Management of long bone fractures and traumatic hip dislocations in paediatric patients: study protocol for a prospective global multicentre observational cohort registry.

INTRODUCTION: Management controversy and clinical equipoise exist in treatments of long bone fractures and traumatic hip dislocation in paediatric patients due to the lack of high-quality clinical evidence. This protocol describes the effort of a large prospective global multicentre cohort study (registry) aiming at providing quality data to assist evidence-based treatment decision-making. METHODS AND ANALYSIS: Eligible paediatric patients (N=750-1000) with open physes suffering from proximal humerus fractures, distal humerus fractures, proximal radius fractures, forearm shaft fractures, traumatic hip dislocations, femoral neck fractures or tibial shaft fractures will be recruited over a period of 24-36 months. Hospitalisation and treatment details (including materials and implants) will be captured in a cloud-based, searchable database. Outcome measures include radiographic assessments, clinical outcomes (such as range of motion, limb length discrepancies and implant removal), patient-reported outcomes (Patient Reported Outcomes Of Fracture, Patient-Reported Outcomes Measurement Information System (PROMIS) and EuroQol-5D (EQ-5D-Y)) and adverse events.Aside from descriptive statistics on patient demographics, baseline characteristics, types of fractures and adverse event rates, research questions will be formulated based on data availability and quality. A statistical analysis plan will be prepared before the statistical analysis. ETHICS AND DISSEMINATION: Ethics approval will be obtained before patients are enrolled at each participating site. Patient enrolment will follow an informed consent process approved by the responsible ethics committee. Peer-reviewed publication is planned to disseminate the study results. TRIAL REGISTRATION NUMBER: NCT04207892.

A Prospective, Multicenter Study of Developmental Dysplasia of the Hip: What Can Patients Expect After Open Reduction?

BACKGROUND: Although there are several predominantly single-center case series in the literature, relatively little prospectively collected data exist regarding the outcomes of open hip reduction (OR) for infantile developmental dysplasia of the hip (DDH). The purpose of this prospective, multi-center study was to determine the outcomes after OR in a diverse patient population. METHODS: The prospectively collected database of an international multicenter study group was queried for all patients treated with OR for DDH. Minimum follow-up was 1 year. Proximal femoral growth disturbance (PFGD) was defined by consensus review using Salter's criteria. Persistent acetabular dysplasia was defined as an acetabular index >90th percentile for age. Statistical analyses were performed to compare preoperative and operative characteristics that predicted re-dislocation, PFGD, and residual acetabular dysplasia. RESULTS: A cohort of 232 hips (195 patients) was identified; median age at OR was 19 months (interquartile range 13 to 28) and median follow-up length was 21 months (interquartile range 16 to 32). Re-dislocation occurred in 7% of hips (n=16/228). The majority (81%; n=13/16) occurred in the first year after initial OR. Excluding patients with repeat dislocation, 94.5% of hips were IHDI 1 at most recent follow-up. On the basis of strict radiographic review, some degree of PFGD was present in 44% of hips (n=101/230) at most recent follow-up. Seventy-eight hips (55%) demonstrated residual dysplasia compared with established normative data. Hips that had a pelvic osteotomy at index surgery had about half the rate of residual dysplasia (39%; n=32/82) versus those without a pelvic osteotomy with at least 2 years follow-up (78%; n=46/59). CONCLUSIONS: In the largest prospective, multicenter study to date, OR for infantile DDH was associated with a 7% risk of re-dislocation, 44% risk of PFGD, and 55% risk of residual acetabular dysplasia at short term follow-up. The incidence of these adverse outcomes is higher than previous reports. Patients treated with concomitant pelvic osteotomy had lower rates of residual dysplasia. These prospectively collected, multicenter data provide better generalizable information to improve family education and appropriately set expectations. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Long-Arm Splinting Versus Above-Elbow Casting for Type 1 Supracondylar Fractures of the Humerus in Children: a Randomized Controlled Trial.

Type 1 supracondylar humerus (SCH) fractures tend to heal well when immobilized by above-elbow casting or long-arm splinting. There is no consensus as to whether one treatment method is more effective than the other for this injury. The purpose of this study was to compare the radiographic and functional outcomes of long-arm splinting and above-elbow casting as the definitive treatment for children with type 1 SCH fractures. The study was set up as a randomized controlled non-inferiority trial. Patients between three and 12 years old presenting with a type 1 SCH fracture were randomized into splint or cast groups, or an observational arm. Baumann's angle, functional assessment scores, and Flynn's criteria score were measured at initial injury and at six months post-injury. In total, 34 patients were enrolled in the study with 13 in the randomized arm and 21 in the observational arm. Due to lack of follow-up data at 6 months post-injury, five splint patients and 10 cast patients were included in the final cohort for data analysis. The average change in Baumann's angle at 6-month follow-up was 3° or less for each treatment arm. The splint group obtained excellent Flynn's criteria scores while the cast group reported good and excellent scores. Complications reported in the splint group included device breakdown, a conversion to above-arm cast, and significant itchiness. Preliminary findings suggest functional and radiological outcomes with splinting are non-inferior to casting; however, a larger sample size is required to more accurately compare the two modalities. This study was registered with the U.S. National Institutes of Health (ClinicalTrials.gov, #NCT01912365).

Caregiver Experiences Using Orthotic Treatment Options for Developmental Dysplasia of the Hip in Children.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common condition affecting 5 in 1000 newborns. The standard first line of treatment is the use of an orthotic, which has generally high success rates, but can pose substantial difficulties and put undue burden on caregivers. The general experience of caregivers using these orthotics has not been well documented on an orthotic-specific basis. The purpose of this study was to investigate caregiver experience using prescribed DDH orthotics to identify challenges, differences between treatment options, and areas of improvement. METHODS: A survey assessing treatment prescription, respondent demographics, and caregiver experience was distributed online to caregivers whose child/children were treated for DDH with an orthotic. Seven-point positively phrased Likert scale statements and open-ended questions were included to assess caregiver experience. The results were analyzed using summary statistics and orthotics with more than 30 responses were selected for more in-depth analysis. RESULTS: A total of 530 survey responses were collected with 63% (334/530) of respondents using a Pavlik harness, 45% (236/530) a Rhino brace, and 13% (67/530) a Denis Browne Bar. The overall weighted average score across all Likert Scale statements was positive for the Pavlik harness, Rhino brace, and Denis Browne Bar at 4.19 (95% CI, 3.83 to 4.54), 4.63 (95% CI, 4.27 to 4.99) and 4.91 (95% CI, 4.58 to 5.24), respectively. In the open-ended responses, all 3 orthotics were perceived as easy to use and not hindering child-caregiver bonding, but raised concerns of discomfort and skin irritation, as well as preventing the ability to cuddle their child the way they desired. The Pavlik harness respondents consistently brought up concerns regarding cleanability. CONCLUSIONS: The results show that the DDH orthotics analyzed are generally easy to use and perceived positively by caregivers, but have orthotic-specific challenges that should be a focus of future improvement work. CLINICAL RELEVANCE: This study evaluated opinions and attitudes of caregivers for children being treated with DDH orthotics, revealing experiences, concerns, and challenges associated with the use of commonly prescribed options.

Application of statistical shape modeling to the human hip joint: a scoping review.

OBJECTIVE: The objective of this scoping review was to identify all examples of the application of statistical shape models to the human hip joint, with a focus on applications, population, methodology, and validation. INTRODUCTION: Clinical radiographs are the most common imaging tool for management of hip conditions, but it is unclear whether radiographs can adequately diagnose or predict outcomes of 3D deformity. Statistical shape modeling, a method of describing the variation of a population of shapes using a small number of variables, has been identified as a useful tool to associate 2D images with 3D anatomy. This could allow clinicians and researchers to validate clinical radiographic measures of hip deformity, develop new ones, or predict 3D morphology directly from radiographs. In identifying all previous examples of statistical shape modeling applied to the human hip joint, this review determined the prevalence, strengths, and weaknesses, and identified gaps in the literature. INCLUSION CRITERIA: Participants included any human population. The concept included development or application of statistical shape models based on discrete landmarks and principal component analysis. The context included sources that exclusively modeled the hip joint. Only peer-reviewed original research journal articles were eligible for inclusion. METHODS: We searched MEDLINE, Embase, Cochrane CENTRAL, IEEE Xplore, Web of Science Core Collection, OCLC PapersFirst, OCLC Proceedings, Networked Digital Library of Theses and Dissertations, ProQuest Dissertations and Theses Global, and Google Scholar for sources published in English between 1992 and 2021. Two reviewers screened sources against the inclusion criteria independently and in duplicate. Data were extracted by 2 reviewers using a REDCap form designed to answer the review study questions, and are presented in narrative, tabular, and graphical form. RESULTS: A total of 104 sources were considered eligible based on the inclusion criteria. From these, 122 unique statistical shape models of the human hip were identified based on 86 unique training populations. Models were most often applied as one-off research tools to describe shape in certain populations or to predict outcomes. The demographics of training populations were skewed toward older patients in high-income countries. A mean age between 60 and 79 years was reported in 29 training populations (34%), more than reported in all other age groups combined, and 73 training populations (85%) were reported or inferred to be from Europe and the Americas. Only 4 studies created models in a pediatric population, although 15 articles considered shape variation over time in some way. There were approximately equal numbers of 2D and 3D models. A variety of methods for labeling the training set was observed. Most articles presented some form of validation such as reporting a model's compactness (n = 71), but in-depth validation was rare. CONCLUSIONS: Despite the high volume of literature concerning statistical shape models of the human hip, there remains a need for further research in key areas. We identified the lack of models in pediatric populations and low- and middle-income countries as a notable limitation to be addressed in future research.

Unilateral versus bilateral reconstructive hip surgery in children with cerebral palsy: A survey of pediatric orthopedic surgery practice and decision-making.

Purpose: This study explored whether surgeons favor unilateral or bilateral reconstructive hip surgery in children with cerebral palsy who have unilateral hip displacement. Methods: An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopedic surgeons. The case of an 8 year old at Gross Motor Function Classification System level IV with migration percentages of 76% and 22% was described. Surgeons selected their surgical treatment of choice and provided their rationale. Respondents were also asked to list and rank radiographic parameters used for decision-making and multidisciplinary team members involved in decision-making. Results: Twenty-eight orthopedic surgeons from nine countries with a mean 21.3 years (range, 5-40 years) of experience completed the survey. A "bilateral VDROs with a right pelvic osteotomy (PO) was selected by 68% (19/28) of respondents; risk of contralateral subluxation (9/19; 47%) and maintaining symmetry (7/19; 37%) were the most common rationales for bilateral surgery. The remaining 32% (9/28) chose a 'right VDRO with a right PO'" with most of these (8/9; 89%) stating the left hip was sufficiently covered. Of 31 radiographic parameters identified, migration percentage, acetabular angle/index, Shenton line, neck shaft angle, and presence of open/closed triradiate growth plates were the most common. Physical therapists (68%) and physiatrists (43%) were most likely to be involved in pre-operative surgical consultation. Conclusion: There is a lack of agreement on management of the contralateral hip in children with unilateral hip displacement. Further studies comparing patient important outcomes following unilateral and bilateral surgery are required. Level of Evidence: V.

The Natural History of Non-operatively Managed Legg-Calvé-Perthes' Disease.

Background: The purpose of this study was to examine the evolution of Legg-Calvé-Perthes' disease (LCPD) among children from British Columbia (BC), Canada who were treated non-operatively and to compare the results to a previously conducted study in India. Methods: This was a retrospective review of patients treated non-operatively for LCPD in BC between 1990 and 2006 compared with a cohort from India. Demographic and treatment information were collected from medical records. Radiographs were assigned modified Waldenstrom, Catterall, Salter-Thompson and Herring classifications and intra- and interobserver reliability were assessed. We evaluated epiphyseal extrusion (EE) and metaphyseal width (MW), and assessed radiographs using the Mose and modified Stulberg classifications. Results: 102 hips (90 patients) had radiographs available for evaluation. 95% of the BC cohort presented as Waldenstrom stages I and II, whereas, 90% of the Indian cohort presented as IIIa. Final EE was similar for both groups (BC 26.8%, India 27.3%) and final MW was 119% in both groups. Modified Waldenstrom and Herring classifications had substantial intra- and interobserver reliability, while Salter-Thompson and Catterall classifications had moderate agreement at best. Most hips were Catterall IV (80%) and Herring C (89%) for the BC cohort compared to only 44% and 43% of Indian hips, respectively. Most hips were irregular according to the Mose classification (BC 43%, India 52%) and aspherical according to the Stulberg classification (BC 78%). Conclusions: We found similar radiographic progression and final radiographic appearances of LCPD in India and BC though differences in the distribution of the classification systems warrant further study. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00543-x.

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.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians.

OBJECTIVE: To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States. STUDY DESIGN: An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated. RESULTS: We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers. CONCLUSIONS: The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

Hip Surveillance for Children with Cerebral Palsy: A Survey of Orthopaedic Surgeons in India.

BACKGROUND: The purpose of this study was to assess Indian orthopaedic surgeons' current practices and beliefs regarding hip surveillance for children with cerebral palsy (CP), to determine potential support for developing hip surveillance guidelines, and to identify knowledge gaps and key obstacles to guideline implementation in India. METHODS: An anonymous, cross-sectional online survey was sent to approximately 350 Paediatric Orthopaedic Society of India (POSI) members who were queried on their practices and beliefs about hip surveillance for children with CP, as well as perceived challenges and requirements for the successful implementation of hip surveillance guidelines in the Indian context. RESULTS: Out of 107 responses obtained from POSI members, almost all (96.2%) agreed that hip displacement requires standardized monitoring, using surveillance and surgery to prevent hip dislocation. Approximately half (51.5%) of respondents reported using existing hip surveillance guidelines, with most (41.2%) using the Australian guidelines. Almost all (97%) surgeons indicated that hip surveillance guidelines in India are needed, with 100% expressing interest in following guidelines specific to India. Respondents most frequently indicated late referrals to orthopaedics (81.2%), loss of patients to follow-up (78.2%), and lack of resources (43.6%) as challenges to successful hip surveillance in India. Perceived requirements for implementation included developing Indian-specific guidelines (83.2%) as well as educating surgeons (56.4%), physiotherapists/pediatricians (90.1%), and families (82.2%). CONCLUSION: Orthopaedic surgeons practicing in India understand the importance of preventing hip dislocations in children with CP through hip surveillance and timely surgical intervention. The results demonstrated strong support for the development of hip surveillance guidelines designed specifically for the Indian healthcare system. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00432-3.

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.

Interobserver and Intraobserver Reliability in the Salter Classification of Avascular Necrosis of the Femoral Head in Developmental Dysplasia of the Hip.

BACKGROUND: Avascular necrosis (AVN) of the femoral head is a concerning complication that can result from treatments for developmental dysplasia of the hip (DDH). AVN can lead to degenerative osteoarthritis, persistent acetabular dysplasia, reduced function, and continuing hip pain. The incidence of AVN reported in the DDH literature is widely varied (0% to 73%). This variability may arise from lack of consensus on what constitutes true AVN in this patient population, and lack of clear criteria provided in studies reporting incidence rates. METHODS: A multicentre, prospective database of infants diagnosed with DDH between 2010 and 2014 from 0 to 18 months of age was analyzed for patients treated by closed reduction (CR). Twelve pediatric orthopaedic surgeons completed 2 rounds of AVN assessments. Deidentified anteroposterior radiographs at most recent follow-up were provided to surgeons along with patient age at radiographic assessment, length of follow-up, ands affected hip. Ten of 12 surgeons completed a third round of assessments where they were provided with 1 to 2 additional radiographs within the follow-up period. Radiographic criteria for total AVN described by Salter and colleagues were used. Surgeons rated the presence of AVN as "yes" or "no" and kappa values were calculated within and between rounds. RESULTS: A total of 69 hips in 60 patients were assessed for AVN a median of 22 months (range: 12 to 36) post-CR. Interobserver kappa values for rounds 1, 2, and 3 were 0.52 (range: 0.11 to 0.90), 0.61 (range: 0.21 to 0.90), and 0.53 (range: 0.10 to 0.79), respectively. Intraobserver agreement for AVN diagnosis was an average of 0.72 (range: 0.31 to 0.96). CONCLUSIONS: Despite using the most commonly referenced diagnostic criteria, radiographic diagnosis of AVN following CR in DDH patients demonstrated only moderate agreement across surgeons. The addition of sequential radiographs did not improve cross-observer reliability, and while substantial agreement was seen within observers, the range of intraobserver kappa values was large. LEVEL OF EVIDENCE: Level I-diagnostic study.

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.

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions.

PURPOSE: In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country's needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India. METHODS: In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway. RESULTS: The Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country's immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging. DISCUSSION/CONCLUSION: In Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways. LEVEL OF EVIDENCE: Level III.

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.

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.

Even Experts Can Be Fooled: Reliability of Clinical Examination for Diagnosing Hip Dislocations in Newborns.

BACKGROUND: The aim of this study was to assess the accuracy of clinical screening examination in newborns with dislocated hips compared with ultrasound scan (USS). METHODS: Newborns, up to 3 months of age, with confirmed hip dislocations on USS were prospectively enrolled in a multinational observational study. Data from 2010 to 2016 were reviewed to determine pretreatment clinical examination findings of the treating orthopaedic surgeon as well as baseline ultrasound indices of developmental dysplasia of the hip (DDH). All infants had been referred to specialist centres with expertise in DDH, due to abnormal birth examination or risk factor. RESULTS: The median age of the study population was 2.3 weeks and 84% of patients were female. Of the total 515 USS-confirmed dislocated hips included in the study, 71 (13.8%) were incorrectly felt to be reduced on clinical examination by the treating orthopaedist (P<0.001). Full hip abduction was documented in 106 hips. Of the hips correctly identified as dislocated, 322 hips were further analyzed based on clinical reducibility. Thirty-three of 322 (10.2%) were incorrectly thought to be reducible when in fact they were irreducible or vice versa. CONCLUSIONS: Expert examiners missed a significant number of frankly dislocated hips on clinical examination and their ability to classify hips based on clinical reducibility was only moderately accurate. This study provides evidence that, even in experienced hands, physical examination findings in DDH are often too subtle to elicit clinically in the first few months of life. This may explain the persistent and measurable rate of late presenting dislocations in countries with screening programmes reliant on clinical examination. LEVEL OF EVIDENCE: Level 1-testing of previously developed diagnostic criteria in series of consecutive patients (with universally applied reference "gold" standard).

Recommendations for the Care of Pediatric Orthopaedic Patients During the COVID-19 Pandemic.

The COVID-19 pandemic has necessitated modifications to pediatric orthopaedic practice to protect patients, families, and healthcare workers and to minimize viral transmission. It is critical to balance the benefits of alterations to current practice to reduce the chances of COVID-19 infection, with the potential long-term impact on patients. Early experiences of the pandemic from orthopaedic surgeons in China, Singapore, and Italy have provided the opportunity to take proactive and preventive measures to protect all involved in pediatric orthopaedic care. These guidelines, based on expert opinion and best available evidence, provide a framework for the management of pediatric orthopaedic patients during the COVID-19 pandemic. General principles include limiting procedures to urgent cases such as traumatic injuries and deferring outpatient visits during the acute phase of the pandemic. Nonsurgical methods should be considered where possible. For patients with developmental or chronic orthopaedic conditions, it may be possible to delay treatment for 2 to 4 months without substantial detrimental long-term impact.