Telehealth Potential in Pediatric Orthopaedics and Sports Medicine Care is Comparable to In-Person Care But Disparities Remain.

BACKGROUND: Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges. METHODS: Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues. RESULTS: Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV. CONCLUSIONS: Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs. LEVEL OF EVIDENCE: Level III.

Seasonal Variation of Pediatric Septic Arthritis in the United States: A PHIS Database Study.

BACKGROUND: The presence of seasonal patterns in pediatric septic arthritis cases is a common orthopaedic teaching. Seasonal variation has been seen in centers outside of the United States and with other inflammatory and infectious joint-related conditions within the country, but it is unknown if a seasonal pattern exists among different regions of the United States. The purpose of this study was to examine the seasonal variation of septic arthritis within specific regions across the United States. METHODS: The Pediatric Health Information System database was queried for all patients 19 years or younger who were treated for septic arthritis. Data from 34 pediatric hospitals in the Pediatric Health Information System initiative were included. Centers were organized by geographical region, and season of presentation was determined using equinoxes/solstices. χ 2 tests were performed to detect seasonal differences in septic arthritis for the entire cohort and separated by geographical region. Proportion differences along with 95% CIs were provided. RESULTS: Between 2016 and 2019, there were 5764 cases of septic arthritis. Median age at diagnosis was 6.2 years (range: 0 to 19.0 y). Each season contributed 24% to 25% of the total septic arthritis cases, and there were no significant differences detected between the 4 seasons ( P =0.66). There was no seasonal variation seen in the Midwest, South, or West ( P =0.71, 0.98, 0.36, respectively). However, there was seasonal variation in the Northeast ( P =0.05), with fall and summer having a higher percentage of cases (28%) than the winter (21%). CONCLUSIONS: This study showed no clear seasonal variation in septic arthritis in children across the United States using a national database of pediatric hospital centers. However, there is regional seasonal variation in the Northeast, which may relate to climate differences. With no clear seasonal variation across the United States, continued diligence is needed in diagnosing septic arthritis throughout the year. LEVEL OF EVIDENCE: Prognostic II.

Do All Pediatric Femoral Shaft Fractures Need a Computed Tomography Scan of the Ipsilateral Femoral Neck? Calculating the Incidence of Concomitant Femoral Neck and Shaft Fractures.

BACKGROUND: In adults, the incidence of ipsilateral femoral neck fractures in the setting of femoral shaft fractures is reported to be as high as 9%; however, scant literature exists on the same clinical scenario in pediatric/adolescent populations. Therefore, the purpose of this study was to investigate the incidence of ipsilateral femoral neck fracture in the setting of femoral shaft fractures in children and adolescents treated in pediatric hospitals across the United States. METHODS: The Pediatric Health Information System database was queried for patients aged 18 years or younger who were treated for a femoral neck, femoral shaft, and pertrochanteric femur fractures through an emergency department, inpatient, ambulatory surgery, or observation visit. Patients were identified using ICD-9 and ICD-10 diagnosis codes. Data from 49 pediatric hospitals between the years 2002 and 2020 were included. Incidence was calculated as the number of cases including the event divided by the total number of cases. RESULTS: A total of 90,146 records were identified from a cohort of 55,733,855 (0.16%). Distal femur fractures, pathologic fractures, and periprosthetic fractures were excluded, resulting in 65,651 unique cases. Of the 65,651 cases, 7104 (11%) were identified as isolated neck fractures. The combined incidence of femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture was 82.3 per 10,000 cases (0.82%). Only 283 cases of concomitant femoral neck and shaft fractures were found among 55,169 femoral shaft fractures (0.5%). CONCLUSIONS: The incidence of ipsilateral femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture is 82.3 per 10,000 patients (0.82%) based on data from Pediatric Health Information System-participating institutions. The incidence of femoral neck/pertrochanteric femur fractures and femoral shaft fractures in children and adolescents is more than 10 times lower than reported for adults; therefore, the routine use of advanced diagnostic imaging in pediatric patients with femoral shaft fractures should be considered cautiously. LEVEL OF EVIDENCE: Level IV; cross-sectional analysis.

Influence of Sex, Race/Ethnicity, and Socioeconomic Factors on Meniscal Treatment With Pediatric and Adolescent ACL Reconstruction.

BACKGROUND: The rate of anterior cruciate ligament (ACL) reconstruction is increasing over time in pediatric/adolescent populations, but there is less evidence to support how concomitant meniscal procedures are changing over time. There are also less data to suggest which characteristics are associated with meniscectomy versus meniscal repair treatment. HYPOTHESIS: Age, sex, race/ethnicity, income, and insurance type may independently affect the rate of concomitant meniscal procedures and treatment modalities in pediatric patients with ACL reconstruction. STUDY DESIGN: Descriptive epidemiology study. METHODS: The Pediatric Health Information System database was queried for all patients aged ≤18 years who underwent ACL reconstruction with or without concomitant meniscal procedures from 2015 to 2019. Basic demographic data including age, sex, self-identified race/ethnicity, rural-urban commuting area code, predicted median income, and insurance status were collected. Linear regression was used to model trends and multiple logistic regression modeling was used to test for associations. RESULTS: A total of 14,398 patients aged ≤18 years underwent ACL reconstruction during the study period, with 8337 patients (58%) having concomitant meniscal procedures with a 1.24-fold increase over 5 years. Of the concomitant meniscal treatment cohort, 41% had a meniscectomy and 59% had meniscal repair. There was a 0.82-fold change in meniscectomy and a 1.67-fold increase in meniscal repair during the study period. Male patients, older patients, Black race, living in an urban area, and those with nonprivate insurance had increased odds of undergoing a concomitant meniscal procedure (all P < .05). Patients of non-White race and those with nonprivate insurance had increased odds of having a meniscectomy versus meniscal repair (all P < .05). There were no associations detected between income bracket and the outcomes in this study. CONCLUSION: This study shows that in pediatric and adolescent patients undergoing ACL reconstruction, there was a rise in concomitant meniscal procedures from 2015 to 2019. In addition, patients of non-White race and those with nonprivate insurance have increased odds of undergoing meniscectomy versus meniscal repair.

Retrospective study of patterns of vitamin D testing and status at a single institution paediatric orthopaedics and sports clinics.

OBJECTIVES: There has been a recent increase in awareness of the importance of bone health in children treated by paediatric orthopaedic and sports medicine providers. The purpose of this study was to assess our utilisation of 25 hydroxy vitamin D (25(OH)Vit D) testing in the past 10 years, and to evaluate the level of 25(OH)Vit D sufficiency in various populations of patients seen. DESIGN: This is a single site, retrospective medical record review study. SETTING: The study took place at a single large, private, paediatric level 1 trauma teaching hospital in the Northeast USA. PARTICIPANTS: Our internal medical records query system identified all patients who have had 25(OH)Vit D testing in the past 10 years, from 1 January 2009 to 31 December 2018. All patients included were seen on an outpatient basis at our Orthopaedic clinics. INTERVENTIONS: No interventions for strict research, however, eligible patients have had 25(OH)Vit D testing during their standard of care treatment. MAIN OUTCOME MEASURES: The varying number of 25(OH)Vit D testing that occurred over the study time period within Orthopaedic groups, and by Vit D levels as sufficient, insufficient and deficient. 25(OH)Vit D sufficiency was ≥30 ng/mL, insufficiency <30 ng/mL and deficiency were <20 ng/mL. Patients were stratified and analysed. RESULTS: Between 2009 and 2018, there were 4426 patients who had 25(OH)Vit D testing. Vitamin D testing increased significantly (p<0.001) in the past 10 years. 43% of patients had sufficient 25(OH)Vit D levels, 41% had insufficient levels and 15% had deficient levels. CONCLUSION: More frequent testing has led to an increased identification of patients with insufficient and deficient 25(OH)Vit D levels. We found over 50% of patients tested were found to have 25(OH)Vit D levels under 30 ng/mL. There should be an increased awareness of patients with orthopaedic problems who may present with 25(OH) insufficiency.

Nationwide Ethnic/Racial Differences in Surgical Treatment of Discoid Meniscus in Children: A PHIS Database Study.

BACKGROUND: Discoid meniscus, a congenital meniscus variant, may have greater incidence in Asian populations. No US population-based studies have examined the discoid meniscus ethnic/racial distribution. In pediatric patients undergoing meniscus surgery, it is hypothesized that ethnic/racial variability exists in patients with discoid meniscus and this variability is different than in patients with medial meniscus tears. METHODS: The Pediatric Health Information System was queried from 48 hospitals to examine patients 18 years of age and younger between 2015 and 2019, using International Classification of Diseases, 10th Revision, Clinical Modification codes. A cohort of patients treated surgically for discoid meniscus was compared with a cohort of patients treated surgically for medial meniscal tear. These 2 populations were compared based on age, sex, ethnicity/race, Current Procedural Terminology code, insurance, urban versus rural, and region of country. Univariate testing and multivariable logistic modeling were used to test for associations. RESULTS: A discoid meniscus cohort of 399 children (median age, 13.0 y) was compared with a medial meniscus tear cohort of 3157 children (median age, 16.0 y) (P<0.001). Hispanic/Latino children accounted for 36.8% of the discoid lateral meniscus and 22.7% of the medial meniscus populations (P<0.001). Among pediatric patients that had surgery for discoid lateral meniscus or medial meniscus, Hispanic/Latino children had 2.36 times the odds of surgery for discoid meniscus compared with White patients after adjusting for age and insurance (P<0.001). Asian children also had 2.41 times the odds of surgery for discoid meniscus compared with White patients (P=0.017). CONCLUSIONS: This study shows a significant association of ethnicity/race with discoid versus medial meniscus surgical treatment in children. Among pediatric patients undergoing surgery for discoid meniscus, Hispanic/Latino and Asian patients were a significantly larger percentage of the population than White patients. Hispanic/Latino children made up a greater percentage of the population having surgery for a torn discoid meniscus versus a torn medial mensicus. When evaluating pediatric patients, younger age and Asian or Hispanic/Latino ethnicity should increase attention to the possibility of a discoid meniscus. LEVEL OF EVIDENCE: Level IV.

Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients.

PURPOSE: Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. METHODS: The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. RESULTS: Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. CONCLUSION: This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. LEVEL OF EVIDENCE: IV.

Institutional Variation in Surgical Rates and Costs for Pediatric Distal Radius Fractures: Analysis of the Pediatric Health Information System (PHIS) Database.

Background: Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database. Methods: The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children's hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year. Results: The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution. Conclusions: In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care.Level of Evidence: II.

Pollicization of the Index Finger in the United States: Early Readmission and Complications.

PURPOSE: Pollicization is a well-accepted treatment for thumb hypoplasia, yet little is known about the reasons why patients return early in the postoperative period and complications that occur after surgery. The purpose of this investigation was to describe 30-day returns, readmission, and complication rates after pollicization in the United States. METHODS: A total of 459 pollicization procedures performed in 408 patients at 38 U.S. pediatric hospitals from 2003 to 2014 were identified using the Pediatric Health Information System database. A stepwise search strategy identified returns and readmissions within 30 days after pollicization to quantify complications and/or additional procedures. Risk factors for readmission and complications were compared across groups using uni- and multivariable general linear modeling. RESULTS: There were 61 patients who returned to the hospital (emergency department, ambulatory surgery, or inpatient hospitalization) within 30 days of their pollicization. Of those, 39 patients returned for suture removal, cast changes, or other expected aspects of postoperative care. The remaining 22 patients had a total of 26 complications, accounting for a 4.8% complication rate. The majority had vascular complications and wound problems. Single complications ranging from wound infection to hemorrhage were found in 20 cases. Overall, 35 of the 61 returns were readmitted to the hospital for treatment of complications or additional procedures. There was no effect of age group, diagnosis, geographical region, or physician subspecialty on the likelihood of complication or readmission. CONCLUSIONS: Sixty-one patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%), most commonly vascular in nature. These baseline data are informative because they identify opportunities for future preventative measures and quality improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Trends in Pediatric ACL Reconstruction From the PHIS Database.

BACKGROUND: Previous studies have suggested that anterior cruciate ligament (ACL) reconstruction surgeries are being performed with increased frequency in children and adolescents. The purpose of this study was to evaluate the trend in the frequency of ACL reconstructions normalized by total orthopaedic surgeries at pediatric hospitals nationwide. METHODS: The Pediatric Health Information System (PHIS) database was queried for patients age 18 years or younger who underwent orthopaedic surgery at any of the PHIS-participating hospitals 2004-2014. The subset of patients who had been treated with ACL reconstruction were identified using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) procedure codes. The yearly rate was expressed as the number of ACL reconstructions per 1000 orthopaedic surgeries, and a linear model was used to fit the data to illustrate the relative trend. RESULTS: In total, 470,126 orthopaedic surgeries, including 15,231 ACL reconstructions, were performed for patients 18 years or younger at 27 pediatric hospitals. ACL reconstructions were performed at a yearly rate of 32.4 per 1000 orthopaedic surgeries. Between 2004 and 2014, the number of ACL reconstructions increased 5.7-fold, whereas orthopaedic surgeries increased 1.7-fold; there was a 2.8-fold increase in ACL reconstructions relative to total pediatric orthopaedic surgeries. The 10-year relative fold increase was nearly equivalent across sexes, and the increasing trend in ACL reconstructions relative to orthopaedic surgeries was also seen across age groups. CONCLUSIONS: The number of ACL reconstructions performed for children and adolescents in pediatric hospitals nationwide markedly increased by nearly 3 times relative to orthopaedic surgeries over a recent 10-year period. LEVEL OF EVIDENCE: Level IV.

Complications and Cost of Syndactyly Reconstruction in the United States: Analysis of the Pediatric Health Information System.

BACKGROUND: Syndactyly is one of the most common congenital differences of the upper extremity and offers an exceptional opportunity to evaluate value-based care in pediatric orthopedic surgery. We designed a study to characterize complications and cost associated to syndactyly surgery among US pediatric hospitals. METHODS: A total of 2047 patients were identified for syndactyly surgery at 38 pediatric hospitals from 2009 to 2012 using the Pediatric Health Information System (PHIS) database. We examined costs as well as complication rates across hospitals stratified by patient and hospital variables. RESULTS: The postoperative complication rate was 1.9% (95% confidence interval [CI]: 1.3%-2.5%). Postoperative infection rate was 1.6% and surgical complication rate was 0.3%. Median adjusted standardized cost was $4112.5 (interquartile range: $2979-$6049). Patients with more than 1 diagnosis had 19 times higher risk of complications and were associated with 13% more hospital cost than those with syndactyly as single diagnosis ( P < .001). Finally, there was a wide variation in cost across hospitals; 8 (21%) yielded confidence limits above the benchmarked value. CONCLUSIONS: In the United States, it is important to recognize variations in practice of syndactyly surgery in hopes of developing quality improvement strategies in pediatric orthopedic surgery.

Reducing the Incidence of Cast-related Skin Complications in Children Treated With Cast Immobilization.

BACKGROUND: Cast immobilization remains the mainstay of pediatric orthopaedic care, yet little is known about the incidence of cast-related skin complications in children treated with cast immobilization. The purposes of this quality improvement project were to: (1) establish a baseline rate of cast-related skin complications in children treated with cast immobilization, (2) identify trends in children who experienced cast-related skin complications, (3) design an intervention aimed at decreasing the rate of cast-related skin complications, and (4) determine the effectiveness of the intervention. METHODS: A prospective interrupted time-series design was used to determine the incidence of cast-related skin complications overtime and compare the rates of skin complications before and after an intervention designed to decrease the incidence of cast-related heel complications. All consecutive patients who were treated with cast immobilization from September 2012 to September 2014 were included. A cast-related skin complications data collection tool was used to capture all cast-related skin complications. A high rate of heel events was noted in our preliminary analysis and an intervention was designed to decrease the rate of cast-related skin complications, including the addition of padding during casting and respective provider education. RESULTS: The estimated cast-related skin events rate for all patients was 8.9 per 1000 casts applied. The rate for the total preintervention sample was 13.6 per 1000 casts which decreased to 6.6 in the postintervention sample. When examining the heel-only group, the rate was 17.1 per 1000 lower extremity casts applied in the preintervention group and 6.8 in the postintervention group. CONCLUSIONS: Incorporating padding to the heel of lower extremity cast was an effective intervention in decreasing the incidence of cast-related skin complications in patients treated with cast immobilization. LEVEL OF EVIDENCE: Level II.

Pediatric orthopaedic lower extremity trauma and venous thromboembolism.

PURPOSE: Research on venous thromboembolism events (VTE), such as deep venous thrombosis (DVT) and pulmonary embolism (PE), in pediatric orthopaedic trauma patients is sparse. We describe the incidence in the USA of VTE associated with pediatric lower extremity orthopaedic trauma, and characterize injury patterns and VTE treatment methods. METHODS: The Pediatric Health Information System (PHIS) was queried from 2004 to 2013 using ICD-9 codes for lower extremity fractures (pelvis, femur, tibia, ankle, foot) and dislocations (hip, knee, ankle, subtalar) and VTE. Records were queried for age, diagnoses, and VTE treatment. RESULTS: During the study period 285,611 clinical encounters reported lower extremity trauma. Of those, 167 patients were simultaneously coded with VTE (99 DVT, 50 PE, 18 combined DVT/PE), to give an incidence of VTE associated with pediatric lower extremity trauma of 0.058 %. Patients were from 39 centers, with an average age of 12.9 years (range 0-19). There were 249 fractures and 21 dislocations, with 25 (15 %) patients sustaining more than one lower extremity injury. The most common fracture locations were the femur/femoral neck (95), tibia/ankle (92), and pelvis (44). 72 % (121/167) of patients were treated with anticoagulation medication, of which the most common was low-molecular-weight heparin (111/167, 66 %). CONCLUSIONS: The incidence of VTE events associated with lower extremity orthopaedic trauma is 0.058 %. Adolescents and polytrauma patients with injuries of the femur/femoral neck, tibia/ankle, and pelvis are more commonly affected. Low-molecular-weight heparin is commonly used to treat VTE in pediatric and adolescent patients.

Disease management and medication compliance.

Lack of medication compliance is harmful to health care systems from both a clinical and economic perspective. This study examines the methods that disease management organizations employ to identify nonadherent patients and to measure effectiveness of compliance programs for patients with diabetes, hyperlipidemia, and cystic fibrosis. In addition, this study investigates the degree to which disease managers assume risk in their contracts, and whether compliance strategies are being coordinated with payers' use of value-based insurance design, in which patient cost sharing is a function of the relative value of pharmaceuticals. This study's findings suggest that disease management may be falling short in terms of: (a) comprehensive commitment to expert-recommended at-home devices used to self-diagnose and measure health indicators; (b) early adoption of expert-recommended new technologies to measure and improve compliance; (c) intensity of use of standard tests in outpatient clinics; (d) coordination of compliance strategies with payers' use of value-based insurance design; and (e) the proportion of risk assumed in disease management contracts.