Pediatric Orthopedic Patients Research Articles

The impact of obesity on pediatric orthopedic polytrauma patients

Objectives: The effect of obesity on fracture care and management in the adult population has been well documented in the literature; there is a scarcity of evidence-based research reporting the impact of obesity on pediatric orthopedic polytrauma patients. The aim of this study was to objectively investigate the impact of obesity on pediatric orthopedic polytrauma patients to optimize care and fracture management. Methods: A single-center retrospective cohort study of pediatric polytrauma patients aged 2–18 years old admitted to a level 1 trauma center was conducted over three years. Patients were categorized based on their body mass index (BMI). A logistic regression model was used to identify significant variables between the study groups. Results: A total of 60 patients were included in the analysis and divided into normal weight group (n = 36) and overweight/obese group (n = 24). A trend of lower injury severity score (ISS) was observed in the overweight/obese group compared to the normal weight group. Non-orthopedic injuries, including head, chest, and abdominal injuries, were found to be less in the overweight/obese group. Higher rates of spine and extremity fractures were reported in the overweight/obese group, as well as the need for surgical fixation (P = 0.05). No specific differences in complications, outcome, or discharge facility were found between the two groups. Conclusion: The paradoxical association between BMI and ISS/non-orthopedic injuries, in contrast to spine and extremity fractures, reflects the complex relationship between obesity and polytrauma patterns. Large multi-center prospective studies are needed to predict clinical outcomes in pediatric orthopedic polytrauma patients.

Automated Measurements of Long Leg Radiographs in Pediatric Patients: A Pilot Study to Evaluate an Artificial Intelligence-Based Algorithm.

Assessment of long leg radiographs (LLRs) in pediatric orthopedic patients is an important but time-consuming routine task for clinicians. The goal of this study was to evaluate the performance of artificial intelligence (AI)-based leg angle measurement assistant software (LAMA) in measuring LLRs in pediatric patients, compared to traditional manual measurements. Eligible patients, aged 11 to 18 years old, referred for LLR between January and March 2022 were included. The study comprised 29 patients (58 legs, 377 measurements). The femur length, tibia length, full leg length (FLL), leg length discrepancy (LLD), hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured automatically using LAMA and compared to manual measurements of a senior pediatric orthopedic surgeon and an advanced practitioner in radiography. Correct landmark placement with AI was achieved in 76% of the cases for LLD measurements, 88% for FLL and femur length, 91% for mLDFA, 97% for HKA, 98% for mMPTA, and 100% for tibia length. Intraclass correlation coefficients (ICCs) indicated moderate to excellent agreement between AI and manual measurements, ranging from 0.73 (95% confidence interval (CI): 0.54 to 0.84) to 1.00 (95%CI: 1.00 to 1.00). In cases of correct landmark placement, AI-based algorithm measurements on LLRs of pediatric patients showed high agreement with manual measurements.

Post-Surgical Dental Precautions/Prophylaxis in Pediatric Patients: Results of a 2023 Survey of the Membership of the Pediatric Orthopaedic Society of North America (POSNA)

IntroductionGuidelines regarding post-surgical dental care have been common in adult total joint arthroplasty patients, despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in post-operative pediatric orthopaedic patients without any published evidence to guide clinicians. Material and MethodsA survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of post-surgical guidelines regarding dental care (procedures and prohylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. ResultsOne hundred and seventy-three POSNA members opened the link to the survey. 163 respondents self-identified as Active, for a response rate of 19.8%. One hundred and fifty-seven (96.3%) reported direct involvement in surgical and post-surgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a post-operative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. ConclusionsThese results demonstrate that many of the active members of POSNA utilize post-surgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients, and no literature regarding use of such guidelines in pediatric orthopaedic patients. Level of EvidenceLevel V

Medial Patellofemoral Ligament Reconstruction in Adolescents: What Parents Care About.

Numerous techniques exist for pediatric medial patellofemoral ligament (MPFL) reconstruction (MPFL-R). Pediatric orthopaedic surgeons and patient families must navigate choices between allograft and autograft, incision type, and surgery cost. While previous research has found similar surgical outcomes among different MPFL-R techniques, minimal data exists on what patients and their families prefer. To engage in shared decision-making (SDM), pediatric orthopaedic surgeons must understand family preferences, including between incision type and cost. We conducted a study utilizing choice-based conjoint (CBC) analysis to explore these preferences. A survey was developed using Sawtooth Software (Lighthouse Studio version 9.2.0) to gather demographic information and preferences on surgical scenarios via CBC analysis. Anonymous participants, recruited via the Prolific crowdsourcing platform, qualified if they were US residents over 18 years of age with children aged 13 to 17. Data analysis involved the Hierarchical Bayes (HB) method to generate utility scores to determine the desirability of attributes. The study included 496 participants who prioritized surgical success (average importance 48.8%) followed by co-pay amount (21.5%), incision size (17.4%), and return to sport (12.3%). Participants earning over $200,000 annually prioritized incision size over cost (25.8% vs. 12.1%, P<0.0053). Those with incomes below $50,000 valued recovery time at a lesser extent than other income groups (10.4% than 12.3% overall importance P<0.0003). The sex of the child significantly influenced preferences: incision size was more important to parents of girls (21.1%) than boys (14.0%, P<.0001). The importance of surgery success and recovery time also differed by sex, being higher for boys (50.4%, 13.1%) than girls (47.0%, 11.7%; P=0.025, 0.026, respectively). This CBC analysis suggests parents of adolescent patients undergoing MPFL-R most value surgical success (avoiding revision surgery), followed by copay, incision size, and time to return to sport. Of note, parent income level and sex of the child significantly influenced parental preferences. We hope this information will assist orthopaedic surgeons in SDM in MPFL-R surgery. Level III.

Validation of Patient-Reported Outcome Measurement Information System for Detection of Posttraumatic Stress in Children and Adolescents Following Procedures for Acute Orthopaedic Trauma.

The efficiency and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were determined for pediatric orthopaedic trauma patients with posttraumatic stress disorder (PTSD) symptoms in a clinic setting. Prospective cohort study. Single-institution, Level I trauma center. All consecutive children aged 8-18 years undergoing procedures or surgery for orthopaedic trauma. The convergent, divergent, and discriminant validity of the PROMIS Anger and Anxiety computerized adaptive tests (CATs) were evaluated and compared with the previously validated Child PTSD Symptom Scale (CPSS). The efficiency in time to completion of the outcome measures was compared between the CPSS and PROMIS surveys. Cutoffs for increased likelihood of PTSD were established for the PROMIS questionnaires. A total of 233 subjects were included in this study (mean age 13.1 years with SD 2.8 years, 71% male). The majority (51%) of injuries were related to sports, and most (60%) involved the upper extremity. Of those included, 41 patients had high levels of PTSD symptoms on the CPSS (18%; 95% CI, 13.1-23.2%). The CPSS took 182 (interquartile range [IQR] 141-228) seconds versus 52 (IQR 36-84) and 52 (IQR 36-70) seconds for PROMIS Anger and Anxiety CATs, respectively. Convergent validity showed patient scores on both PROMIS instruments significantly correlated with CPSS scores (Anger: P < 0.001, r = 0.51; Anxiety: P < 0.001, r = 0.41). Neither PROMIS score correlated with University of California Los Angeles Activity Score (Anger: r = -0.26; Anxiety: r = -0.22), a functional outcome measure, demonstrating divergent validity. Both PROMIS instruments sufficiently discriminated across PTSD risk groups (Anger P < 0.001; Anxiety P < 0.001). A score of at least 53 on PROMIS Anger or at least 48 on PROMIS Anxiety indicated an increased likelihood of PTSD risk. PROMIS Anger and Anxiety CATs are efficient and valid for evaluating posttraumatic stress in children following orthopaedic trauma procedures. Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Predicting appointment no-shows in pediatric orthopedic patients using machine learning

Predicting appointment no-shows in pediatric orthopedic patients using machine learning

Effect of Short-term Deep Breathing Exercises on Perioperative Anxiety and Pain in Pediatric Orthopedic Patients: A Randomized Controlled Trial

PurposeThere are currently no pediatric studies examining the effects of deep breathing on perioperative pain and anxiety. This study sought to determine the effect of short-term deep breathing exercises on perioperative anxiety and pain in pediatric patients and their parents. DesignA randomized controlled trial was conducted in the Department of Orthopaedic Surgery where pediatric patients about to undergo surgery were allocated to a control group or a deep breathing group. In the intervention group, patients and their main guardian were guided to practice 10 minutes of deep breathing exercises twice a day for 3 to 4 days prior to surgery. Perioperative anxiety and pain were measured for both the children and parents as outcome indicators. MethodsPerioperative anxiety was measured using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) and state anxiety was measured using the State-Trait Anxiety Inventory (STAI). Patients reported their pain levels daily using the Wong-Baker FACES Pain Rating Scale. The following cutoffs were determined as high levels of anxiety: STAI (adult) > 44, STAI (child) > 36, and mYPAS-SF ≥ 30. FindingsNo significant differences were found in the STAI, mYPAS-SF, and Wong-Baker FACES Pain Rating Scale scores of the patients between the intervention and control group. Overall statistics showed that parents had significantly higher postoperative state anxiety levels toward female children (44.93 ± 9.01) compared to male children (40.18 ± 9.89). Preoperative and postoperative parental state anxiety levels were correlated with the child’s postoperative anxiety. Furthermore, children’s postoperative state anxiety was slightly correlated with postoperative pain. ConclusionsShort-term use of our deep breathing exercises was ineffective in reducing incidences of perioperative pain and anxiety in pediatric orthopedic patients. A longer period of deep breathing administration may be required for the intervention to be effective. Parental anxiety may have an effect on anxiety levels in children, and postoperative parental anxiety may be affected by the gender of the child.

The Impact of Social Deprivation on Health Care Utilization Patterns Following Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

BackgroundDisparities in social determinants of health have been linked to worse patient reported outcomes, higher postoperative pain, and increased risk of revision surgery following orthopaedic procedures. Identification of perioperative predictors of healthcare utilization is of particular interest to mitigate cost and improve patient outcomes. The aim of this study is to elucidate the effect of social deprivation levels, using the Area Deprivation Index (ADI), on healthcare utilization following pinning of supracondylar humerus (SCH) fractures. Identifying risk factors for discrepancies in healthcare utilization following SCH fracture fixation can help mitigate unnecessary healthcare spending and improve care of vulnerable patient populations. MethodsThis is a retrospective review of a single institution’s experience with SCH fracture pinning between 2010 and 2023. Demographic variables and healthcare utilization data were recorded within 90 days of surgery. The ADI was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. Results1186 patients from a single level one trauma center were included in this study. The upper, middle, and lower terciles of ADI consisted of 226, 458, and 502 patients, respectively. The most deprived tercile had greater emergency department visitation within 90 days of surgery relative to the least and intermediate deprived terciles (IRR 1.85, 95% CI 1.10-3.08). Identifying as White was an independent risk factor for increased outpatient clinic utilization (IRR 1.17, 95% CI 1.03-1.34). Higher levels of social deprivation were independent risk factors for increased ED visitation. There was no difference in 90-day inpatient readmission rates or telephone/telehealth calls made to the clinic between the least, intermediate, and most deprived patients. ConclusionsThis study begins to shed light on how social determinants of health impact the postoperative care of the pediatric orthopedic patient and which patient populations are the most at-risk for disproportionate resource utilization after pinning of SCH fractures. Understanding these differences may lead to improved patient outcomes while decreasing potentially unnecessary burden on the healthcare system. Level of EvidenceIII; retrospective comparative study Key Concepts1.Social determinants of health impact the postoperative care of the pediatric patient in the setting of supracondylar humerus fractures, more socially deprived patients are at higher risk of postoperative emergency department visits, patient race is shown to be a factor in postoperative clinic utilization.

Rare genetic skeletal disorders: Evolving terminology, therapies, education and advocacy

In the US, rare diseases are defined as disorders affecting fewer than 200,000 US residents or disorders for which there is no reasonable expectation that drug development costs will be recoverable by US sales. Almost 800 of the approximately 10,000 defined rare diseases are bone disorders. Until recently, their rarity and heterogeneity have unfortunately hindered their exploration at both clinical and scientific levels. However, wider availability of genetic testing, development of new surgical and pharmaceutical treatment options, and patient advocacy have motivated efforts to study, diagnose, and treat these disorders. Thus, care of the patient with a rare skeletal disorder is now evolving rapidly. This report presents a brief summary of important developments in skeletal disorders impacting bone quality and frequently co-managed by pediatric orthopaedic surgeons. Key Concepts(1)Although a “cure” is not yet available for most rare bone disease patients, new agents are frequently being advanced as new genes and their products are identified as molecules to target.(2)Medical therapies, often combined with surgical interventions and physical therapy, are reducing pain and increasing function in many pediatric orthopaedic patients with rare bone disorders.(3)New tools for physician education and patient management are increasingly available to assist the pediatric orthopaedic surgery community.

Therapy deserts: A call to action to address inequitable access to therapy services among pediatric orthopaedic patients

Background"Food deserts" are areas with limited access to affordable and healthy foods, disproportionately affecting low-income and ethnic minority communities in the United States. Analogous disparities exist in other disciplines. Our interprofessional team observed "therapy deserts” in orthopaedic and rehabilitation settings, wherein pediatric patients (particularly those with Medicaid-type insurance) appeared to lack equal access to physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. Inadequate access to therapy services places patients at risk for worse outcomes. MethodsWe conducted a quality improvement project to assess pediatric patients’ access to therapy care in our region. We surveyed all local PT, OT, and SLP clinics identified from a comprehensive listserv maintained by pediatric therapy teams in our institution. Using a scripted questionnaire, we contacted 113 PT, 38 OT, and 82 SLP clinics external to our institution, collecting data on accepted conditions, appointment waitlist periods, and accepted insurance types. Our primary objective was to determine the percentage of clinics that accepted patients with Medicaid-type insurance. We supplemented our survey with an examination of the Area Deprivation Index (ADI) for each clinic location. Results59 PT clinics (52%), 15 OT clinics (39%), and 36 SLP clinics (44%) completed the survey. Clinics often had limited capacity to care for medically complex conditions. Waitlist times varied, with a median wait of 1 week for PT services, 1 month for OT services, and immediate availability for SLP services. Only 14% of responding PT clinics, 53% of OT clinics, and 22% of SLP clinics accepted patients with Medicaid-type insurance. Insufficient reimbursement rates were frequently cited as the reason for not accepting Medicaid-type insurance. Waitlist times were longer for PT and SLP clinics that accepted Medicaid-type insurance compared to those that did not. Moreover, clinics that accepted Medicaid-type insurance were, on average, in more disadvantaged locations. ConclusionsOur findings suggest the existence of “therapy deserts,” where limited access to therapy services is influenced by insurance type and patient complexity. These restrictions likely exacerbate existing health disparities and illustrate a systemic problem rooted in complex social drivers of health. Addressing "therapy deserts" requires collaborative efforts from multidisciplinary teams. Level of EvidenceLevel III

Are radiographs overutilized in pediatric orthopaedic emergency room care?

BackgroundIt is estimated that $12.8 billion to $28.6 billion is wasted annually on unnecessary imaging studies and treatment in the United States. This is especially important to the pediatric population, which is unable to make decisions for themselves and vulnerable to radiation exposure. We hypothesized that a significant number of unnecessary radiographs are performed in the pediatric emergency department, leading to excessive time, cost, and radiation exposure to pediatric patients. MethodsWe retrospectively reviewed 406 patients who were evaluated in a pediatric emergency department (ED) for possible fracture at a single institution during the 2020 calendar year. Records were reviewed for demographics, history and physical exams, as well as the sequential order that radiographs were performed. All radiographs were evaluated by the senior author to determine if they resulted in a change in management. All data was recorded and analyzed by the senior author and our statistician using Student’s t-test. Results406 patient encounters were included. 2807 radiographs were deemed unnecessary, with an average of 6.9 radiographs per patient. $454,734 were spent on radiographs that ultimately did not change management. A total of 216 hours and 43 minutes were spent in the x-ray suite alone, for an average of 32 minutes per patient. The estimated amount of radiation exposure that did not change management was potentially as high as 69 millirem per patient. ConclusionsThere is an excessive amount of monetary waste, radiation exposure, and encounter time spent in pediatric orthopedic patients in the ED. There are several potential strategies to alleviate this problem, which we hope can be taken into consideration to help address this widespread healthcare issue.

Remote Patient Monitoring for Postoperative Pediatric Patients with Peripheral Nerve Catheters

Background: Close follow up of postoperative orthopedic and pectus excavatum surgical patients discharged with a nerve catheter is required to ensure adequate pain management and recognize medication toxicity. Assessing ambulatory pediatric patients using a smartphone application is convenient and effective. Methods: A novel Remote Patient Monitoring (RPM) program was developed to improve follow-up and ability to assess postoperative pain management, analgesic toxicity, and catheter site. Adherence and successful graduation were measured to determine the success of the program. Additionally, patient and caregiver experience and opioid use were measured. Interventions: Patients were enrolled in RPM postoperatively for four days. The RPM nursing team reviewed patient reported data in real-time to address concerns and develop a plan of care. Pain management education was provided via video prior to removing the nerve catheter. Results: Adherence to RPM is over 90% for both populations, with 82% success rate in orthopedic patients and 93% success rate in pectus excavatum patients. Experience scores have been high, and opioid prescriptions have been reduced by half for the orthopedic population. Conclusions: RPM is an effective tool used to manage pediatric postoperative orthopedic and pectus excavatum surgical patients with significant patient and caregiver buy-in.

Urinary tract infections in pediatric orthopedic surgical patients: a Single Institution National Surgical Quality Improvement Program Study.

Perioperative urinary tract infections (UTIs) are poorly studied among pediatric orthopedic surgical patients. We evaluated the incidence of and risk factors for UTI in a large volume of pediatric orthopedic surgical patients. Children <18 who underwent orthopedic surgery between March 2015 and December 2018 were analyzed using our institution's National Surgical Quality Improvement Program (NSQIP) data. Demographic, perioperative and outcome data of patients who developed a UTI within 30 days of surgery were compared to patients without UTI. NSQIP data were available for 520 surgeries (324 girls and 196 boys). Median age at surgery was 13.5 years. A Foley was placed in 301/520 cases (88/196 boys and 213/324 girls) in 264 children. Six cases of UTI occurred within 30 days of surgery (1.2% of surgeries). The UTI rate among patients with a Foley was 2.3%, and among girls with a Foley was 2.8%. No UTIs occurred without a Foley, nor any in boys. All six occurred in the American Society of Anesthesiologists Class 2 females, ages 7-15 undergoing elective surgery with Foley for over 48 h. Factors associated with an increased odds of developing UTI included: higher BMI [OR, 1.12 (CI, 1.01-1.22; P = 0.03)], developmental delay [OR, 7.82 (CI, 1.40-43.7; P = 0.02)], structural central nervous system abnormality [OR, 17.5 (CI, 3.89-90.4; P = 0.01)], longer duration with Foley [OR, 1.68 (CI, 1.22-2.32; P = 0.002)] and hospital readmission within 30 days [OR 14.2 (CI, 2.32-87.3; P = 0.004)]. Risk of UTI is low after pediatric orthopedic surgery. Girls with comorbidities including structural central nervous system abnormality, developmental delay and higher BMI with prolonged Foley catheterization may have higher postoperative UTI risk. Level of Evidence: II.

Comparison of the radiographic and functional outcome in pediatric orthopaedic patients with Gartland type II supracondylar fracture treated by operative versus non operative management

Background: The non-operative method of closed reduction and application of long arm posterior splint and the operative method of closed reduction and percutaneous pinning are both putative management for Gartland II supracondylar fracture. The purpose of this study is to compare which method is superior in the management of this type of fracture thru the comparison of the radiographic as well as the functional outcome. Methods: This study includes 51 pediatric patients undergoing supracondylar fracture treatment. The enrolled participants were randomly allocated to one of the two groups to receive either non operative or operative treatment. Radiographic and functional outcome was assessed post treatment. Results: The operative group exhibited significant superiority versus the non operative group as reflected by the results of the post-treatment radiographs utilizing the anterior humeral line while the Baumann’s angle showed no significant difference between the two groups. Moreover, the operative group demonstrated a better Mayo elbow performance score total per follow up, only in the first 3 months but showed no significant difference thereafter. Conclusions: We therefore conclude that non operative and operative management are both effective treatment for Gartland II supracondylar fracture. The operative group showed significant superiority with results of the anterior humeral line falling mostly at the central one-third of the capitellum. The operative group manifested a better Mayo elbow performance score total only during the first 3 months of follow up.

Arthroereisis with a Talar Screw in Symptomatic Flexible Flatfoot in Children

Background: Pes planovalgus, or flexible flatfoot, deformity is a common problem in pediatric orthopedic patients. There is no consensus on using the technique of arthroereisis in the treatment of symptomatic pes planovalgus. The aim of our study was to prospectively assess the functional outcomes following symptomatic pes planovalgus treatment with the use of the Spherus talar screw. Methods: Twenty-seven patients (11 females, 16 males), at a mean age of 10.5 years (7–14 years) were included in the prospective study. We assessed the level of physical activity (including sports) based on the University of California, Los Angeles (UCLA) activity scale, a 10-point level-of-activity VAS scale, and the Grimby physical activity scale. Pain was assessed based on a VAS pain scale; foot function was assessed with the revised Foot Function Index (FFI-R); and ankle joint mobility was measured. Results: The mean follow-up period was 18 months (14–26 months). There was a significant improvement in VAS-measured physical activity scores from 5.47 to 7 at follow-up, p = 0.048. There was a significant improvement in UCLA activity scale scores from 4.78 to 6.05 at follow-up, p = 0.045. Pain levels decreased from a mean VAS score of 4.73 prior to surgery to a mean score of 2.73 at follow-up, p = 0.047. The functional FFI-R scores showed a significant improvement from 140 points prior to surgery to 97.75 points at follow-up, p = 0.017. Comparison of the preoperative and follow-up values of the range of plantar flexion, adduction, and abduction in the operated limb also showed no significant changes in those individual parameters. The mean values of dorsiflexion, plantar flexion, adduction, and abduction at the ankle joint at follow-up, compared individually between the operated and non-operated foot showed no statistically significant differences. Conclusions: The use of a talar screw in the treatment of symptomatic pes planovalgus helps reduce pain and improve functional outcomes after treatment. Foot function assessments showed diminished pain, improved levels of physical and sport activity, and no effect on the range of motion after surgery in comparison with preoperative data. Arthroereisis with a talar screw is a valid surgical technique for the treatment of symptomatic pes planovalgus.

Quality of patient- and proxy-reported outcomes for children with impairment of the lower extremity: A systematic review using the COnsensus-based Standards for selection of health Measurement INstruments methodology.

Patient-reported outcome measures have become crucial in the clinical evaluation of patients. Appropriate selection, in a young population, of the instrument is vital to providing evidence-based patient-centered healthcare. This systematic review applies the COnsensus-based Standards for selection of health Measurement INstruments methodology to provide a critically appraised overview of patient-reported outcome measures targeted at pediatric orthopedic patients with lower limb impairment. A systematic search of electronic databases was performed to identify original studies reporting the development and/or validation of patient-reported outcome measures evaluating children with impairment of the lower extremity. Data extraction, quality assessment, and risk of bias evaluation were performed following the COnsensus-based Standards for selection of health Measurement INstruments guidelines and Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. A total of 6919 articles were screened. Thirty-three studies were included, reporting evidence on the measurement properties of 13 different patient-reported outcome measures and 20 translations. Four studies reported on content validity and patient-reported outcome measure development. The methodological quality of studies on structural validity, content validity, or patient-reported outcome measure development was mostly rated as "doubtful" or "very good." The quality of evidence on measurement properties varied noticeably, with most studies needing to perform improve their methodological quality to justify their results. This review provides an extensive overview of all available patient-reported outcome measures for patients with lower extremity impairment within pediatric orthopedics. We cautiously advise the use of four patient-reported outcome measures. However, the scarce availability of research on content validity and patient-reported outcome measure development highlights an area for future research endeavors to improve our knowledge on the currently available patient-reported outcome measures. Diagnostic level 1.

Impact of opioid law on prescriptions and satisfaction of pediatric burn and orthopedic patients: An epidemiologic study.

The objective of this study was to determine the reduction in prescribed opioid pain dosage units to pediatric patients experiencing acute pain and to assess patient satisfaction with pain control 90-day post discharge following the 2017 Ohio opioid prescribing cap law. The retrospective chart review included 960 pediatric (age 0-18 years) burn injury and knee arthroscopy patients treated between August 1, 2015-August 31, 2019. Prospectively, legal guardians completed a survey for a convenience sample of 50 patients. Opioid medications (days and morphine milligram equivalents (MMEs)/kg) prescribed at discharge before and after the Ohio law implementation were collected. Guardians reported experience and satisfaction with their child's opioid prescription at 90-days post discharge. From pre-law to post-law, there was a significant decrease (p<0.001) within the burn and knee cohorts in the median days (1.7 to 1.0 and 5.0 to 3.8, respectively) and median total MMEs prescribed (15.0 to 2.5 and 150.0 to 90.0, respectively). An interrupted time series analysis revealed a statistically significant decrease in MMEs/kg and days prescribed at discharge when the 2017 Ohio opioid prescription law went into effect, with an abrupt level change. Prospectively, more than half of participants were satisfied (72% burn and 68% knee) with their pain control and felt they received the right amount of medication (84% burn and 56% knee). Inpatient opioid use was not changed pre- and post-law. Discharge opioids prescribed for pediatric burn and knee arthroscopy procedures has decreased from 2015-2019. Caregivers varied greatly in their satisfaction with pain control and the amount of opioid prescribed.

Examining The Impact of The COVID-19 Pandemic On Pediatric Orthopedic Cases: A Systematic Review and Meta-Analysis

Background: This study examines the adverse effects of COVID-19 pandemic on pediatric orthopedics globally, including decreased patient admissions. The adverse effects of pandemic on pediatric orthopedic patients and surgeries have not been determined. This study aims to conduct a comprehensive systematic review and meta-analysis to investigate the specific impact of COVID-19 pandemic on pediatric orthopedic admissions and surgical cases.Methods: A thorough examination of published literature was performed by searching databases such as PubMed, ScienceDirect, and Cochrane Library, using PRISMA guidelines, and limiting the search to articles published up to January 2022. The primary focus of this review was to inspect the ratio of admission and surgical cases, expressed as a risk ratio (RR) with a 95% confidence level. The study also evaluated any variation among outcomes using the I2 test and examined potential bias using the Egger test. The study findings were calculated using Review Manager 5.4.Results: Fifteen studies were reviewed, revealing a 70% decrease in pediatric orthopedic admissions during the pandemic but no significant difference in admissions between the pandemic and pre-pandemic eras (RR 1.08, 95% CI 0.76-1.54, p=0.66). Furthermore, in the perspective of the pediatric orthopedic surgical case, the pooled analysis also did not show any significant difference between both periods (RR 1.05, 95% CI 0.95 to 1.17, p=0.35). Egger's test result showed no evidence of small-study effects (p = 0.22).Conclusion: This study found that the number of children admitted for orthopedic surgeries and other orthopedic treatments was not greatly impacted during the COVID-19 pandemic.

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients.

Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution. We identified pediatric patients (ages below 18y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships. Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types (P=0.036). Higher BMI was positively correlated with more prescribed opioid doses (R2=0.647, P<0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10. We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization.

Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. Economic Level II.