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In this article, we outline several key concepts to help develop your operating room team. This is an evolutionary process with numerous benefits to the team members, surgeon, and most importantly the patients. We outline strategies for engaging and preparing your team members so that the operating room runs more efficiently. We also outline the do's and don'ts of building trust amongst team members which is critical to transforming into a high functioning team.

Purpose Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen. Methods AIS patients aged 10–18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon’s practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement. Results A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23). Conclusion In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.

Introduction: Percutaneous fetoscopic surgery is hampered by an increased risk of preterm prelabor rupture of membranes (PPROM). Recent surgical techniques have shown that suturing the chorioamniotic membranes following laparotomy and uterine exteriorization is associated with a lower risk of PPROM compared to percutaneous in utero surgery. This study presents the ChorioAnchor, a novel resorbable device that percutaneously anchors the chorioamniotic membranes to the uterine wall. Methods: Human factors testing and peel tests were used to simulate the worst-case in-use loading conditions, establishing the device strength requirements. Tensile testing was used to measure the time-zero strength of the device. Porcine cadaver testing was used to examine ultrasound visibility and acute handling characteristics. Short-term host response was examined through an acute 7-day implantation study in a rabbit model. Results: With a time-zero tensile strength of 47 N, the ChorioAnchor exceeded the established 4 N strength requirement. Both the ChorioAnchor and delivery device were seen to be clearly visible under ultrasound imaging. Short-term host response to the device was well within the range expected for this type of device. Conclusion: The ChorioAnchor meets its engineering requirements in the early stages of implantation. Future studies will examine the kinetics of degradation of the device in vitro and in vivo.

BACKGROUND Osteochondromas are the most common benign bone tumor, accounting for 36% of benign bone tumors. Often found within the appendicular skeleton, osteochondromas of the spine are rare, comprising 4% to 7% of primary benign spinal tumors. CASE SUMMARY We report a case of a solitary lumbar osteochondroma in an 18-year-old male with a history of a suprasellar pineal germinoma treated with combined chemotherapy and radiation. He underwent mass excision and partial laminectomy with the ultrasonic bone scalpel (Misonix, Farmingdale, NY, United States) at the L5 Level without the use of adjuvants. The patient returned to work and full activities without back pain at 3 mo postoperatively. CONCLUSION Osteochondromas are common tumors of the appendicular skeleton but rarely occur within the spine. This case discussion supplements current osteochondroma literature by describing an unusual presentation of this tumor.

There is no consensus on the optimal surgical treatment for high-grade spondylolisthesis (HGS) in adolescents. The purpose of this study was to assess the radiographic and clinical outcomes of a novel surgical approach to HGS consisting of a single-level anterior reduction, placement of a lordotic cage, and circumferential fixation without decompression. This was a retrospective consecutive case series of 11 adolescents who underwent anterior reduction through placement of a lordotic cage followed by posterior fusion using pedicle screws and rods confined to L5–S1. Radiographic data included slip percentage, slip angle, lumbar lordosis, and pelvic sagittal parameters assessed at clinical visits preoperatively and at 2 years postoperatively. A telephone survey was conducted to obtain current information about function, activity level, work status, and retrograde ejaculation. Patients were followed for an average of 7.8 years (range 2–16). Mean age was 15.5 years (range 12–19). The mean percent slip corrected from 55 to 18%. The average slip angle was + 17.1° preoperatively and − 14.1° at final assessment (average correction of 20.7°). Thirty-six percent (4/11) of patients improved by three Meyerding grades and an additional 55% (6/11) improved by two grades. Complications included one instance each of superficial infection, wound dehiscence, and transient neuralgia. There were no cases of instrumentation failure, cage subsidence, pseudoarthrosis, or retrograde ejaculation. Radiographic evidence of fusion was observed in all cases. Single-level anterior reduction and circumferential fusion without decompression appears to be a safe and effective alternative for the surgical treatment of pediatric HGS. IV.

Decreasing radiation exposure is important for scoliosis patients who require serial imaging. Microdose protocol stereoradiography is now increasingly utilized. Previous studies have reported similar reliability of concurrent Sanders skeletal maturity staging based on standard low-dose stereoradiography and standard hand radiographs. The purpose of our study was to investigate the reliability and radiation exposure of concurrent Sanders staging using microdose protocol compared to a standard protocol for adolescent idiopathic scoliosis. We hypothesized that surgeon-performed Sanders staging would have similar reliability when comparing microdose and standard-dose imaging protocols. A randomized survey of 30 hand images using standard protocol spinal stereoradiography and an equal number from microdose protocol were distributed to six experienced pediatric orthopaedic spine surgeons. Images were graded by each surgeon according to the Sanders skeletal maturity grading system. Items were again randomized and graded after a 2-week interval. Fleiss’ weighted kappa for inter and intraobserver reliability was calculated and an unpaired t test was used to test for significance. Interobserver reliability for all modalities was in the strong to almost perfect agreement (average weighted κ > 0.8) range. For the microdose protocol, κ was 0.82 and 0.84 for each separate round of grading. Standard low-dose protocol κ was 0.83 and 0.79. Intraobserver κ was 0.86 for microdose and 0.82 for standard. Average radiation for microdose was significantly less radiation (82.6%) than standard stereoradiography (0.3 ± 0.1 mGy vs. 1.9 ± 0.4 mGy, p

Adolescent idiopathic scoliosis (AIS) has evidence-based, nonoperative treatments proven to be effective with early diagnosis and prompt treatment. The purpose of this study was to identify potential disparities in access to nonoperative treatment for AIS. Specifically, we sought to determine the interaction of socioeconomic factors on a major curve magnitude and recommend treatment at the initial presentation.A retrospective review of AIS patients who underwent surgery at a single tertiary pediatric hospital between January 1, 2013 and December 31, 2018 was conducted. Patients were divided into 2 groups for comparison: patients with public insurance (PUB) and those with private insurance (PRV). Primary variables analyzed were patient race, Area Deprivation Index (ADI), major curve magnitude, and treatment recommendation at the initial presentation. Univariate and multivariate analyses were conducted to identify the predictors of the major curve magnitude at presentation.A total of 341 patients met the inclusion criteria; PUB and PRV groups consisted of 182 (53.4%) and 159 (46.6%) children, respectively. Overall, the major curve magnitude at presentation was significantly higher in PUB compared with PRV patients (50.0° vs. 45.1°; P =0.004) and higher in Black patients compared to White patients (51.8 vs. 47.0, P =0.042). Surgery was recommended for 49.7% of the PUB group and 43.7% of the PRV group. A lesser number of PUB patients had curve magnitudes within the range of brace indications (≤40°) compared to PRV patients (22.5% vs. 35.2%, respectively; P =0.010). The odds of having an initial major curve magnitude40 degrees were 67% lower among Black patients with public insurance compared to Black patients with private insurance (OR=0.33; 95% CI: 0.13-0.83; P =0.019).This study demonstrated disparity in access to nonoperative treatment for pediatric scoliosis. Black patients with public insurance were the most at-risk to present with curve magnitudes exceeding brace indications. Future work focused on understanding the reasons for this significant disparity may help to promote more equitable access to effective nonoperative treatment for adolescent idiopathic scoliosis.III.

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.Level V.

BACKGROUND Long-leg casts (LLCs) are an established treatment for pediatric tibial shaft fractures including fractures involving the distal third. There is a paucity of literature assessing the use of short-leg cast (SLC) for tibial shaft fractures. The purpose of this study was to determine if SLC were as effective as LLC for the treatment of pediatric distal third tibial shaft fractures. METHODS A retrospective review was conducted on consecutive distal third tibial shaft fractures treated at a tertiary pediatric hospital from 2013 to 2018. Exclusion criteria included midshaft and proximal fractures of the tibia, distal fractures that violated the tibial physis or plafond, and pathologic fractures. We compared primary outcomes of time to weight-bearing, time to union, and final angulation between LLC and SLC groups. RESULTS Eighty-five patients aged 5 to 17 years (mean age: 9.2±3.2 y) met inclusion criteria, including 50 LLC and 35 SLC patients. Time to weight-bearing for SLC (3.3±0.6 wk) was shorter compared with LLC (6.4±0.7 wk, P

Oxytocin is a peptide neurophysin hormone made up of nine amino acids and is used in induction of one in four births worldwide (more than 13 percent in the United States). Herein, we have developed an antibody alternative aptamer-based electrochemical assay for real-time and point-of-care detection of oxytocin in non-invasive saliva samples. This assay approach is rapid, highly sensitive, specific, and cost-effective. Our aptamer-based electrochemical assay can detect as little as 1 pg/mL of oxytocin in less than 2 min in commercially available pooled saliva samples. Additionally, we did not observe any false positive or false negative signals. This electrochemical assay has the potential to be utilized as a point-of-care monitor for rapid and real-time oxytocin detection in various biological samples such as saliva, blood, and hair extracts.

There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period.A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications.Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation.Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application.Level IV.

BACKGROUND Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to

BACKGROUND Children who are prohibited from returning to daycare (RTD) after treatment with cast immobilization place an increased burden on parents and caregivers. The purpose of this study was to assess the impact of cast immobilization on RTD. Specifically, we sought to determine the prevalence of RTD after orthopaedic immobilization based on daycare facility policy. METHODS This was a survey study of randomly selected daycare facilities servicing a total of 6662 children within 10 miles of a major metropolitan city center. The 40-question survey included information on daycare policies and experience caring for children treated with orthopaedic immobilization. The survey also included questions about daycare type, enrollment, and geographic location. Photographs of the types of immobilization were embedded in the survey to facilitate understanding. Daycare facilities were randomly selected based on a power analysis to estimate a 50% prevalence of RTD after spica casting within 10% margin of error. RESULTS Seventy-three daycare facilities completed the survey study. The average child-staff ratio was 5:1 and most daycare facilities (78%) did not have a nurse on staff. Predetermined policies regarding RTD after injury were available at 81% of daycares. Twenty-eight (38.5%) facilities had encountered a child with a cast in the previous year. The rate of RTD for children with upper limb injuries was 90.5% compared with 79% for lower limb injuries (P=0.003). Spica casts showed the lowest RTD rate: single leg (22.5%), 1 and a half leg (18%), and 2 leg (16%) (P 5 y) had a higher RTD rate compared with less experienced facilities (P=0.026). CONCLUSIONS The ability to RTD is dependent on immobilization type. Children with long leg and spica casts are disproportionately restricted when compared with other cast types. At minimum, surgeons should consider the socioeconomic implications of orthopaedic immobilization. There is also a need for orthopaedic involvement in policy formation at the local level to provide standardized guidelines for re-entry into childcare facilities following orthopaedic immobilization. LEVEL OF EVIDENCE Level IV.

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

BACKGROUND Spica casting (Spica) remains the widely accepted treatment of closed femoral shaft fractures in young children aged 6 months to 5 years. In some centers, there has been a recent trend towards surgical fixation of these fractures with flexible intramedullary nails (FINs). Despite numerous studies evaluating both Spica and FIN treatment of femoral shaft fractures, there remains a paucity of data regarding patient burden during the intraoperative period. The purpose of this study was to compare the intraoperative burden, defined as anesthetic exposure, fluoroscopic duration, and radiation load, between Spica and FIN treatment of femoral shaft fractures in young children. METHODS A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Comparison groups included pediatric femur fractures treated with Spica and those treated with FIN. Outcomes included anesthetic exposure, fluoroscopy duration, and radiation exposure. In addition, length of stay, clinic visits, and complications were recorded. RESULTS Of 449 consecutive pediatric femur fractures treated at our center, 143 patients ages 2 to 6 years (mean age 3.8±1.4 y) met inclusion criteria. The Spica group contained 91 patients; FIN contained 52 patients. Mean anesthetic exposure was less for Spica compared with FIN [45.1 min, 95% confidence interval (CI): 38.0-52.3 vs. 90.7 min, 95% CI: 80.5-100.8 min; P

Background/Purpose: The majority of pediatric fracture treatment involves immobilization. There is a paucity of literature assessing the impact of immobilization on the ability of pediatric patients to return to daycare. The purpose of this study was to assess return to daycare after fracture immobilization based on daycare facility policy. We hypothesized that daycare facilities would be less likely to accept patients with increased amounts of immobilization. Methods: A 40-question survey of …

Background/Purpose: Rapid recovery protocols have gained traction in various surgical specialties including pediatric spine deformity. Previous studies have assessed outcomes after implementation of multiple concurrent interventions. Due to the nature of bundled implementation, previous work has not identified the relative importance of each bundle component. The role of early mobilization has not been established. …

BACKGROUND The primary objective of the Pediatric Orthopaedic Society of North America (POSNA)-Children's Orthopaedics in Underserved Regions (COUR) Visiting Scholar Program is to engage emerging leaders from low-income and middle-income countries (LMICs) in POSNA educational offerings. This study aims to outline the educational and leadership activities pursued by the alumni of the POSNA-COUR Visiting Scholars Program. We hypothesized that there may be a discrepancy between visiting scholar interest level and actual participation in key follow-up educational and leadership activities. METHODS A 32-question online survey developed by the POSNA-COUR committee was electronically delivered to the POSNA-COUR visiting scholarship recipients from 2007 to 2019. The survey inquired about scholars' educational background, clinical practice, and academic interests. Respondents also reported educational, research, and leadership activities that occurred following program participation. RESULTS Fifty-seven percent (44/77) of the previous scholars participated in the survey. Sixty-eight percent reported that >75% of their practice was comprised of pediatric patients. The COUR scholarship afforded 15 scholars the opportunity to attend their first educational conference in North America. The majority (86%) of respondents consulted POSNA members on care-related issues, 52% organized a POSNA member's visit to their country, and 13% have become members of POSNA. Scholars shared their knowledge with colleagues through lectures (73%), demonstration of surgical skills (63%), mentorship (59%), hosting local courses (43%), and research (14%). There was a significant discrepancy between interest and actual participation in research (98% vs. 16%, P

Background/Purpose:Long leg casts (LLC) with delayed weight-bearing is an established treatment for pediatric tibial shaft fractures including fractures involving the distal third. There is a paucity of literature assessing the use of SLC for tibial shaft fractures. The purpose of this study was to determine if SLC and early weight-bearing was as effective as LLC with delayed weight-bearing for the treatment of pediatric distal third tibial shaft fractures. Methods:A retrospective review was conducted on consecutive distal third tibial shaft fractures treated at a tertiary pediatric hospital from 2015 to 2018. Exclusion criteria included midshaft and proximal fractures of the tibia, distal fractures that violated the tibial physis or plafond, and pathologic fractures. We compared primary outcomes of time to weight-bearing, time to union, and final angulation between LLC and SLC groups. Results:Eighty-five patients aged 5 to 17 years (mean age 9.2±3.2 years) met inclusion criteria, including 50 LLC and 35 SLC patients. Fracture type (p=0.14), presence of associated fibula fracture (p=0.49), open fracture (p=0.46), and injury mechanism (p=0.18) were similar between the two groups. Time to weight-bearing for SLC (3.3±0.6 weeks) was shorter compared to LLC (6.4±0.7 weeks, p

Introduction A shortage of medical devices designed for children persists due to the smaller pediatric population and market factors. Furthermore, pediatric device development is challenging due to the limited available funding sources. We describe our experience with pediatric device projects that successfully received federal grant support towards commercializing the devices that can serve as a guide for future innovators. Methods The developmental pathways of pediatric device projects at a tertiary-care children's hospital that received NIH SBIR/STTR funding between 2016–2019 were reviewed. The clinical problems, designs, specific aims, and development phase were delineated. Results Pediatric faculty successfully secured NIH SBIR/STTR funding for five pediatric devices via qualified small business concerns (SBC's). Three projects were initiated in the capstone engineering design programs and developed further at two affiliated engineering schools, while the other two projects were developed in the faculty members’ labs. Four projects received funding via established SBC's, while one was awarded funding via a newly established SBC. Conclusion NIH SBIR/STTR grants are an essential source of external non-dilutive funding for pediatric device innovation and especially for academic-initiated projects. This funding can provide needed early-stage support to facilitate commercialization. In addition, these grants can serve as achievable accomplishments for pediatric faculty portfolios toward academic promotion. Our experience shows that it is possible to build a robust innovation ecosystem comprised of academic faculty (clinical/engineering) collaborating with local device development companies while jointly implementing a product development strategy leveraging NIH SBIR/STTR funding for critical translational research phases of pediatric device development.

Decreasing radiation exposure is important for scoliosis patients who require serial imaging. Microdose protocol stereoradiography is now increasingly utilized. Previous studies have reported similar reliability of concurrent Sanders skeletal maturity staging based on standard low-dose stereoradiography and standard hand radiographs. The purpose of our study was to investigate the reliability and radiation exposure of concurrent Sanders staging using microdose protocol compared to a standard protocol for adolescent idiopathic scoliosis. We hypothesized that surgeon-performed Sanders staging would have similar reliability when comparing microdose and standard-dose imaging protocols.A randomized survey of 30 hand images using standard protocol spinal stereoradiography and an equal number from microdose protocol were distributed to six experienced pediatric orthopaedic spine surgeons. Images were graded by each surgeon according to the Sanders skeletal maturity grading system. Items were again randomized and graded after a 2-week interval. Fleiss' weighted kappa for inter and intraobserver reliability was calculated and an unpaired t test was used to test for significance.Interobserver reliability for all modalities was in the strong to almost perfect agreement (average weighted κ 0.8) range. For the microdose protocol, κ was 0.82 and 0.84 for each separate round of grading. Standard low-dose protocol κ was 0.83 and 0.79. Intraobserver κ was 0.86 for microdose and 0.82 for standard. Average radiation for microdose was significantly less radiation (82.6%) than standard stereoradiography (0.3 ± 0.1 mGy vs. 1.9 ± 0.4 mGy, p 0.001).Sanders staging reliability of a well-positioned hand during scoliosis stereoradiography was similarly excellent for both microdose and standard low-dose protocol. Microdose protocol used less radiation while still preserving the reliability of Sanders staging.

With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [ Orthopedics . 2020;43(5):e338–e344.]

Spinal fusion is among the most commonly performed surgical procedures for elderly patients with spinal disorders – including degenerative disc disease with spondylolisthesis, deformities, and trauma. With the large increase in the aging population and the prevalence of osteoporosis, the number of elderly osteoporotic patients needing spinal fusion has risen dramatically. Due to reduced bone quality, postoperative complications such as implant failures, fractures, post-junctional kyphosis, and pseudarthrosis are more commonly seen after spinal fusion in osteoporotic patients. Therefore, pharmacologic treatment strategies to improve bone quality are commonly pursued in osteoporotic cases before conducting spinal fusions. The two most commonly used pharmacotherapeutics are bisphosphonates and parathyroid hormone (PTH) analogs. Evidence indicates that using bisphosphonates and PTH analogs, alone or in combination, in osteoporotic patients undergoing spinal fusion, decreases complication rates and improves clinical outcomes. Further studies are needed to develop guidelines for the administration of bisphosphonates and PTH analogs in osteoporotic spinal fusion patients in terms of treatment duration, potential benefits of sequential use, and the selection of either therapeutic agents based on patient characteristics.

There is no consensus on the optimal surgical treatment for high-grade spondylolisthesis (HGS) in adolescents. The purpose of this study was to assess the radiographic and clinical outcomes of a novel surgical approach to HGS consisting of a single-level anterior reduction, placement of a lordotic cage, and circumferential fixation without decompression.This was a retrospective consecutive case series of 11 adolescents who underwent anterior reduction through placement of a lordotic cage followed by posterior fusion using pedicle screws and rods confined to L5-S1. Radiographic data included slip percentage, slip angle, lumbar lordosis, and pelvic sagittal parameters assessed at clinical visits preoperatively and at 2 years postoperatively. A telephone survey was conducted to obtain current information about function, activity level, work status, and retrograde ejaculation.Patients were followed for an average of 7.8 years (range 2-16). Mean age was 15.5 years (range 12-19). The mean percent slip corrected from 55 to 18%. The average slip angle was + 17.1° preoperatively and - 14.1° at final assessment (average correction of 20.7°). Thirty-six percent (4/11) of patients improved by three Meyerding grades and an additional 55% (6/11) improved by two grades. Complications included one instance each of superficial infection, wound dehiscence, and transient neuralgia. There were no cases of instrumentation failure, cage subsidence, pseudoarthrosis, or retrograde ejaculation. Radiographic evidence of fusion was observed in all cases.Single-level anterior reduction and circumferential fusion without decompression appears to be a safe and effective alternative for the surgical treatment of pediatric HGS.IV.

Study Design:Narrative review.Objectives:Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.Methods:A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.Results:SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.Conclusions:Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

Purpose Although spica casting remains the benchmark for treating diaphyseal femur fractures in preschool children, some authors advocate using flexible intramedullary nails in certain situations. The aim of the current study was to evaluate the anatomic feasibility of flexible nailing in young children. Methods Consecutive patients between the ages of zero and ten years with normal femurs who received femur radiographs at a tertiary paediatric hospital over a two-year period were included. Anteroposterior femur radiographs were evaluated for length and isthmus width measurements. Each femur was templated for flexible nail size. The proportions of each age group capable of accommodating two flexible nails up to 4.0 mm in size were determined and compared. Results A total of 381 full-length femur radiographs were reviewed. There was a strong, direct linear relationship between age and femoral length (R2 = 0.896) and a moderate correlation between age and femoral isthmus width (R2 = 0.417). Although the percentage of femurs able to accommodate flexible nails continued to increase with age, this increase did not represent a significant difference when comparing preschool-aged children with older age groups. Conclusions Age and femoral length demonstrated a strong, positive correlation while age and isthmus width had weaker correlation. The ability of femurs to accommodate flexible nails increased with age with most children age two years and older able to accommodate two flexible nails of at least 2.5 mm in size. Level of Evidence III

Study Design:Narrative review.Objectives:The purpose of this article is to perform a review of the literature assessing the efficacy of opioid alternatives, multimodal pain regimens, and rapid recovery in pediatric spine surgery.Methods:A literature search utilizing PubMed database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease postoperative pain and expedite recovery after posterior spinal fusion in adolescent idiopathic scoliosis patients have been provided based on results of studies with the highest level of evidence.Results:Refining perioperative pain management to lessen opioid consumption with multimodal regimens may be useful to decrease recovery time, pain, and complications. Nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, neuraxial blockades, and local anesthesia alone offer benefits for postoperative pain management, but their combination in multimodal regimens and rapid recovery pathways may contribute to faster recovery time, improved pain levels, and lower reduction in total opioid consumption.Conclusion:A rapid recovery pathway using the multimodal approach for pediatric scoliosis correction may offer superior postoperative pain management and faster recovery than traditional opioid only pain protocols.

Background/Purpose:Long leg casts (LLC) with delayed weight-bearing is an established treatment for pediatric tibial shaft fractures including fractures involving the distal third. There is a paucity of literature assessing the use of SLC for tibial shaft fractures. The purpose of this study was to determine if SLC and early weight-bearing was as effective as LLC with delayed weight-bearing for the treatment of pediatric distal third tibial shaft fractures. Methods:A retrospective review was conducted on consecutive distal third tibial shaft fractures treated at a tertiary pediatric hospital from 2015 to 2018. Exclusion criteria included midshaft and proximal fractures of the tibia, distal fractures that violated the tibial physis or plafond, and pathologic fractures. We compared primary outcomes of time to weight-bearing, time to union, and final angulation between LLC and SLC groups. Results:Eighty-five patients aged 5 to 17 years (mean age 9.2±3.2 years) met inclusion criteria, including 50 LLC and 35 SLC patients. Fracture type (p=0.14), presence of associated fibula fracture (p=0.49), open fracture (p=0.46), and injury mechanism (p=0.18) were similar between the two groups. Time to weight-bearing for SLC (3.3±0.6 weeks) was shorter compared to LLC (6.4±0.7 weeks, p

It is believed that an effective vaccine against leishmaniasis will require a T helper type 1 (TH 1) immune response. In this study, we investigated the adjuvanticity of the Toll-like receptor (TLR) 7/8 agonist 3M-052 in combination with the Leishmania donovani 36-kDa nucleoside hydrolase recombinant protein antigen (NH36). NH36 and 3M-052 were encapsulated in separate batches of poly(lactic-co-glycolic acid) (PLGA) microparticles (MPs). The loading efficiency for NH36 was 83% and for 3M-052 was above 95%. In vitro stimulation of bone marrow-derived dendritic cells, measured by IL-12 secretion, demonstrated that 3M-052 (free or MP-formulated) had a concentration-dependent immunostimulatory effect with an optimum concentration of 2 µg/mL. In immunogenicity studies in BALB/c mice, MP-formulated NH36 and 3M-052 elicited the highest serum titers of TH 1-associated IgG2a and IgG2b antibodies and the highest frequency of IFNγ-producing splenocytes. No dose dependency was observed among MP/NH36/3M-052 groups over a dose range of 4-60 µg 3M-052 per injection. The ability of MP-formulated NH36 and 3M-052 to elicit a TH 1-biased immune response indicates the potential for PLGA MP-formulated 3M-052 to be used as an adjuvant for leishmaniasis vaccines. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1587-1594, 2018.

Purpose Intra-operative imaging plays a key role in screw placement for slipped capital femoral epiphysis (SCFE). Complications have been associated with inadequate screw position. The purpose of this study was to evaluate computed tomography (CT) (3D fluoroscopy) and standard fluoroscopy (C-arm) images as compared with direct anatomic measurement to determine final screw position in a cadaveric SCFE model. Methods Osteotomy with pinning was performed at the physeal scar in ten cadaveric hips. A standardised approach-withdrawal technique was performed with C-arm images taken at 15° increments. We also obtained a CT (3D fluoroscopy) scan of each hip. The screw tip-subchondral bone (STSB) distance was measured on digital imaging software and also with a digital calliper directly when the femoral head was cut in plane to expose the STSB distance anatomically. Statistical analysis included t-tests and Fisher's exact test. Results Moderate SCFE osteotomies were achieved with a mean Southwick angle (39.5° ± 7°). The 60° fluoroscopic image was found to be the most representative image (41% of the time) compared with both anteroposterior (AP) and lateral images (8% and 21%). Both fluoroscopy (2.7 ± 0.8 mm, p < 0.001) and CT (1.6 ± 0.7 mm, p = 0.03) overestimated the STSB distance compared with direct measurement (0.94 ± 0.51 mm). Two-thirds (67%) of CT measurements were within 1 mm of the cadaveric measurement, while only 20% of C-arm measurements fulfilled this criterion (p = 0.04). Conclusions Both standard fluoroscopy and CT overestimated the STSB distance when compared with direct measurement in a cadaveric model of SCFE. Surgeons should be aware of the limitations of intra-operative imaging to determine the STSB distance. We suggest that using the known pitch of a screw (2.9 mm in a 7.3-mm cannulated screw) as an intra-operative tool to help guide screw placement.

Background: Removal of hardware with irrigation and debridement in patients with surgical site infections (SSIs) is performed commonly. However, the removal of hardware from patients with SSIs after spinal procedures is controversial. Moreover, primary spinal infections such as spondylodiscitis may require instrumentation along with surgical debridement. The purpose of this article was to evaluate critically and summarize the available evidence related to retention of hardware in patients with deep SSIs, and the use of instrumentation in surgical treatment of primary spinal infections. Methods: A literature search utilizing PubMed database was performed. Studies reporting the management of deep SSIs after instrumented spinal procedures, and of primary spinal infections using instrumentation published in peer-reviewed journals were included. Identified publications were evaluated for relevance, and data were extracted from the studies deemed relevant. Results: Because SSIs occur typically during the early post-operative period before stable bony fusion has been achieved, the removal of instrumentation may be associated with instability of the spinal column, pseudarthrosis, progressive deformity, pain, loss of function, and deterioration in the activities of daily living (ADL). Hence, early SSIs after spinal instrumentation are usually treated without removal of hardware. Moreover, primary spinal infections such as spondylodiscitis may require surgical debridement and instrumentation in cases with associated instability. Conclusions: Retaining or using instrumentation in patients with SSIs after spinal procedures or in patients with primary spinal infections, respectively, are commonly practiced in the field of spine surgery. Further evidence is required for the development of definitive algorithms to guide spine surgeons in decision making regarding the fate of instrumentation in the treatment of spinal infections.

The field of global health has undergone remarkable growth and development over the past half century. Pediatric orthopedists have been at the forefront of much of this work. From the beginning, these individuals have understood what it means to perform global outreach and have helped our profession and Society focus on how to do so in meaningful and impactful ways. In 2001, the Children’s Orthopedics in Underserved Regions (COUR) committee was formed to help POSNA members carry out this work in resource-limited environments. The COUR committee was initially approached and asked to consider changing the name to better reflect the modern verbiage used in the field. As we began to consider and explore this request, it became apparent that this also was an opportunity to recognize the evolved role the committee has for our membership and the Society. After a thorough process of consultation and debate, the committee recommended that the name be changed to the Pediatric Orthopedic Global Outreach (POGO) committee. After review, the Board of Directors approved this name change in September 2019. In this manuscript we present the history, rationale for change, and vision for the future. The mission of POGO will be carried out through a combination of Education, Coordination, and Research. While the name of the committee has changed to POGO, the principals that made COUR so successful remains at its core. This is an opportunity to build on the work of the visionary leaders who laid the foundation for us to shape the future.

Fluidic transmission mechanisms use fluids to transmit force through conduits. We previously presented a transmission mechanism called solid-media transmission (SMT), which uses conduits filled with spheres and spacers for push-only bidirectional transmission. In this paper, we present new designs of SMT-actuated one-degree-of-freedom (DoF) and two-degree-of-freedom positioning manipulators, and report experiment studies to assess their performance. In these studies, closed-loop position control was performed with a PI controller and/or master-slave control. With braided PTFE tubing, SMT exhibited sub-millimeter accuracy, with a tolerance of ±0.05 mm for the tested transmission lines with lengths up to 4m.

Background Sagittal profile descriptions of supracondylar humerus fractures are limited. We describe a reverse oblique (RO) pattern in which the distal fragment has a prominent anterior spike that is displaced posterior to the proximal fragment. This pattern presents a challenge during closed manipulation utilizing traditional reduction maneuvers. The purpose of this study is to compare the clinical and radiographic characteristics of the RO and non-RO patterns of supracondylar humerus fractures. We hypothesized that the RO pattern would be associated with greater soft tissue trauma. Methods Retrospective evaluation of operative supracondylar humerus fractures treated at a tertiary pediatric hospital from 2014 to 2016. Patients were categorized into RO and non-RO groups for analysis. Associated neurovascular injuries were compared between groups. Results Two hundred ninety-nine consecutive patients were reviewed. The RO fracture pattern was seen in 12 patients. All displaced RO fractures were able to be closed reduced with a modification to the traditional reduction sequence. Overall cohort rates of preoperative soft tissue injury included antecubital ecchymosis 16.8%, nerve palsies 15%, and vascular compromise 6.4%. Compared with non-RO fractures, the RO fracture group had significantly higher rates of anterior interosseous nerve (AIN) palsies (P=0.013), antecubital ecchymosis (P=0.018), and compartment syndrome (P=0.043). When comparing RO with non-RO type II fractures, there were no differences in soft tissue injury (P=0.439). Compared with non-RO type III fractures, RO type III fractures had higher rates of AIN injury (P=0.047), antecubital ecchymosis (P=0.007), and overall soft tissue injury (P=0.009). Conclusions This study introduces a previously undescribed supracondylar humerus fracture subtype: the RO fracture. We found increased rates of soft tissue compromise including antecubital ecchymosis and AIN palsy in this fracture type. Further, traditional reduction methods proved to be ineffectual for this fracture pattern. We utilized a simple modification that allowed for closed reduction and percutaneous pinning of displaced RO fractures. Level of evidence Level III-prognostic.

Simulation-based surgical skills training is recognized as a valuable method to improve trainees’ performance and broadly perceived as essential for the establishment of a comprehensive curriculum in surgical education. However, there needs to be improvement in several areas for meaningful integration of simulation into surgical education. The purpose of this focused review is to summarize the obstacles to a comprehensive integration of simulation-based surgical skills training into surgical education and board certification and suggest potential solutions for those obstacles. First and foremost, validated simulators need to be rigorously assessed to ensure their feasibility and cost-effectiveness. All simulation-based courses should include clear objectives and outcome measures (with metrics) for the skills to be practiced by trainees. Furthermore, these courses should address a wide range of issues, including assessment of trainees’ problem-solving and decision-making abilities and remediation of poor performance. Finally, which simulation-based surgical skills courses will become a standard part of the curriculum across training programs and which will be of value in board certification should be precisely defined. Sufficient progress in these areas will prevent excessive development of training and assessment tools with duplicative effort and large variability in quality.

Leishmania donovani is the major cause of visceral leishmaniasis (kala-azar), now recognized as the parasitic disease with the highest level of mortality second only to malaria. No human vaccine is currently available. A 36 kDa L. donovani nucleoside hydrolase (LdNH36) surface protein has been previously identified as a potential vaccine candidate antigen. Here we present data on the expression of LdNH36 in Pichia pastoris and its purification at the 20 L scale to establish suitability for future pilot scale manufacturing. To improve efficiency of process development and ensure reproducibility, 4 N-linked glycosylation sites shown to contribute to heterogeneous high-mannose glycosylation were mutated to glutamine residues. The mutant LdNH36 (LdNH36-dg2) was expressed and purified to homogeneity. Size exclusion chromatography and light scattering demonstrated that LdNH36-dg2 existed as a tetramer in solution, similar to the wild-type recombinant L. major nucleoside hydrolase. The amino acid mutations do not affect the tetrameric interface as confirmed by theoretical modeling, and the mutated amino acids are located outside the major immunogenic domain. Immunogenic properties of the LdNH36-dg2 recombinant protein were evaluated in BALB/c mice using formulations that included a synthetic CpG oligodeoxynucleotide, together with a microparticle delivery platform (poly(lactic-co-glycolic acid)). Mice exhibited high levels of IgG1, IgG2a, and IgG2b antibodies that were reactive to both LdNH36-dg2 and LdNH36 wild-type. While the point mutations did affect the hydrolase activity of the enzyme, the IgG antibodies elicited by LdNH36-dg2 were shown to inhibit the hydrolase activity of the wild-type LdNH36. The results indicate that LdNH36-dg2 as expressed in and purified from P. pastoris is suitable for further scale-up, manufacturing, and testing in support of future first-in-humans phase 1 clinical trials.

Summary Background Indwelling ureteral stents are commonly used in pediatric surgeries for kidney stones and urinary tract obstruction, but often require instrumentation or anesthesia for removal. We evaluated the use of novel magnet devices to remove indwelling ureteral stents with a distally attached magnetic bead. Since the forces required for stent removal are unknown, we aimed to characterize and quantify the forces required for stent removal for future prototype testing. Methods A custom 3-D urinary tract model was used for benchtop testing, and 6 female porcine subjects were used for in vivo testing after obtaining institutional approval. A modified porcine urethral model that patterned the human female urethral anatomy with approximately 4.5 cm urethral length was used. A HF-10 digital force gauge measured the force required to remove stents with varying properties (stent size, presence of curl, and size of distal magnetic bead). These force measurements were compared to the quantified magnetic forces generated by external magnets and catheter tip magnets. Furthermore, the magnetic retrieval devices were tested with various magnetic beads on both benchtop and porcine models. Results The required force for removal of a 5 Fr x 14 cm double J stent was significantly higher in the benchtop model compared to the porcine model (4.7N v. 0.8N, p Conclusions The forces required for ureteral stent removal are Extended Summary Table . Maximum forces required to remove ureteral stents with varying properties (stent size, presence of curl, size of distal magnetic bead) from the bladder in both benchtop and porcine models. For the benchtop model, the stents were placed solely in the bladder and then also in the ureter with just the distal coil in the bladder. In the porcine model they were all placed in the ureter. With the exception of the porcine model 4 Fr trials (n = 3,5 for 4 Fr straight and 4 Fr JJ respectively), all conditions are based on n = 9 trials or greater. Entries marked with ∗∗∗ are significantly different from the values for the corresponding stent type in the benchtop bladder model to the p = 0.01 level using a two-tailed student's t-test BENCHTOP - Max Retrieval Force in N PORCINE - Max Retrieval Force in N Stent size + bead type Bladder Ureter Ureter 5 Fr JJ, stent unfurling only 0.79 ± 0.22 4 Fr Straight 0.17 ± 0.04 5 Fr Straight 0.29 ± 0.16 4.20 ± 0.62 ∗∗∗ 0.23 ± 0.06 4 Fr JJ 0.55 ± 0.08 5 Fr JJ 0.79 ± 0.23 4.73 ± 0.65 ∗∗∗ 0.82 ± 0.40 5 Fr JJ + 2 mm 0.85 ± 0.45 5 Fr JJ + 3.2 mm 0.99 ± 0.14 4.05 ± 0.59 ∗∗∗ 0.81 ± 0.38 5 Fr JJ + 4.8 mm 1.68 ± 0.16 3.92 ± 0.66 ∗∗∗

The growing body of evidence documenting the effectiveness of brace treatment for scoliosis has renewed interest in potential benefits of early detection through school screening. We aimed to assess the prevalence and identify barriers of screening. We hypothesized that school screening is more frequent in schools that have a nurse on staff compared to schools without nurse on staff.A questionnaire survey.All schools located in four counties in Louisiana, United States of America comprising the New Orleans metropolitan area between September 2015 and January 2016 were contacted by phone to assess rates of scoliosis screening, report the availability of a school nurse, and specify barriers if screening was not performed.Two hundred and ninety-one schools responded to the survey including 152 public, 30 charter, and 109 private schools (101 had religious affiliation). A staff nurse was available in 180 schools (61.8%). Only 21 schools (7.2%) performed scoliosis screening. The majority were charter schools (11 schools), while six were private and four were public (P 0.0001). Of these 21 schools, 16 (76.2%) had a nurse on staff while five schools did not (P = 0.16). Lack of a referral pathway in the event of a positive screen was the most common barrier to performing scoliosis screening.Scoliosis screening is infrequent in the examined school districts. Efforts to support school screening can facilitate clear referral pathways for schools in the event of a positive screen. These findings suggest a potential need for different pathway of scoliosis screening. Pediatricians and family physicians can assist with scoliosis screening during the annual visit. While universal screening is overburdensome and likely unnecessary, targeted screening of underserved populations may prove to be beneficial. Further investigation should include assessment of the economic viability of targeted screening programs.IV.

Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting.This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups.Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023).TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN.Level III, this was a retrospective comparative study.

Magnetic resonance imaging (MRI)-guided, manipulator-assisted interventions have the potential to improve patient outcomes. This work presents a force transmission mechanism, called solid-media transmission (SMT), for actuating manipulators inside MRI scanners. The SMT mechanism is based on conduits filled with spheres and spacers made of a nonmagnetic, nonconductive material that forms a backbone for bidirectional transmission. Early modeling and experimental studies assessed SMT and identified limitations and improvements. Simulations demonstrated the detrimental role of friction, which can be alleviated with a choice of low friction material and long spacers. However, the length of the spacer is limited by the desired bending of the conduit. A closed-loop control law was implemented to drive the SMT. The 3rd order system fit ratio is 92.3%. A 1-m long SMT was experimentally tested under this closed-loop controller with heuristically set parameters using a customized benchtop setup. For commanded displacements of 1 to 50 mm, the SMT-actuated 1 degree of freedom stage exhibited sub-millimeter accuracy, which ranged from 0.109 ± 0:057 mm to 0.045 ± 0.029 mm depending on the commanded displacement. However, such accuracy required long control times inversely proportional to displacement ranging from 7.56 ± 1.85s to 2.53 ± 0.11s. This was attributed to friction as well as backlash which is due to suboptimal packing of the media. In MR studies, a 4-m long SMT-actuated 1 DoF manipulator was powered by a servo motor located inside the scanner room but outside the 5 Gauss line of the magnet. With shielding and filtering, the SNR of MR images during the operation of the servo motor and SMT- actuation was found to be 89 ± 9% of the control case.

Pediatric cervical spine conditions are relatively uncommon. Pathology usually begins at the time of early development; however, it is not usually recognized until late childhood (incidental finding) or early adulthood when patients may become symptomatic. It is also important to recognize other anomalies associated with cervical spine anomalies and manage in a timely manner to achieve optimal care of the child. This chapter reviews some of the higher-yield information regarding pseudosubluxation, atlantoaxial instability, atlantoaxial rotatory subluxation, anomalies of the dens, Klippel-Feil syndrome, congenital muscular torticollis, and basilar impression.