 annual meeting, the POSNA Wellness Taskforce launched a web-based survey in which members were asked to respond to 2 previously validated questions related to personal and team burnout. The survey was distributed by a closed POSNA membership e-mail list and responses were analyzed anonymously. Descriptive statistics were calculated. Pearson χ testing was used to analyze differences in burnout rates as a function of age and sex. A total of 615 POSNA members completed the survey, a 47% response rate. Overall, 38% reported personal burnout and 46% reported team burnout. Women were more likely to report both personal (P<0.001) and team burnouts (P<0.005). Members aged 40 to 59 years were more likely to report personal burnout, irrespective of sex (P<0.001). Members aged 50 to 59 years were more likely than those in other age groups to report team burnout (P<0.001). There was no significant association found between the presence of burnout and either race, ethnicity, LGBTQ status, or educational background. As a group, pediatric orthopaedists report moderately high rates of both personal and team member burnout. Individual-specific factors such as age and sex may play an important role in determining one's risk for experiencing burnout. Recognizing that burnout affects a significant minority of POSNA members is a crucial first step. Level III.

164. The reliability of the AOSpine thoracolumbar spine injury classification system in children: results of a multicenter study

BACKGROUND CONTEXT In the adult population, there have been significant endeavors in developing classification systems of thoracolumbar injuries. These systems evolved from simple morphologic classifications to more complex systems based on fracture morphology (injury mechanism), evaluation of posterior ligamentous integrity, and neurologic status of the patient. There does not yet exist a dedicated classification system for pediatric thoracolumbar fractures despite the discordance in presentation. Pediatric thoracolumbar fractures vary in morphology, severity, and morbidity. Treatments vary from observation to surgery depending on factors such as fracture stability, displacement, and neurologic status. PURPOSE The purpose of this study was to determine if the new AOSpine thoracolumbar spine injury classification system is reliable and reproducible when applied to the pediatric population. STUDY DESIGN/SETTING Multicenter review of single institutional case series. PATIENT SAMPLE Patients under the age of 18 years who had been treated operatively for a thoracolumbar fracture between 2006 and 2016 were identified. Inclusion criteria included patients with preinjury computed tomography (CT) scans and magnetic resonance imaging (MRI) and who were less than 18 years of age. OUTCOME MEASURES Classification through AOSpine Thoracolumbar Spine Injury Classification System METHODS A group of nine POSNA (Pediatric Orthopaedic Society of North America) member surgeons were sent an electronic link containing educational videos and schematic papers describing the AOSpine Thoracolumbar Spine Injury Classification System. The link also contained MRI (magnetic resonance imaging) and CT (computed tomography) imaging of 25 pediatric patients with thoracolumbar spine injuries organized into cases to review and classify. The evaluators classified injuries into 3 primary categories: A, B, and C. Interobserver reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals (CI). For A and B type injuries, subclassification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff's alpha (αk) along with bootstrapped 95% CIs. Imaging was reviewed a second time by all 9 evaluators approximately one month from the initial read. All patient imaging was blinded and randomized for each read independently. Intraobserver reproducibility was assessed for the primary classifications using Fleiss's kappa and subclassification reproducibility was assessed by Krippendorff's alpha (αk) along with 95% CIs. Interpretations for reliability estimates were based on Landis and Koch (1977): 0-0.2, slight; 0.2-0.4, fair; 0.4-0.6, moderate; 0.6-0.8, substantial; and >0.8, almost perfect agreement. RESULTS Twenty-five cases were read by 9 raters for a total of 225 initial and 225 repeated evaluations. Interobserver reliability was almost perfect (kF = 0.82; CI = 0.77 - 0.87) across all 9 raters. Subclassification reliability was substantial (αK = 0.79; CI = 0.62 - 0.90). Intraobserver reproducibility was almost perfect (kF= 0.81; CI = 0.71 - 0.90) for both primary classifications and for subclassifications (αk = 0.81; CI = 0.73 - 0.86). CONCLUSIONS The reliability for the AOSpine classification system was high amongst POSNA surgeons when applied to pediatric patients. Given a lack of a uniform classification in the pediatric population, the AOSpine Thoracolumbar Spine Injury Classification System has the potential to be used as the first universal spine fracture classification in children. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Treatment of Clubfoot with Dynamic Supination and No Deformity: A Survey of the POSNA Membership

Purpose: Anterior tibialis tendon transfer (ATTT) is a procedure, which is used to treat recurrent clubfoot with dynamic supination, but there are a wide variety of guidelines or strategies for the procedure. In this study, members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed in order to determine the varied methods used in the execution of ATTT. Methods: The survey was designed using Research Electronic Data Capture (REDCap) survey software. It …

The Pediatric Orthopaedic Society of North America (POSNA) Adopts a Member Health and Wellness Charter

The Pediatric Orthopaedic Society of North America took actions to address the well-being of its members. The epidemic of physician burnout interferes with the delivery of high-quality care that our patients and families need and deserve, and at the same time places the care-providers at an increased risk of depression and suicide. The actions taken by Pediatric Orthopaedic Society of North America serve as a model for other professional medical societies to emulate.

Are We Spending Wisely? Impact of POSNA Grants on Scholarly Productivity and Future Funding Success.

The Pediatric Orthopaedic Society of North America (POSNA) funds grants to improve pediatric musculoskeletal care and maximize new knowledge through publications, presentations, and further funding. We assessed the productivity of POSNA grants by number and rate of grant-specific publications, citations, and extramural funding; determined whether project type or completion status was associated with extramural funding; and compared the success of POSNA-funded versus all other podium presentations by publication rate and POSNA awards. We reviewed final reports for all 85 POSNA grants from 2003 to 2014. To determine grant productivity, we assessed the publication, presentation, and extramural funding rates, and the percentage of grants that achieved at least 1 scholarly output (publication or presentation). Citation counts were determined within 3 years after publication. Overall, each grant achieved ~1.53 publications and 15.4 citations. Thirty-three percent secured extramural funding. However, 25% of grants could not be tracked to a scholarly product. Projects that reached completion and were of the basic science type (compared with clinical) were more likely to receive extramural funding. Compared with all other podiums, a greater proportion of POSNA-funded presentations led to a publication (64% vs. 48%, respectively; P=0.02) and were more likely to receive a POSNA award. Approximately 52% of funded projects were not presented at POSNA meetings. Although most POSNA-funded projects led to scholarly output, 25% of them produced no publications or podium presentations. POSNA-funded projects were more likely to lead to a publication and to have a higher chance of winning a POSNA award compared with all other projects. The POSNA grant process is effective at identifying impactful research, but continued process improvement, such as a prospectively maintained database of grant recipient productivity and improved tracking of grant submission histories, are both in development as the first steps to improve accountability of grant recipients in translating their projects to scholarly products.

Abstract Submission and Acceptance Rates for Men and Women in Academic Pediatric Orthopaedic Surgery: An Analysis of POSNA Annual Meeting Abstract Submissions 2012-2015.

It has recently been demonstrated that women members of the Pediatric Orthopaedic Society of North America (POSNA) participate at the Annual Meeting at disproportionately lower rates than men members, as defined by accepted abstract(s). We hypothesize that this discrepancy is associated with lower abstract submission rates by women members. POSNA membership directories for the years 2012-2015 were used to record the name, sex, membership category, and years of membership for each member. Final programs for Annual Meetings and abstract submission records for the same time period were used to record the number of accepted and rejected abstracts for each member. General estimating equations with a binomial model and logit link were used to compare the proportion of abstract acceptances between sexes across years. During the period 2012-2015, active members included 534 men (83.8%) and 103 women (16.2%), whereas candidate members included 207 men (64.7%) and 113 women (35.3%). When active and candidate members were considered collectively, men were significantly more likely to have an accepted abstract (P=0.009) and this significant difference did not change over the 4-year period (P=0.627). However, men submitted significantly more abstracts per member per year than women (means: 1.5 abstracts/man/y; 0.8 abstracts/woman/y; P<0.001). This held true for both candidate members (early career) (P=0.001) as well as active members (mid-career) (P<0.001). When the total number of abstract submissions per year per member was taken into account, the percentage of abstract acceptances was similar for men and women (men=42%, women=40%; P=0.847). Abstract acceptance rates were similar for women and men members of POSNA for the 2012-2015 Annual Meetings. However, men had a significantly greater number of abstract submissions per member than women, and consequently, men presented a higher proportion of abstracts relative to their membership numbers. This supports our hypothesis that the disproportionately lower rate of active participation amongst women members at POSNA Annual Meetings, defined as abstract acceptance, is due to lower rates of abstract submissions, rather than to lower rates of acceptances. It is not applicable as it is not a clinical or basic science study.

Availability of global health opportunities in North American Paediatric Orthopaedic Fellowship Programmes.

PurposeOrthopaedic residents are increasingly seeking international health electives (IHEs) during training, many of which involve providing paediatric orthopaedic care. However, little is known about the availability of IHEs during orthopaedic fellowship training. Our study sought to assess the global health opportunities available to North American paediatric orthopaedic fellows.MethodsWe conducted an online, REDCap-based survey of paediatric orthopaedic fellowship programme directors (PDs) in the United States and Canada. The survey link was sent by the Pediatric Orthopaedic Society of North America (POSNA) Evidence-Based Medicine Committee to all POSNA-approved paediatric orthopaedic fellowship PDs. Follow-up reminder emails were delivered at set time intervals.ResultsThe overall response rate was 55% (26/47). Only three of 26 responding programmes (11.5%) offered a structured global health programme but 42.3% of programmes (11/26) reported fellow IHE participation within the last ten years. In all, 91% of PDs reported that fellows were extremely satisfied with their IHE, and 91% agreed that IHEs are valuable for trainees. Perceived barriers to fellow participation in IHEs included lack of funding, lack of established partner sites, lack of interest among fellows and concerns related to time away compromising clinical/call coverage. In all, 65.4% of PDs agree that IHE participation during training plays a major role in shaping fellows’ future volunteer activities.ConclusionThere are limited global health opportunities among North American paediatric orthopaedic fellowship programmes, with only 11.5% offering a structured global health programme. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during paediatric orthopaedic fellowship training.Level of EvidenceLevel II

Evidence-based Medicine in Pediatric Orthopaedics: Evidence-based Practice Committee Summary of Levels of Evidence, Clinical Practice Guidelines, Appropriate Use Criteria, and Best Practice Guidelines.

The concept of evidence-based medicine has evolved over the past 2 decades, and has become a cornerstone to clinical decision-making in virtually every aspect of medicine. With a commitment to providing its members with high-quality evidence-based guidelines, the American Academy of Orthopaedic Surgeons has instituted concerted efforts since 2006 to develop clinical practice guidelines (CPGs) and appropriate use criteria (AUCs) for certain orthopaedic conditions. Many of these CPGs and AUCs detail the management of pediatric orthopaedic conditions. By the same token, members of the Pediatric Orthopaedic Society of North America (POSNA) Evidence Based Practice Committee have been publishing succinct evaluations of randomized controlled trials in pediatric orthopaedic surgery to create an evidence-based repository for quick reference to available high-level evidence as well as resource to identify gaps in the current research and identify opportunities for future investigation. In instances where higher-level evidence needed to develop CPGs is not available to address a critically important clinical question, consensus recommendations from experts in the field have been obtained to develop best practice guidelines (BPGs). The purpose of this review is to provide readers with a deeper understanding of the key principles of evidence-based medicine and methodologies used for the development of CPGs, AUCs, and BPGs.

Diagnostic and treatment preferences for developmental dysplasia of the hip: a survey of EPOS and POSNA members.

PurposeThe aim of this study was to elucidate developmental dysplasia of the hip (DDH) diagnosis and treatment preferences among members of the Pediatric Orthopaedic Society of North America (POSNA) and European Paediatric Orthopaedic Society (EPOS).MethodsA 54-question survey on DDH diagnosis and treatment preferences was distributed to POSNA and EPOS members. Descriptive statistics were performed.ResultsA total of 459 responses were analyzed. Ultrasound was the preferred modality for diagnosing DDH in infants less than six months old; few surgeons preferred radiographs. In all, 57% of POSNA members had radiology technicians perform ultrasounds, only 7% of EPOS members did. The percent coverage defining a dislocated hip varied greatly, the most frequent response being < 20% for POSNA and < 40% for EPOS members. Pavlik harnesses were the most popular harness/brace, used by 90% of POSNA and 71% of EPOS members. POSNA members were more likely than EPOS members to use a rigid abduction brace following initial harness/brace failure. For residual acetabular dysplasia, POSNA members were twice as likely as EPOS members to institute hip abduction bracing. Most surgeons would not perform closed reduction at less than three months of age or open reduction at less than six months of age. Most EPOS ­members used traction prior to reduction; few POSNA members did. Few POSNA and EPOS members believed that reduction should be delayed until the ossific nucleus was visible.ConclusionThere is great variation in the preferred methods for diagnosing and treating DDH. This survey is the largest transcontinental survey to compile diagnostic and treatment preferences for DDH. With wide variations in practice, there is room for quality improvement.Level of Evidence II

The Use of Outpatient Analgesic Opioids After Surgery or Treatment in Pediatric Orthopaedics

Purpose: Opioid analgesics are a mainstay for pain management after pediatric orthopaedic surgery or fracture treatment. Scrutiny of their use has mounted recently, due to evolving data on the potential complications inherent to these medications. In effort to better understand current prescribing practices of pediatric orthopaedists, a survey was conducted of members of the Pediatric Orthopaedic Society of North America (POSNA). Methods: The POSNA membership was surveyed by email on their prescribing preferences of outpatient opioid analgesics for a variety of situations. The survey presented a number of scenarios that may require pain …

The Surgical Management of Tibial Spine Fractures in Children: A Survey of the Pediatric Orthopaedic Society of North America (POSNA)

Background: Tibial spine fractures are rare yet significant injuries and surgical management remains varied given the lack of consensus about the optimal approach. Thus, the purpose of this study is to determine the prevailing treatment strategies among pediatric orthopedic surgeons and establish areas of agreement and ongoing controversy Methods: An electronic REDCap survey was distributed to the Pediatric Orthopaedic Society of North America (POSNA) membership. Surgeon demographics, experience treating tibial spine fractures, and responses to clinical vignettes were collected. Standard descriptive statistics were used to summarize …

Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics From the Advocacy Committee of the Pediatric Orthopaedic Society of North America.

The opioid epidemic in the United States has reached crisis proportions. Urgent response is needed. Hydrocodone in combination with acetaminophen is the most prescribed drug in the United States. The most common source of opioids available for misuse is the unused portions of postoperative prescriptions. Among high school seniors, 80% of those who reported nonmedical use of prescription opioids previously had legitimate prescriptions but recreationally used leftover doses. Roughly one-quarter of patients do not take any of their postoperatively prescribed opioids and the remainder take one-third to two-thirds of the prescribed doses. A summary of the literature is presented beginning from historical perspective to current status and pertinent strategies in dealing with this complicated problem. This review includes data from an electronic survey of the members of the Pediatric Orthopaedic Society of North America (POSNA) with regard to the prescriptions they would provide for 7 treatment scenarios. Strategies for the preoperative, intraoperative, and postoperative phases of management of pain as well as strategies for education, research, and advocacy are presented. The Pediatric Orthopaedic Society of North America survey yielded 264 respondents. The 3 most commonly used opioid medications were hydrocodone, oxycodone, and acetaminophen with codeine, in that order, for most of the scenarios. The time period covered by postoperative prescriptions varied considerably. The magnitude of this problem is overwhelming. Education of care providers, patients and families, standardization of narcotic prescribing practices which incorporate patient characteristics, and appropriate plans for disposal of unused narcotics are immediate concepts to consider in correcting this problem. Long-term issues to tackle will be changing patient a family expectations, legislation, and obtaining additional resources directed towards this issue.

The Surgical Management of Tibial Spine Fractures in Children: A Survey of the Pediatric Orthopaedic Society of North America (POSNA)

The Surgical Management of Tibial Spine Fractures in Children: A Survey of the Pediatric Orthopaedic Society of North America (POSNA)

Pediatric Orthopaedic Surgeons Dissatisfied in On-Call Practices Despite Improving Call Conditions. The 2015 POSNA Membership Survey Regarding Trauma Care.

To examine the current trends in trauma call coverage of pediatric orthopaedic surgeons in North America and to identify predictors of surgeon on-call satisfaction. In 2015, ∼1200 active members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding emergency room on-call practices. In total, 410 members completed the survey with a response rate of 35%. Information collected included call frequency, practice setting and satisfaction with call. This information was analyzed and compared with the 2006 and 2010 trauma call surveys of Pediatric Orthopaedic Society of North America membership using 2 sample difference in proportion, χ tests for trend and the Fisher exact tests. Logistic regression analyses were used to identify predictors of call satisfaction among pediatric orthopaedic surgeons. In total, 47% of pediatric orthopaedic surgeons had access to a designated trauma operating room in 2015, up from 39% in 2010 and 24% in 2006. In total, 43% of pediatric orthopaedic surgeons currently receive a stipend for taking call, up from 35% in 2010 and 28% in 2006. Although 83% of pediatric orthopaedic surgeons believe that trauma call is an integral part of their practice, only 53% are satisfied with their call experience. Controlling for covariates, believing that call is integral to one's practice doubles odds of call satisfaction. Having resident or fellow support and being financially compensated for orthopaedic trauma call also increases one's odds of satisfaction. The odds of being satisfied with call decrease by 7% for each year of increase in age of the surgeon. Access to a designated trauma operating room and financial compensation for call coverage have steadily increased over the past decade. A sizable majority of respondents continue to believe that trauma care is an integral part of being a pediatric orthopedist. Despite this, 47% of respondents remain dissatisfied with their trauma call arrangements. The age and attitude of the individual surgeon and extent of hospital support predict satisfaction of surgeons providing trauma coverage. Level V-economic and decision analysis.

The Surgical Management of Osteochondritis Dissecans of the Knee in the Skeletally Immature: A Survey of the Pediatric Orthopaedic Society of North America (POSNA) Membership.

While the characteristics of osteochondritis dissecans (OCD) of the knee that require surgery to heal have been described, several surgical techniques/procedures exist with no consensus established regarding timing of treatment and specific surgical intervention. In this study, we aim to determine current trends in surgical treatment for OCD lesions in the skeletally immature who have failed 6 months of nonoperative management by surveying a large cohort of orthopaedic surgeons. An electronic survey designed using REDCap to capture surgeon treatment preferences for OCD lesions was distributed to members of the Pediatric Orthopaedic Society of North America (POSNA). The survey inquired about treating physicians' training and demographics. It then offered a series of clinical vignettes alongside imaging describing patients with varying degrees of severity of OCD following nonoperative treatment. Surgeons were prompted to select from a variety of multiple-choice-based options for further patient management. Standard descriptive statistics were used to summarize and compare the responses. Of the 129 POSNA members completing the pediatric survey, 97.7% were attending level orthopaedic surgeons, the majority identifying with an academic institution and treating mostly skeletally immature patients. In the skeletally immature population, the majority would treat intact, stable OCD lesions with drilling in a retroarticular or transarticular manner. Preferred treatment for unstable, salvageable lesions was screw fixation using bioabsorble materials or metal with variable pitch with no bone graft. The majority of respondents would treat unstable, unsalvageable OCD lesions with chondroplasty and osteochondral transplant/transfer or microfracture/drilling. The POSNA membership appears to agree on principle in terms of treatment modalities for various stages of OCD lesions in the skeletally immature, whereas individual techniques of achieving these principles may vary. Members endorse drilling for stable intact lesions; fixation for unstable, salvageable lesions; and "defect fill" for unsalvageable lesions. OCD surgical treatment patterns can be used in future studies to determine which techniques are most effective for given indications, with the goal of designing a research-proven optimal treatment regimen for skeletally immature patients.

Hip Surveillance for Children With Cerebral Palsy: A Survey of the POSNA Membership.

Currently, hip surveillance programs for children with cerebral palsy exist in Europe, Australasia, and parts of Canada, but a neuromuscular hip surveillance program has yet to be adopted in the United States. The purpose of this study was to report the current orthopaedic practice of hip surveillance in children with cerebral palsy, identify areas of practice variation, and suggest steps moving forward to generate guidelines for national neuromuscular hip surveillance. The entire membership of the Pediatric Orthopaedic Society of North America (POSNA) was surveyed in 2016 for information regarding their practice for hip surveillance in children with cerebral palsy. Detailed information regarding timing, frequency, and practice of hip surveillance was obtained in answers to 26 different questions. A survey response rate of 27% was obtained (350/1300 members) during the study period. The majority of respondents treated pediatric patients exclusively (97%), worked in an academic practice (70%), and was affiliated with a university (76%). In total, 18% (69/350) of respondents followed a regular cerebral palsy hip surveillance program, about half of whom (44%, 30/69) had adopted the Australian guidelines. Respondents agreed that a dislocated hip in a child with cerebral palsy was painful (90% agreement) and should be prevented by hip surveillance (93% agreement). Furthermore, 93% of respondents indicated they would follow a national surveillance program if one was in place. Age (79%), Gross Motor Function Classification System (81%), and migration percentage (MP) (78%) were all identified as critical elements to a hip surveillance program. The majority of respondents felt that a hip "at risk" for hip displacement had a MP between 20% and 30% (57% of respondents), whereas surgery should be utilized once the MP exceeded 40% (50% of respondents). Results from this survey demonstrate 90% of respondents agree that a dislocated hip could be painful and 93% would follow a national surveillance program if available. At a societal level, we have the ability to standardize cerebral palsy hip surveillance, thereby decreasing practice variation and improving quality of care delivery. Level V.

The Surgical Management of Tibial Spine Fractures in Children: A Survey of the Pediatric Orthopaedic Society of North America (POSNA).

Tibial spine fractures are rare, complex injuries. Management remains varied given a lack of consensus about the optimal approach. Thus, the purpose of this study is to determine prevailing strategies among pediatric orthopaedists and establish areas of agreement and ongoing controversy in the management of tibial spine fractures. An electronic survey was distributed to the Pediatric Orthopaedic Society of North America (POSNA) membership. Surgeon demographics, experience, and responses to clinical vignettes were collected. Surgeons were grouped according to how frequently they treat tibial spine fractures and responses were compared. Of the 180 POSNA members who completed the survey, all were attending surgeons and nearly all (90.4%) had academic affiliations, treated mostly skeletally immature patients (88.5%), and 3 or fewer fractures per year (62.4%). In younger patients, respondents were more likely to treat type II fractures closed and less likely to cross the physis. Arthrofibrosis was the most commonly reported complication and postoperative duration of immobilization was identified as a risk factor by most. However, high-frequency surgeons identified this risk factor more often (P=0.015) and recommended immobilization for <2 weeks more frequently (P=0.018). There was, however, considerable discrepancy regarding the duration of immobilization. Although there were areas of agreement on general principles, there continues to be disagreement regarding specific treatment strategies. Surgeons within POSNA agree on general principles of treatment for tibial spine fractures. Members, regardless of high-volume or low-volume caseload, are all less likely to pursue surgical options when treating younger patients and treating arthrofibrosis during the first 2 postoperative months. The most commonly reported adverse outcome after treatment was arthrofibrosis, for which high-frequency surgeons identified length of immobilization as a significant risk factor more often and thus, recommended shorter periods of immobilization. Although surgeons may agree on general principles in some cases, there continues to be disagreement regarding specific strategies suggesting that a prospective multicenter study of this topic is warranted. Level V.