A Retrospective Study of Risk Factors and Outcomes in the Surgical Management of Slipped Capital Femoral Epiphysis.

PURPOSE: Slipped capital femoral epiphysis is commonly treated with in situ pinning (ISP) and more recently the modified Dunn procedure (MDP). This study retrospectively examines the preoperative risk factors and postoperative complications of patients treated with either ISP or MDP over a 12-year period. METHODS: A single-center, retrospective review was conducted on patients diagnosed and surgically treated with slipped capital femoral epiphysis from 2004 to 2016. Patients must have had preoperative imaging and a minimum of 6 months of clinical follow-up. Six preoperative demographic data (age, sex, intensity of symptoms, stability, trauma, and severity of slip), surgical details, and treatment outcomes were collected. Descriptive statistics were used to identify pertinent preoperative risk factors and postoperative complications in each treatment group. RESULTS: A total of 129 hips in 98 patients were treated (118 with ISP and 11 with MDP). Complications developed in 12 hips. Six hips developed osteonecrosis, two hips developed osteonecrosis and chondrolysis, two hips developed osteonecrosis and slip progression, and two hips developed slip progression only. Four of the 11 hips (36.4%) treated with MDP developed complications; 8 of the 118 hips (6.8%) treated with ISP developed complications. DISCUSSION: Complications developed in 9.3% of hips treated with ISP or MDP, with a higher rate of complications observed in the MDP group compared with the ISP group. This study is limited by the small sample size of the cohort and the disproportion in the number of cases in each treatment group. A multicenter study with larger sample sizes will be required to confirm these findings.

Variability in the Follow-up Management of Pediatric Femoral Fractures.

INTRODUCTION: Variability in follow-up has previously been identified in orthopaedic trauma. Variability in follow-up for pediatric femur fractures has not previously been documented. The aim of this study was to document the variability in clinical and radiographic follow-up for pediatric femur fractures based on the fixation method and the treating surgeon. METHODS: This retrospective case series identified isolated femoral fractures in patients younger than 18 years, treated by eight surgeons at a single center from 2010 to 2015. The total number and frequency of clinical visits, radiographic visits and discrete radiograph views, demographic data, fracture classification, treatment method, and presence of complications were extracted. Variability in follow-up was assessed through descriptive statistics and linear and Poisson regression models. RESULTS: One hundred sixty-four femoral fractures in 160 patients were included. Fractures were stratified by the treating surgeon. The mean length of follow-up ranged from 6.5 to 13.6 months. Complications increased follow-up time by mean 1.7 months (1.3 to 2.4). Patients who were treated with rigid locking nails were followed for the shortest amount of time, averaging 9.9 months, while traction followed by rigid locking nails averaged 24.4 (0.5 to 9.3) months of follow-up. DISCUSSION: Variation in the length of follow-up was identified and was associated with the fixation method and the treating surgeon. Few patients were followed long enough to definitively identify complications and sequelae known to occur after femur fractures such as femoral overgrowth or growth arrest. The results of this study indicate a need for additional study and consensus on an appropriate follow-up for pediatric femur fractures.

Evaluating paediatric orthopaedic teleradiology services at a tertiary care centre.

Telehealth services are innovative healthcare strategies that utilize communication technologies to improve healthcare access for patients. Teleradiology is a form of telehealth service that involves the transmission of radiological images, such as x-rays, CTs and MRIs, from one location to another to share patient information with other physicians. The purpose of this study was to assess teleradiology consultations for orthopaedic patients at a paediatric tertiary care centre. A retrospective review was conducted of patients who received teleradiology consultations with a single orthopaedic surgeon from 2015 to 2018 through the paediatric orthopaedic hip clinic at our institution. Teleradiology consultations involved follow-up radiographic imaging at a local community facility for patients who initially received healthcare services at our institution, followed by a telephone consultation to review imaging results and communicate next steps in care. Data collected included patient demographics, imaging type, facility location and distance from our institution. Eighty patients (F = 66, M = 14) who received teleradiology services were reviewed. Mean age was 3.5 years [95% confidence interval (CI): 2.5-4.4] at time of imaging. The average distance from community facilities to our institution was 1167 km (95% confidence interval: 920-1414), a measure of the total distance saved in travel for each patient in a single direction. The travel distance saved was substantial. Paediatric orthopaedic teleradiology services provide families specialized consultations and care continuity without costly travel. With increased implementation of teleradiology services, more patients and families can remain in their home communities while receiving the same quality of care.

Content Analysis of Frequency of Information About Developmental Dysplasia of the Hip on Twitter.

INTRODUCTION: Early detection and screening of developmental dysplasia of the hip (DDH) are critical in reducing complications; thus, advocacy and awareness are paramount. Social media, Twitter, in particular, connects users based on their content engagement, allowing global audience to interact with one another, providing an opportunity to spread awareness and support for children and families affected by conditions such as DDH. The objective of this study was to assess the frequency and content of information being published on Twitter pertaining to DDH. METHODS: A search strategy using key terms was developed. An a priori coding guide using search terms was then created to establish a framework to identify themes regarding DDH on Twitter. Data were extracted over one-week periods in June and July of 2019 and 2020. An excel-based coding guide was developed to organize and analyze the extracted data. RESULTS: A total of 142 tweets were extracted for analysis; 41 in 2019 and 101 in 2020. The most frequently used search terms were hip dysplasia, developmental dysplasia of the hip, and dislocated hip. In 2019, the most frequent tweet authors were healthcare organizations (13/41, 31.7%) and healthcare professionals (12/41, 29.3%). In contrast in 2020, 32.7% (33/101) tweets were authored by patients. Prevention, treatment, and general discussions were top categories in 2019, compared to education, awareness, and general discussions in 2020. CONCLUSION: Our data indicate that user engagement with DDH content on Twitter increased by 2.5-fold from 2019 to 2020. We found similar patterns regarding the types of authors and content type in both years. However, focus shifted toward topics of education and awareness in 2020. SIGNIFICANCE: Our analysis identified trends and gaps in the use of Twitter that could be implemented by users to optimize messages, such as connecting directly and conversing with users through replies. Findings also indicate the importance of multi-author engagement to increase the breadth of distribution of information. Social media platforms can efficiently disseminate information to a wide range of individuals; however, they must be leveraged appropriately to accurately inform the public about DDH. Engaging with Twitter users hold great potential to promote advocacy and increase early detection and screening for DDH. LEVEL OF EVIDENCE: 3.

Inter-rater and Intra-rater Reliability in the Radiographic Diagnosis of Growth Arrest in Paediatric Physeal Fractures.

BACKGROUND: Fractures through the physis account for 18-30% of paediatric fractures and can lead to growth arrest in 5-10% of these cases. Long-term radiographic follow-up is usually necessary to monitor for signs of growth arrest at the affected physis. Given plain radiographs of a physeal fracture obtained throughout patient follow-up, different surgeons may hold different opinions about whether or not early growth arrest has occurred despite using identical radiographs to guide decision-making. This study aims to assess the inter-rater and intra-rater reliability of early growth arrest diagnosis among orthopaedic surgeons given a set of identical plain radiographs. METHODS: A retrospective chart review was conducted on patients aged 2-18 years previously treated for a physeal fracture at a paediatric tertiary care hospital between 2011 and 2018. De-identified anteroposterior (AP) and lateral radiographs of 39 patients from the date of injury and minimum one-year post-injury were administered in a survey to international paediatric orthopaedic surgeons. Each surgeon was asked whether they would diagnose the patient with growth arrest based on the radiographs provided. Surgeons were asked to complete this process again two weeks after the initial review, but using identical shuffled radiographs. Inter-rater and intra-rater reliability was calculated using appropriate kappa statistics. RESULTS: A total of 11 paediatric orthopaedic surgeons completed the first round of the survey, and 9 of these 11 completed the second round. The inter-rater reliability for the first round was 0.22 [95% CI (0.06, 0.35)] and 0.21 [95% CI (0.02, 0.32)] for the second round. The average kappa for intra-rater reliability was - 0.05 [95% CI (- 0.31, 0.21)]. Comparison by injury side showed no significant variation in diagnosis {p = 0.509, OR = 0.90, [95% CI (0.67, 1.22)]}, while comparison by location of injury varied significantly (p = 0.003). CONCLUSIONS: Radiographic diagnosis of growth arrest among paediatric orthopaedic surgeons demonstrated 'fair' inter-rater agreement and no intra-rater agreement, suggesting critical differences in identifying growth arrest on plain radiographs. Further research is necessary to develop an improved diagnostic approach for growth arrest among orthopaedic surgeons. LEVEL OF EVIDENCE: Diagnostic level III.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India.

BACKGROUND: We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India. METHODS: An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019. RESULTS: 173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12 months, and 49.1% had assessed children with DDH aged > 2 years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays. CONCLUSIONS: In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

Inter-rater and Intrarater Reliabilities of the Identification of a "Gothic Arch" in the Acetabulum of Children With Cerebral Palsy.

BACKGROUND: Progressive hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage (MP) on anteroposterior (AP) pelvis radiographs. Accurate measurement of MP requires the lateral margin of the ossified acetabulum to be identified for the placement of Perkin's line. It has been suggested that when there is an erosion of the acetabular rim, described as a gothic arch, the midpoint of the arch be used for the placement of Perkin's line. However, this requires that there be agreement on what constitutes a gothic arch. The purpose of this study was to evaluate the inter-rater and intrarater reliabilities of identifying a gothic arch on pelvis radiographs. METHODS: An online survey with 100 AP pelvis images (200 hips) of children with CP was sent to international experts. Participants were asked to identify which hip(s) had a gothic arch (left, right, both, and neither). The Fleiss κ statistic for inter-rater reliability was calculated. Eight weeks later, the images were shuffled and redistributed to calculate intrarater reliability. RESULTS: The initial survey was completed by 10 participants with 9 participants completing the second survey. The average inter-rater κ value was 0.18 [95% confidence interval (CI), 0.14-0.23] and 0.19 (95% CI, 0.14-0.24) for the 2 surveys, respectively. Among the pediatric orthopaedic surgeons subgroup, the κ values were 0.06 (95% CI, 0.02-0.1) and 0.08 (95% CI, 0.03-0.13). The average intrarater reliability κ value was 0.61 (95% CI, 0.2-1), ranging from 0.32 to 0.86. CONCLUSIONS: There were poor inter-rater and moderate intrarater reliabilities in identifying a gothic arch on AP pelvis radiographs in children with CP. Further characterization and clarification of what constitutes a gothic arch are required. The lack of agreement on the identification of a gothic arch may negatively impact the measurement of MP and referrals to a pediatric orthopaedic surgeon.

Is the modified Gartland classification system important in deciding the need for operative management of supracondylar humerus fractures?

PURPOSE: This study examined levels of agreement between paediatric orthopaedic surgeons in the need for operative management of extension-type supracondylar humerus fractures. METHODS: This was the second phase of a two-part study. De-identified baseline anteroposterior and lateral elbow radiographs from 60 paediatric patients with extension-type supracondylar humerus fractures were compiled. After classifying each fracture according to Gartland classification guidelines, radiographs were randomized, and surgeons indicated whether they would use operative or non-operative management to treat each fracture. Kappa statistics using pairwise comparisons were calculated to determine agreement levels. RESULTS: In total, 11 international surgeons participated, and 10/11 completed both survey rounds. The overall weighted interobserver agreement was moderate (0.530, 95%CI [0.215,0.854]) while overall weighted intraobserver agreement was substantial (0.740, 95%CI [0.513,0.963]). The largest variability in preferred treatment methods between surgeons was observed for type IIA fractures, with 6/11 preferring non-operative and 5/11 preferring operative management. The largest individual surgeon variability was observed for type IIA fractures, with 8/11 showing variability (defined by not having made the same decision for at least 90% of the cases) in choosing whether to operate. CONCLUSIONS: Our findings suggest moderate interobserver, and substantial intraobserver agreement in treatment decision making. The largest disagreements between surgeons were observed for type IIA and IIB fractures and treatment decisions did not follow expected trends based on surgeons' preferred treatment methods for each fracture type. This suggests differences in treatment approaches between surgeons in the management of type IIA fractures and highlights the role of other variables that underlie differences between surgeons' treatment preferences. LEVEL OF EVIDENCE: III.

The use of virtual reality in reducing anxiety during cast removal: a randomized controlled trial.

PURPOSE: While virtual reality (VR) has been shown to be an effective distractor in children across a range of procedures, no studies have looked at its use within paediatric orthopaedics. The purpose of this study was to look at the use of VR in reducing anxiety levels in children during cast removal. In addition, the study aimed to find ways to enhance the efficiency of future VR trials in paediatrics. METHODS: A non-blinded randomized control trial took place in children aged four to 18 years. Intraprocedural anxiety was measured using the Children's Emotional Manifestation Scale (CEMS), while pre- and post-procedural anxiety was measured using the Short State Anxiety Inventory Scale. Additional data was collected on trait anxiety, nausea levels, desire for future VR use and areas of improvement for future VR studies. RESULTS: A total of 90 subjects were included in the study (control n = 45, intervention n = 45) with a mean age of 10.25 years (sd 3.35). Post-procedural anxiety and intraprocedural anxiety were 18% (p = 0.03) and 24% (p = 0.01) lower in the VR group, respectively, with the CEMS facial component showing a 31% (p < 0.001) reduction in the VR group. In all, 99% (n = 89) of subjects experienced no nausea, with one patient experiencing mild nausea that may have been present prior to VR use. Finally, 90% (n = 81) of subjects said they would like to use VR again, 1% (n = 1) said 'no' and 9% (n = 8) said 'maybe'. CONCLUSION: VR appears to be an effective distraction technique in reducing anxiety levels in children during cast removal.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatric Orthopaedic Surgeons in North America.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common condition, affecting 1% to 2% of full-term infants. The American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Pediatrics have published guidelines detailing best practices for DDH screening and treatment. The purpose of this survey was to determine DDH treatment practices of pediatric orthopaedic surgeons in North America. METHODS: We queried orthopaedic surgeon members of the Pediatric Orthopaedic Society of North America (POSNA) about referral patterns, treatment practices, and use of DDH guidelines. The survey included demographics, clinical scenarios, referrals patterns, and ultrasound practices. RESULTS: Of the 1392 members of POSNA, we received 432 total responses and included 353 in statistical analyses. Results show that 68% (233/342) of surgeons practice in an institution that does not endorse a standard care pathway for DDH. Of surgeons who personally use a DDH care pathway, the AAOS guidelines were most cited (143/353, 41%). The majority (94%, 316/337) of surgeons do not believe that universal ultrasound screening should be adopted in the United States. Responses regarding ultrasound screening for "high risk" infants as outlined by AAOS varied based on risk factor. Many (57%, 200/353) surgeons have performed initial evaluations for patients over 12 months of age. While 80% (260/327) of orthopaedic surgeons believe that primary care providers are referring patients appropriately, only 57% (183/323) believe that primary care providers are ordering imaging studies appropriately. CONCLUSIONS: Results from this survey of POSNA membership indicate an opportunity to better distribute and implement DDH guidelines. In addition, the implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by: (1) reducing the total cost of care, (2) increasing the use of appropriate imaging, (3) increasing timely referral for DDH care, and (4) reducing the presentation rate of walking age DDH patients. LEVEL OF EVIDENCE: The level of evidence rating for this survey-based study is level IV.