Pediatric Orthopaedic Surgeons Research Articles

Pediatric Orthopaedic Surgeons Manage Pediatric Diaphyseal Clavicle Fractures Differently Than Nonpediatric Orthopaedic Specialists.

Pediatric clavicle fractures are often managed by physicians with and without pediatric subspecialty training. The aim of this study is to identify if variability of practice exists between pediatric orthopaedic surgeons versus nonpediatric orthopaedic specialists during management of pediatric diaphyseal clavicle fractures. Patients ≤18 years of age with an acute, closed diaphyseal clavicle fracture treated between January 2018 and July 2023 by a large hospital-employed multispecialty orthopaedic practice (in a regional and academic health network) were retrospectively reviewed. The study involved 26 orthopaedic surgeons (including 3 pediatric, 8 sports medicine, and 6 general) and 11 nonoperative sports medicine physicians, all of which accept patients ranging 0 to 18 years of age. Exclusion criteria included open or impending open fractures and insufficient data. Demographic, radiographic, and outpatient treatment parameters were recorded. Age groups were separated into <10 and ≥10 years old to control for age-associated differences. Among 560 pediatric clavicle fractures, 385 met inclusion criteria (43.6% of which were treated by a pediatric orthopaedic surgeon), and 361 were treated nonoperatively. Follow-up averaged 48.8 days until orthopaedic discharge and 16.9 months until the most recent well-child visit (80% had a well-child visit after orthopaedic discharge). No patient <10 years of age had elective surgery, but pediatric orthopaedic surgeons demonstrated lower surgical rates in adolescent patients than nonpediatric specialties (4.3% vs. 14.4%, OR=3.8, P=0.027). Among the 169 nonoperative patients <10 years of age, pediatric orthopaedic surgeons completed fewer outpatient visits (2.1±0.8 vs. 2.4±0.8, P<0.037), shorter follow-up durations (28.5±18.9 vs. 41.8±22.6d, P<0.001), less radiographic series (2.1±0.8 vs. 2.4±1.0, P<0.047), and less total radiographs (4.3±1.8 vs. 5.0±2.3, P<0.013) than nonpediatric specialists. The surgical rate of acute, closed diaphyseal clavicle fractures is lower among pediatric versus nonpediatric orthopaedic surgeons in adolescents. During nonoperative management of pediatric clavicle fractures, pediatric orthopaedic surgeons treat young patients (but not adolescents) with less outpatient visits and radiographs than nonpediatric orthopaedic physicians. Level III.

Changes in diagnostics and treatment pathways for developmental dysplasia of the hip after the introduction of national guidelines: An updated questionnaire amongst paediatric orthopaedic surgeons in The Netherlands.

Diagnostics and treatment pathways for developmental dysplasia of the hip are highly variable in clinical practice. Recently, two national guidelines were developed in the Netherlands, providing a uniform protocol for the diagnosis and treatment of developmental dysplasia of the hip in children under the age of 1 year. The aim of this survey study was to assess whether diagnostic and treatment strategies have changed amongst paediatric orthopaedic surgeons in the Netherlands compared to a similar survey study in 2011, after the introduction of the guidelines. A web-based online questionnaire was developed and shared amongst the members of the Dutch Paediatric Orthopaedic Society. The questions concerned the diagnosis and treatment of developmental dysplasia of the hip, ranging from mildly dysplastic to dislocated hips, in children under the age of 1 year. We used a questionnaire similar to the previous study and evaluated the results. Thirty-four participants completed the survey. Regarding diagnosis and follow-up, ultrasonography was generally applied for children younger than 6 months, while radiography was more frequently used for children aged 6-12 months. In 2011, radiography was more widely applied in all age groups. Initial treatment for dysplastic, stable hips was mostly active monitoring, while this was generally a rigid splint in 2011. For dislocated unstable hips, the first step in treatment was generally the Pavlik harness, as in 2011. The diagnostic and treatment pathways of developmental dysplasia of the hip in children under the age of 1 year seem to have partially changed amongst Dutch paediatric orthopaedic surgeons compared to 2011, after the publication of new guidelines.

What imaging does my AIS patient need? A multi-group survey of provider preferences.

Adolescent idiopathic scoliosis (AIS) is a common diagnosis managed by pediatric orthopedic surgeons with nonoperative radiographic monitoring representing a cornerstone of treatment. Differences in practices and techniques for obtaining radiographic studies contribute to variation, cost of care, and hamper data aggregation. We surveyed several large organizations dedicated to children's orthopedics or scoliosis care to obtain a consensus for radiographic evaluation of AIS. A REDCap-based survey was developed across four institutions and beta-tested by staff and fellows from a single institution. The finalized survey was distributed to members of POSNA, PSSG, and SOSORT, and shared on social media. Participants were asked to rank the importance of various datapoints in radiographic assessment of the spinal deformity, skeletal maturity, and study indications during initial, subsequent, preoperative, and final office visits for AIS. Response rate for the overall group was 26%. Cobb angle was considered the most important (> 94%) radiographic index across all time points. For positioning, 46% of respondents favored arms bent touching clavicles as the ideal positioning for X-rays, and another 24% favored arms down with palms forward (Table2). The majority of respondents obtain lateral X-rays at the first visit (99%) and at the preoperative visit (70%). At the preoperative visit, sagittal contour (86%), apex location (85%), and Lenke classification (73%) were considered important factors to record. Flexibility studies are primarily obtained at the preoperative visit (89%) and 81% of respondents prefer bending films as the flexibility technique of choice. Regarding measures of skeletal maturity, Sanders bone age was considered to be the most important by over 70% of respondents across initial, subsequent, preoperative and brace wean visits (Fig.2). MRIs were obtained routinely by 34% of respondents and only when the patient had a concerning symptom or finding for 67% of respondents. Despite large variations in radiographic examination of AIS, large areas of agreement were found. It is important to establish standards for positioning patients, evaluating skeletal maturity, and obtaining assessments including lateral views, flexibility studies, and advanced imaging. Establishing common practices for radiographic evaluation of AIS will allow for less variation in care and for critical questions to be answered through registry formation and large multicenter data collection. This study establishes current practitioner opinion on the radiographic evaluation of the AIS patient. Minimum data sets are useful for data aggregation and answering research questions in the face of data variability. Level V.

Practice Patterns Vary Widely in the Care of Pediatric and Adolescent Pelvic and Acetabular Fractures: A CORTICES Survey.

Pediatric pelvic and acetabular fractures are rare but potentially devastating injuries and significant management variation exists across the United States. This study sought to elucidate treatment decision-making trends, involvement of adult trauma fellowship-trained surgeons in pediatric care, and pre- and postoperative transfer patterns. Pediatric orthopaedic surgeons who serve as trauma liaisons at 20 PTCs were surveyed regarding training, practice volume, and factors contributing to institutional management of pelvic and acetabular injuries. Five clinical scenarios of pelvic ring and acetabular fractures that varied by injury pattern, age, and sex were presented. Descriptive statistics were used to summarize the results. Eighteen institutions responded to the survey (90% response rate, 16 Level, 1 PTC). All surgeons were pediatric fellowship-trained (77.7% in practice >5y). The four most common factors affecting whether surgeons independently managed both pelvic ring and acetabular fractures were patient age, fracture characteristics, displacement and need for surgery. The majority reported managing <10 acetabular (72.2%) but >10 pelvic ring (77.8%) injuries per year. In the clinical scenarios, patients <10 were more likely to have treatment decisions made by a pediatric orthopaedic surgeon. Older patients were more likely to be transferred to another institution for surgery but were often transferred back to the PTC postoperatively. In all clinical scenarios other than posterior hip dislocation, a trauma fellowship-trained surgeon was more likely to be the operative surgeon, even when the patient was not transferred. There is substantial variation in the management of pediatric and adolescent pelvic and acetabular fractures. Even at tertiary care PTCs, volumes are low, and trauma fellowship-trained surgeons are often involved in decision-making and operative management. Age and injury pattern seem to play a large role in variation, and patient transfers between facilities are common. V.

Perioperative Management of Tibial Spine Fractures in Pediatric Patients: A Delphi Study to Identify Principles of Treatment.

The Delphi technique is a structured, iterative group survey method utilized to reach a consensus among experts in a field regarding topics with evidence-based equipoise. Currently, there are few studies at the highest levels of evidence published on the perioperative tibial spine management, making it an ideal subject to utilize expert opinion to reach consensus decision. The purpose of this study was to utilize a Delphi-method survey to achieve consensus statements regarding the perioperative management of tibial spine fractures. Before study initiation, 3 rounds of surveys were agreed upon, maintaining the traditional Delphi principles. Consensus was defined as 75% agreement or disagreement on a Likert scale. An anonymous survey consisting of 50 statements describing the management of tibial spine fractures preoperative and postoperative in varying scenarios was distributed to a group of 44 pediatric sports medicine orthopaedic surgeons utilizing an electronic survey software system. Of 44 surgeons invited to participate, 24 responded to round 1, 28 responded to round 2, and 25 responded to round 3. Consensus was achieved for the following: use of x-ray to determine initial treatment; casting for a minimum of 3 weeks for nonoperative management, but <3 weeks if treated with surgical fixation; advanced imaging to avoid missing concomitant injury; the necessity of physical therapy, but not continuous passive motion (CPM); and for arthroscopic surgical intervention. It was also agreed that functional testing is important in return-to-play (RTP) decision-making, though the specific timelines and clearance criteria could not be agreed upon. There were statements that displayed continued disagreement, including the role of aspiration, preoperative range of motion management, and the timing of surgical scheduling. Utilizing a Delphi methodology with experienced surgeons on tibial spine treatment, consensus in the management of tibial spine fracture was achieved for definitive management strategies. Further study will be important to optimize our management of this youthful population with tibial spine fractures.

Do Not Forget the Spine MRI in Children With Arthrogryposis Multiplex Congenita: High Prevalence of Tethered Spinal Cord and Preliminary Clinical Findings Following Detethering.

Arthrogryposis multiplex congenita (AMC) encompasses congenital conditions with joint contractures in 2 or more joints. Patients with AMC may have scoliosis and neural axis malformations. The study aimed to determine the prevalence of tethered spinal cord (TSC), characterized by a low-lying conus medullaris, and secondarily, present preliminary findings following surgical untethering in children with AMC. Patients 18 years of age and younger with a diagnosis of AMC and a spine MRI were identified. The presence of a TSC was defined as a low-lying conus with termination at or below the lower third of the L2 vertebral body. A pediatric neurosurgeon and a pediatric orthopaedic surgeon independently reviewed MRIs. The medical records of patients with AMC who underwent untethering were examined to evaluate preoperative and postoperative clinical findings. The prevalence of TSC in our AMC patients was compared with published normative data using χ2 analysis. Forty-two of 105 AMC patients (40%) had TSCs. There was a greater percentage of patients with AMC and a TSC compared with the unaffected population (P<0.0001). Sixteen patients underwent detethering through filum terminale sectioning. Nine patients had preoperative neurological deficits in addition to their AMC. There were no postoperative complications. All patients had improvement in their bowel and bladder symptoms within 3 months after their detethering procedure. TSC is more prevalent in the pediatric population with AMC compared with those without AMC. MRI is recommended for all patients with AMC due to its high prevalence. Although not a benign procedure, surgical detethering may have potential benefits for children with AMC. Level IV-therapeutic study.

The inferior sacral iliac line as a horizontal reference plane in paediatric pelvic radiographs.

While often used, Hilgenreiner's line may not always be a reliable reference plane following triple innominate pelvic osteotomy or trauma to the triradiate cartilage. The inferior sacral-iliac line is a horizontal line connecting the sclerotic corners of the inferior sacral-iliac joints. This is a consistent landmark in the ossifying infant pelvis as well as the fully developed adult pelvis. The goal of this study was to determine if there is a difference in measurements between the inferior sacral-iliac line and Hilgenreiner's line in order to identify an alternative horizontal reference plane. 3 reviewers (fellowship-trained paediatric orthopaedic surgeon, junior orthopaedic resident, senior orthopaedic resident) reviewed 100 paediatric non-osteotomized pelvises. The difference between Hilgenreiner's line and the inferior sacral-iliac line were measured and reported. Measurements were repeated a minimum of 48 hours apart, resulting in 600 comparisons between Hilgenreiner's line and the inferior sacral-iliac line. The standard error of measurement was calculated to assess the variation in measurements between each individual observer and the group as a whole. The mean standard error of measurement between Hilgenreiner's line and the inferior sacral-iliac line was 0.44° (95% CI, ± 0.86). Reviewers 1-3 demonstrated a mean standard error of measurement of 0.38, 0.28, and 0.35 (95% CI, ± 0.74, 0.55, and 0.86) respectively. There was no statistically significant difference between reviewers (p > 0.05). Intra-observer reliability for reviewers 1, 2, and 3 was 0.64 (0.47-0.76), 0.75 (0.63-0.83), and 0.54 (0.32-0.69) respectively, with an inter-observer reliability of 0.42 (0.20-0.60) degrees. In this proof-of-concept study, the inferior sacral-iliac line was found to be an appropriate alternative to Hilgenreiner's line that is easily identifiable for all levels of orthopaedic training. Future inferior sacral-iliac line studies should demonstrate the reliability of multiple acetabular measurements, both pre- and post-osteotomy.

Pediatric orthopedic surgeons may perform better in terms of surgical outcomes in type 3 supracondylar humerus fractures: a comparative analysis

Supracondylar fractures of the humerus represent the most common surgical fractures in pediatric patients. There is a discourse regarding the influence of the surgeon training on treatment. Different studies show equivocal effect of subspecialty training. We conducted a single center case control study to evaluate the outcomes of type 3 fractures (fully displaced) comparing pediatric-trained orthopedic surgeons (PTOS) and non-pediatric trained orthopedic surgeons (NTOS). In this retrospective study, we investigated the surgical outcomes of type 3 supracondylar fractures of the humerus in children treated between the years 2012 and 2019, divided by surgeon type. During the research, a policy reform at our department was established and PTOS became the only surgeons for those injuries starting from September 2017. Patients’ demographics, perioperative details, and postoperative course were recorded. Primary outcome was reoperations, and secondary outcomes were open reductions, infections, length of surgery, and neurological deficits. 1175 patients were diagnosed with supracondylar fractures at our Level I trauma center, and 346 cases were diagnosed with radiologically confirmed type 3. Overall, 312 cases were analyzed; 113 cases were diagnosed before 1 September 2017 and treated by NTOS, and 199 cases were treated by PTOS until 31 December 2019; 7.1% (8) of the patients treated by NTOS had to be reoperated compared to 1.5% (3) of the patients treated by PTOS (P = 0.014). There was significant difference looking at postsurgical complications and surgery length. This study’s findings suggest that PTOS achieve superior outcomes when treating patients with type 3 supracondylar humerus fractures. Level of evidence: Level III.

Timely Hip Surgery Access in Children With Cerebral Palsy: Unaffected by Social Disadvantage at a Large Urban Safety Net Hospital.

Socioeconomic disadvantage has been shown to limit timely access to pediatric orthopaedic care and can result in poor surgical outcomes. Insurance coverage has often served as a proxy for socioeconomic status; however, area deprivation index (ADI) and child opportunity index (COI) are more comprehensive measures of social determinants of health (SDOH). The treatment of hip displacement in children with cerebral palsy (CP) requires early radiographic identification and continuous surveillance, which may be impacted by SDOH. This study seeks to evaluate the influence of insurance, ADI, and COI on preoperative Reimer migration percentage and need for pelvic osteotomy during varus derotation osteotomy (VDRO) in children with CP. This retrospective cohort study examined 219 patients with CP who underwent VDRO surgery for hip subluxation or dislocation at a tertiary referral center (135 male, mean age 7.9y, SD: 2.9, range: 2.4 to 17.2; 17 GMFCS II, 21 GMFCS III, 89 GMFCS IV, 92 GMFCS V) from 2004 to 2022. Imaging and clinical documentation for patients with CP and hip displacement, age <18 years with ≥1 year of follow-up, treated with VDRO were reviewed. GMFCS level, preoperative Reimer migration percentages (MP), surgical details, and demographic and socioeconomic data were collected, and addresses were used to determine ADI (2018 version) and COI (2.0 database). The relationship of ADI, COI, and insurance type to preoperative Reimer MP of the more displaced hip and the need for pelvic osteotomy were analyzed with linear regressions and logistic regressions. The mean preoperative Reimer MP was 64.4% (SD: 25.0, range: 0 to 100). As expected, patients functioning at higher GMFCS levels presented with greater Reimer MPs. The average Reimer MP was 34.0 for GMFCS II, 44.2 for GMFCS III, 64.6 for GMFCS IV, and 74.5 for GMFCS V (P<0.01). The mean ADI state decile (1 to 10 scale) and COI (1 to 100 scale) for the cohort were 5.6 (SD: 2.2, range: 1 to 10) and 37.2 (SD: 28.1, range: 4 to 100), respectively. ADI (P=0.77), COI (P=0.30), and insurance type (P=0.78) were not related to preoperative Reimer MP. However, patients with lower ADIs (OR 0.83, 95% CI [0.70, 0.99], P=0.04) and higher COIs (OR 1.01, 95% CI [1.00, 1.03], P=0.03) underwent pelvic osteotomies at a higher rate. ADI, COI, and insurance type were not related to preoperative Reimer MP. Interestingly, greater social disadvantage was associated with a lower frequency of pelvic osteotomy at the time of VDRO. Our data demonstrate that at our institution, greater social disadvantage does not result in limited access to timely orthopaedic care for children with CP. This is likely due to adequate governmental insurance coverage for children with neuromuscular disorders in this state and the active involvement of pediatric orthopaedic surgeons in government-sponsored clinics, including ongoing hip screening programs for children with CP. These results provide hope that healthcare disparities can potentially be mitigated.

Diagnosis of suspected pediatric distal forearm fractures with point-of-care-ultrasound (POCUS) by pediatric orthopedic surgeons after minimal training

BackgroundSeveral studies have advocated the use of ultrasound to diagnose distal forearm fractures in children. However, there is limited data on the diagnostic accuracy of ultrasound for distal forearm fractures when conducted by pediatric surgeons or trainees who manage orthopedic injuries in children. The objective of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) for pediatric distal forearm fractures when conducted by pediatric surgeons and trainees after minimal training.MethodsThis diagnostic study was conducted in a tertiary hospital emergency department in Germany. Participants were children and adolescents under 15 years of age who presented to the emergency department with an acute, suspected, isolated distal forearm fracture requiring imaging. Pediatric surgeons and trainees, after minimal training for sonographic fracture diagnosis, performed 6-view distal forearm POCUS on each participant prior to X-ray imaging. All data was retrospectively collected from the hospital’s routine digital patient files. The primary outcome was the diagnostic accuracy of POCUS compared to X-ray as the reference standard.ResultsFrom February to June 2021, 146 children under 15 met all inclusion and exclusion criteria, and 106 data sets were available for analysis. Regarding the presence of a fracture, X-ray and Wrist-POCUS showed the same result in 99.1%, with 83/106 (78.3%) fractures detected in both modalities and one suspected buckle fracture on POCUS not confirmed in the radiographs. Wrist-POCUS had a sensitivity of 100% (95% CI [0.956, 1]) and a specificity of 95.8% (95% CI [0.789, 0.999]) compared to radiographs. In 6 cases, there were minor differences regarding a concomitant ulnar buckle. The amount of prior ultrasound training had no influence on the accuracy of Wrist-POCUS for diagnosing distal forearm fractures. All fractures were reliably diagnosed even when captured POCUS images did not meet all quality criteria.ConclusionPediatric surgeons and trainees, after minimal training in POCUS, had excellent diagnostic accuracy for distal forearm fractures in children and adolescents using POCUS compared to X-ray.

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.

Variation in Treatment of Young Adult Distal Radius Fractures by Pediatric and Adult Orthopaedic Surgeons.

There remains a lack of consensus on the optimal treatment of isolated distal radius fractures in young adults. The primary aim of this study was to identify differences in treatment of isolated distal radius fractures in patients aged 17 to 21 years treated by adult versus pediatric orthopaedic surgeons. The secondary aim was to identify whether there is a variation in utilization of open reduction and internal fixation (ORIF) versus closed reduction and percutaneous pinning when treated surgically by adult versus pediatric orthopaedic surgeons. Patients aged 17 to 21 years with isolated distal radius fractures who were treated by adult or pediatric orthopaedic surgeons at 1 of 3 hospitals were identified through retrospective chart review. 72 patients in the pediatric surgeon cohort and 64 patients in the adult surgeon cohort were included. Demographic details were recorded, and radiographs from the initial clinic visit and final follow-up were obtained. Bivariate analysis was used to evaluate for primary and secondary aims. 40 of 136 patients were treated surgically. Bivariate analysis showed that factors associated with surgical treatment were treatment by an adult orthopaedic surgeon, higher body mass index, radiographic severity, AO classification, intraarticular involvement, distal radial-ulnar joint involvement, and meeting AAOS clinical practice guideline surgical criteria. Factors associated with ORIF compared with closed reduction and percutaneous pinning included treatment by an adult orthopaedic surgeon, older age, higher body mass index, and greater articular step-off. In comparable cohorts of young adult patients with distal radius fractures with similar fracture characteristics, there was notable variation in treatment between adult and pediatric orthopaedic surgeons. Surgical treatment was used more by adult surgeons, and when treated surgically, ORIF was used more by adult surgeons. Variation among surgeons illustrates the persistent lack of consensus on the optimal treatment in this population and highlights the need for additional research on this topic to guide management. Level IV.

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.

Incidence of chronic recurrent multifocal osteomyelitis in children and adolescents in the UK and Republic of Ireland.

Chronic Recurrent Multifocal Osteomyelitis (CRMO), also known as chronic nonbacterial osteomyelitis (CNO), is a rare autoinflammatory condition affecting the bones in children and teenagers. The actual incidence of CRMO remains uncertain. The objective of this study is to identify the incidence of CRMO in children and young people under the age of 16 years in the United Kingdom (UK) and Republic of Ireland (ROI). We also aim to delineate the demographics, clinical presentation, investigations, initial management and healthcare needs for children and adolescents with CRMO. We conducted monthly surveys among all paediatric consultants and paediatric orthopaedic surgeons to identify patients newly diagnosed with CRMO between October 2020 and November 2022. A standardised questionnaire was sent to reporting clinicians to collect further information. Over the surveillance period, 288 patients were reported, among which, 165 confirmed and 20 probable cases were included in the analysis. The highest incidences were among 8-10 year-olds. A two-to-one female-to-male difference in incidence was observed, and male patients were more likely to present with multifocal disease. A negative correlation was observed between reporting clavicular and leg pain. Investigation-wise, 80.0% of patients were reported to have undergone whole-body MRI and 51.1% had bone biopsies. The most common initial treatments were NSAIDs (93.9%) and bisphosphonates (44.8%). This study estimates an average annual CRMO incidence of 0.65 cases per 100 000 children and adolescents in the UK and ROI. These findings establish a crucial baseline for ongoing research and improvement in the care of individuals with CRMO.

Management of Syndesmotic Injuries in Children and Adolescents: Results of a Cross-Sectional Survey of Pediatric Orthopaedic Surgeons

Management of Syndesmotic Injuries in Children and Adolescents: Results of a Cross-Sectional Survey of Pediatric Orthopaedic Surgeons

Health State Utilities and Cost-Effectiveness Economic Evaluation for Treatment of a Symptomatic Accessory Navicular.

Treatment strategies for a symptomatic accessory navicular include both operative and nonoperative approaches. The primary aim of this study is to define health utility values for 7 health states experienced by those with a symptomatic accessory navicular who undergo operative and/or nonoperative treatment. Secondarily, the study incorporates the health utility values with treatment costs, probabilities of various outcomes, and duration of health states into a cost-effectiveness model comparing the nonoperative treatment protocol at our institution vs surgical excision. Institutional review board approval was obtained to call parents of patients 10-20 years old at the time of interview who were evaluated for a symptomatic accessory navicular from February 1, 2016, to March 2, 2023, at a single institution by one of 4 pediatric orthopaedic surgeons. Participants were asked to rate 7 health states from 0 to 100, with 0 representing death (if 18 years or older) or the worst health imaginable (if under 18 years) and 100 representing perfect health. Using published values for the probabilities of various treatment outcomes, time spent in various health states, and Medicare costs from the perspective of the payor and society, a decision analysis was constructed. Health utility values for 7 health states were obtained. Operative treatment was preferred to nonoperative treatment in the base case model. Surgery was more expensive ($16 825) than nonoperative treatment ($7486). Using a willingness-to-pay threshold of <$50 000 per quality-adjusted life year (QALY), surgery was cost-effective compared to nonoperative treatment with an incremental cost-effectiveness ratio of $20 303/QALY. Sensitivity analysis revealed that the only variable that indicated a preference for nonoperative treatment is a 71% likelihood of nonoperative treatment resolving the condition. Unless a physician suspects at least a 71% chance of a symptomatic accessory navicular resolving without operative treatment, surgical excision is recommended from a cost-effectiveness perspective.

Inter-Rater and Intrarater Reliability of Radiographs in the Diagnosis of Pediatric Scaphoid Fractures.

Pediatric scaphoid fractures can be challenging to diagnose on plain radiograph. Rates of missed scaphoid fractures can be as high as 30% to 37% on initial imaging and overall sensitivity ranging from 21% to 97%. Few studies, however, have examined the reliability of radiographs in the diagnosis of scaphoid fractures, and none are specific to the pediatric population. Reliability, both between different specialists and for individual raters, may elucidate some of the diagnostic challenges. We conducted a 2-iteration survey of pediatric orthopedic surgeons, plastic surgeons, radiologists, and emergency physicians at a tertiary children's hospital. Participants were asked to assess 10 series of pediatric wrist radiographs for evidence of scaphoid fracture. Inter-rater and intrarater reliability was calculated using the intraclass correlation coefficient of 2.1. Forty-two respondents were included in the first iteration analysis. Inter-rater reliability between surgeons (0.66; 95% confidence interval, 0.43-0.87), radiologists (0.76; 0.55-0.92), and emergency physicians (0.65; 0.46-0.86) was "good" to "excellent." Twenty-six respondents participated in the second iteration for intrarater reliability (0.73; 0.67-0.78). Sensitivity (0.75; 0.69-0.81) and specificity (0.78; 0.71-0.83) of wrist radiographs for diagnosing scaphoid fractures were consistent with results in other studies. Both inter-rater and intrarater reliability for diagnosing pediatric scaphoid fractures on radiographs was good to excellent. No significant difference was found between specialists. Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely. Our study demonstrates that poor sensitivity stems from the test itself, and not rater variability.

Knowledge and Utilization of Sex-Specific Lead Aprons Among Pediatric Orthopaedic Surgeons.

Orthopaedic surgeons routinely face exposure to ionizing radiation during intraoperative use of fluoroscopy. Lead personal protective equipment reduces occupational radiation exposure. Female-specific lead aprons are designed with expanded lateral coverage to improve protection of breast tissue against radiation beams. The purpose of this study was to identify current trends in knowledge and utilization of female-specific lead aprons as well as any barriers to utilization. An anonymous electronic survey including 20 multiple choice and multiple selection responses was distributed to all members of the Pediatric Orthopaedic Society of North America (POSNA). Respondents who reported the use of intraoperative fluoroscopy in their practice were included in the study. Most respondents were attending surgeons (91%) and practiced in an academic setting (85%) in an urban environment (75%). Most respondents reported using a lead apron for every case (76%) and a thyroid shield for every case (75%), while most respondents reported they do not wear lead glasses (73%). Fifty-one percent of respondents were aware of female-specific lead aprons. The majority of respondents reported female-specific lead is unavailable (45%) or available in insufficient quantities (5.5%) at their institution. Ninety percent of females reported they do not wear female-specific lead with the common reasons being lack of availability and discomfort. Knowledge of female-specific lead is low with lack of availability as a common barrier to utilization. As female presence in the field of orthopaedic surgery expands, efforts should be made to improve education and availability of sex-specific lead aprons.

A new method for assessing tibial torsion using computerized tomography in a pediatric population.

Tibial torsion disorders may lead to abnormal gait, frequently leading to a consultation with a pediatric orthopedic surgeon. The present study evaluated an alternative method for assessing tibial torsion on computerized tomography (CT) images that considers the tibial distal axis to be equivalent to the geometric axis of the tibiotalar joint. One hundred CT scans were reviewed retrospectively, and four measurements were taken: proximal transtibial angle (PTTA), posterior margin tibial plateau angle (PMTPA), intermalleolar angle (IMA), and talar angle (TA). The tibial torsion angle was then calculated using these different angles. The patient cohort comprised 38 girls and 62 boys, with a mean age of 12 ± 4.4 years. Median PTTA and PMTPA were -8.4° ± 14.7° and -8.8° ± 14.2°, respectively, with no statistically significant difference. Mean IMA and TA were 23° ± 16.2° and 17.2° ± 16.9°, respectively, with a statistically significant difference. Mean total measurement time per patient was 6'44", with means of 2'24" for PTTA, 36" for PMTPA, 2'14" for IMA, and 1'12" for TA. Tibial torsion values may differ significantly depending on the axis chosen to define tibial orientation. At the level of the proximal tibia, the choice of PTTA or PMTPA had little influence on the calculation of the tibial torsion angle. There was a significant difference of 5.8° when measuring the distal tibia. Measuring the PMTPA and TA is probably more suited for use in clinical practice because their tracing is simple and faster.

Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors.

It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States. County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey. A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon. Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 2024;47(4):e204-e210.].