Application of Accepted Use Criteria for the Treatment of Developmental Dysplasia of the Hip Decreases the Number of Infants Treated With a Pavlik Harness.

BACKGROUND: This analysis examined how the application of the American Academy of Orthopedic Surgeons appropriate use criteria (AUC) for developmental dysplasia of the hip in infants would change treatment patterns and outcomes for Graf IIA hips at a single quaternary pediatric hospital. METHODS: After Institutional Review Board approval, patient medical records were reviewed and data were collected. Graf IIa hips were defined as alpha angle (AA) 50 to 59 degrees. AA and femoral head coverage (FHC) were measured from initial and 6-month ultrasounds and acetabular index (AI) was measured from radiographs at 6 months of age. Instability (positive Ortolani and Barlow tests) was noted. On the basis of the American Academy of Orthopedic Surgeons AUC for managing developmental dysplasia of the hip, hips were further categorized as normal (FHC ≥45%), borderline (FHC 35% to 44%), or dysplastic (FHC <35%). RESULTS: Overall, 13% (49/371) of Graf IIa hips (AA 50 to 59 degrees) were dysplastic (FHC <35%). Total 24% (89/371) were clinically unstable. Total 42% (37/89) of unstable Graf IIa hips were dysplastic. Only 4% of stable Graf IIa hips were dysplastic (12/282). Out of 371 Graf IIa hips, 256 were treated with Pavlik harness (n=250) or Rhino brace (n=6). Among stable, nondysplastic (SND) hips (those with normal and borderline FHC≥35%), 33% (52/158) were treated because of a more severe contralateral side. If the AUC had been applied, 67% (106/158) of SND Graf IIa hips would not have been treated. Among the n=162 hips that returned for a 6-month radiograph, there was no difference in AI in the 115 treated and 47 untreated SND hips (mean difference treatment vs. no treatment: -1.5, 95% CI, -3.1 to 0.2, P =0.0808). CONCLUSIONS: Using AUC recommendations, our center could reduce the number of SND Graf IIa hips we treat by 67%. Although 24% of Graf IIa hips were clinically unstable and 13% were dysplastic based on FHC, most Graf IIa hips had normal or borderline FHC per the AUC and may do well with observation and follow-up ultrasound at 12 weeks old. LEVEL OF EVIDENCE: Level III-diagnostic study.

Twelve-week standard of care protocol longer than median time to normalization among IIc hips treated with Pavlik harness.

Best treatment protocols for infants with developmental dysplasia of the hip (DDH) are poorly defined. This study estimates the time to normalization among Graf IIc hips undergoing Pavlik harness treatment. Following institutional review board approval, patients referred for DDH evaluation at a pediatric institution between 2009 and 2018 (n = 1424 hips/712 patients) were identified. We isolated all Graf IIc hips that underwent Pavlik harness treatment (n = 132 hips/n = 106 patients). Demographic and outcome measures were collected. Normalization was defined as alpha angle greater than or equal to 60° and femoral head coverage greater than or equal to 50%. Kaplan-Meier and Cox proportional hazards regression analyses modeled time to normalization and identified factors associated with earlier normalization. Median time to normalization was 7.0 weeks. At 12 weeks standard treatment, 85.8% [95% confidence interval (CI): 80.2-91.9%] had normalized. Greater femoral head coverage [hazard ratio (HR) per 1% increase: 1.03; 95% CI: 1.01-1.05; P = 0.0068] and hip stability at treatment initiation (HR unstable vs. stable: 0.64; 95% CI: 0.44-0.93; P = 0.0192) were associated with longer time to normalization. Some patients may not need 12 weeks of Pavlik bracing, particularly those with stable presentation who normalize before week 12. Shorter treatment lengths offer benefit without sacrificing long-term outcomes. Findings reinforce growing evidence that femoral head coverage should be a more significant consideration during diagnosis and instability is a concerning finding on examination.

Disseminated Nocardiosis Masquerading as Soft-Tissue Malignancy: A Case Report.

CASE: A 59-year-old man, immunosuppressed after renal transplant, presented with a painful posterior thigh mass concerning for malignancy, as well as pulmonary and posterior chest wall nodules. Cultures and mass spectrometry identified Nocardia paucivorans. The patient underwent operative irrigation and debridement of the posterior thigh and chest wall, with 12 months of antibiotic therapy. CONCLUSION: A 2-week delay in appropriate treatment was due to low suspicion for infectious etiology. Since cultures generally take weeks for positive diagnosis, advanced molecular or biochemical methods should be used. This case demonstrates importance in maintaining a high index of suspicion for nocardiosis in immunocompromised patients with soft-tissue masses.

Influence of Body Bass Index (BMI) on post-operative Opioid Requirements in Primary Total Joint Arthroplasty Patients.

BACKGROUND: The aim of our study was to evaluate whether an association exists between body mass index (BMI) category and post-operative opioid requirements among primary total joint arthroplasty (TJA) patients. METHODS: We retrospectively reviewed all primary unilateral total hip and total knee arthroplasty (THA/TKA, respectively) cases performed over a two-year period. We evaluated whether a relationship exists between five BMI categories (≤24.9, 25-29.9, 30-34.9, 35-39.9, ≥40) and morphine milligram equivalent (MME) use for total in-hospital, daily in-hospital, and total during six weeks post-discharge. Secondary outcomes included relationship with length of stay, discharge location, opioid refill rate, and pre-operative opioid usage. RESULTS: For all patients undergoing primary TJA, increasing BMI resulted in an incremental increase in post-operative total in-hospital MME use for each successive BMI category when compared to those with BMI ≤24.9 (p < 0.05). This association held true for the THA subset. Within the cohort as a whole, higher categories of BMI were associated with increased length of stay (35-39.9, ≥40), higher odds of needing a refill (30-34.9, 35-39.9, ≥40), and higher odds of discharging to a rehab facility (25-29.9, ≥40) (p < 0.05). There was an increasing proportion of pre-operative opioid use as BMI category increased (p < 0.0001). DISCUSSION/CONCLUSION: BMI category is associated with increased in-hospital opioid requirements among primary TJA patients. Such findings are an important step to better understanding pain control expectations and can help facilitate development of opioid reduction strategies.

Assessment of Orthopedic Educational Research in 2015 Publications.

BACKGROUND: Due to orthopedic surgery's unique educational model, recent changes within graduate medical education have the potential to impact the methods and outcomes of specialty training significantly. Using Mind the Gap: Representation of Medical Education in Cardiology-Related Articles and Journals (Allred et al., 2016) as a framework, this study investigates educational research within the field of orthopedics. OBJECTIVE: Two main objectives were evaluated: (1) quantitative analysis of the amount and type of orthopedic education-related research in orthopedic, general surgery, and medical education journals and (2) estimate the priority of orthopedic journals to publish education-focused articles. METHODS: Using a composite citation-based 5-metric scoring system, a complete list of journals pertaining to orthopedics, nonorthopedic specific surgery journals, and general medical education journals was ranked. All publications during 2015 for the selected cohort of journals were then analyzed for orthopedic education-related publications. Aim and scope of the top 15 selected orthopedic journals (along with the mission statements of their associated societies) were evaluated with a word cloud generator to determine priority on education. RESULTS: Review of 7112 articles from the top 15 selected orthopedic journals yielded 37 publications with an educational focus. Evaluation of 15 general surgery or medical education journals, containing 4661 publications, generated an additional 28 positive articles. In total, 51 unique orthopedic education-related publications (0.43% of total evaluated articles) were identified from the 11,773 articles published in the selected 30 journals for 2015. CONCLUSION: The lack of emphasis on orthopedic educational research output is multifactorial, needing further evaluation to determine specific causes and methods of improvement. This article adequately sheds light on the need to increase support of educational research programs within the field of orthopedics.

The spatiotemporal dynamics of scene gist recognition.

Viewers can rapidly extract a holistic semantic representation of a real-world scene within a single eye fixation, an ability called recognizing the gist of a scene, and operationally defined here as recognizing an image's basic-level scene category. However, it is unknown how scene gist recognition unfolds over both time and space-within a fixation and across the visual field. Thus, in 3 experiments, the current study investigated the spatiotemporal dynamics of basic-level scene categorization from central vision to peripheral vision over the time course of the critical first fixation on a novel scene. The method used a window/scotoma paradigm in which images were briefly presented and processing times were varied using visual masking. The results of Experiments 1 and 2 showed that during the first 100 ms of processing, there was an advantage for processing the scene category from central vision, with the relative contributions of peripheral vision increasing thereafter. Experiment 3 tested whether this pattern could be explained by spatiotemporal changes in selective attention. The results showed that manipulating the probability of information being presented centrally or peripherally selectively maintained or eliminated the early central vision advantage. Across the 3 experiments, the results are consistent with a zoom-out hypothesis, in which, during the first fixation on a scene, gist extraction extends from central vision to peripheral vision as covert attention expands outward.