Hip Imaging in Children With Cerebral Palsy: Estimation and Intrapatient Comparison of Patient-Specific Radiation Doses of Low-Dose CT and Radiography.

OBJECTIVES: Hip displacement is the second most common orthopedic problem affecting children with cerebral palsy (CP). Routine radiographic hip surveillance typically involves an anteroposterior (AP) pelvis radiograph. Unfortunately, this imaging protocol is limited by its projectional technique and the positioning challenges in children with CP. Alternatively, hip low-dose computed tomography (LDCT) has been advocated as a more accurate strategy for imaging surveillance as it provides biofidelic details of the hip that is independent of patient positioning. However, the tradeoff is the (presumed) higher radiation dose to the patient. The goal of this study is to estimate patient-specific radiation doses of hip LDCTs and AP pelvis radiographs in CP patients, and perform an intrapatient dose comparison. MATERIALS AND METHODS: A search of our imaging database was performed to identify children with CP who underwent hip LDCT and AP pelvis radiograph within 6 months of each other. The LDCTs were performed using weight-adjusted kVp and tube current modulation, whereas the radiographs were obtained with age-/size-adjusted kVp/mAs. The patient-specific organ and effective doses for LDCT were estimated by matching the patients to a nonreference pediatric phantom library from the National Cancer Institute Dosimetry System for Computed Tomography database with Monte Carlo-based dosimetry. The patient-specific organ and effective doses for radiograph were estimated using the National Cancer Institute Dosimetry System for Radiography and Fluoroscopy with Monte Carlo-based dose calculation. Dose conversion k-factors of dose area product for radiography and dose length product for LDCT were adapted, and the estimation results were compared with patient-specific dosimetry. RESULTS: Our study cohort consisted of 70 paired imaging studies from 67 children (age, 9.1 ± 3.3 years). The patient-specific and dose length product-based effective doses for LDCT were 0.42 ± 0.21 mSv and 0.59 ± 0.28 mSv, respectively. The patient-specific and dose area product-based effective doses for radiography were 0.14 ± 0.09 mSv and 0.08 ± 0.06 mSv, respectively. CONCLUSIONS: The radiation dose for a hip LDCT is ~4 times higher than pelvis radiograph, but it is still very low and poses minimal risk to the patient.

Assessment of foot alignment and function for ambulatory children with cerebral palsy: Results of a modified Delphi technique consensus study.

Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. Level of Evidence: V.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Preoperative Considerations for Teenagers Undergoing Orthopaedic Surgery: VTE Prevention, Mental Health Assessment, Vaping, and Drug Addiction.

INTRODUCTION: Adolescents undergoing pediatric orthopaedic surgery typically experience an uncomplicated postoperative course. However, adolescence represents a unique transition period from pediatric to adult physiology. As a result, the astute pediatric orthopaedic surgeon will be aware of unique medical and social scenarios which are relevant to adolescents during the perioperative course including the risk of venous thromboembolism (VTE), prevalence of mental health conditions, and rising use of electronic cigarettes or "vaping" to consume nicotine and cannibas. DISCUSSION: Adolescents are at a greater risk of VTE after pediatric orthopaedic surgery. In particular, adolescent females with a family history of blood clotting disorders and those with a change in mobility after surgery should be considered for prophylaxis. The prevalence of adolescent mental health conditions including anxiety, depression, and behavioral issues is increasing in the United States. Higher levels of preoperative anxiety and the presence of mental health pathology are associated with slower recovery, higher levels of postoperative pain, and the increased likelihood for chronic pain. Several quick screening instruments are available to assess adolescents for preoperative anxiety risk, including the Visual Analogue Scale for Anxiety or the Amsterdam Perioperative Anxiety Information Scale. Unfortunately, electronic cigarettes have become increasingly popular for the consumption of nicotine and cannabis among adolescents. Preoperative use of combustive cigarettes (nicotine/cannabis) represents perioperative risks for induction/anesthesia, postoperative pain, and analgesia requirements and issues with delayed wound and fracture healing. CONCLUSIONS: VTE, underlying mental health conditions, and usage of nicotine and cannabis are clear detriments to the recovery and healing of adolescent patients following orthopaedic surgery. Therefore, standardized screening for adolescents before orthopaedic surgery is indicated to identify perioperative risk factors which have negative impacts on functional outcomes.

Trends in Leadership at Pediatric Orthopaedic Fellowships.

BACKGROUND: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs. METHODS: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles. RESULTS: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%). CONCLUSIONS: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership.

Hospital resource use after hip reconstruction surgery in children with neurological complex chronic conditions.

AIM: To assess how co-occurring conditions influence recovery after hip reconstruction surgery in children with neurological complex chronic conditions (CCCs). METHOD: This was a retrospective analysis of 4058 children age 4 years or older with neurological CCCs who underwent hip reconstructive surgery between 1st January 2015 and 31st December 2018 in 49 children's hospitals. The presence of co-occurring chronic conditions was assessed using the Agency for Healthcare Research Chronic Condition Indicator system. Multivariable, hierarchical regression was used to assess the relationship between co-existing conditions and postoperative hospital length of stay (LOS), cost, and 30-day readmission rate. RESULTS: The most common co-occurring conditions were digestive (60.1%) and respiratory (37.9%). As the number of co-existing conditions increased from one to four or more, median LOS increased 67% (3d [interquartile range {IQR} 2-4d] to 5d [IQR 3-8d]); median hospital cost increased 41% ($20 248 [IQR $14 921-$27 842] to $28 692 [IQR $19 236-$45 887]); and readmission rates increased 250% (5.5-13.9%), p<0.001 for all. Of all specific co-existing chronic conditions, malnutrition was associated with the greatest increase in postoperative hospital resource use. INTERPRETATION: Co-occurring conditions, and malnutrition in particular, are a significant risk factor for prolonged, in-hospital recovery after hip reconstruction surgery in children with a neurological CCC. Further investigation is necessary to assess how improved preoperative optimization of multiple co-occurring conditions may improve postoperative outcomes and resource utilization. WHAT THIS PAPER ADDS: Children with neurological complex chronic conditions (CCCs) often develop hip disorders which require hip reconstruction surgery. Co-occurring conditions are common in children with neuromuscular CCCs. Having four or more chronic conditions was associated with a longer length of stay, increased costs, and higher odds of readmission. Malnutrition was a significant risk factor for prolonged hospitalization after hip reconstruction surgery.

Changing practice patterns: the impact of a cost analysis project on surgeons' preference for treatment of pediatric displaced humeral lateral condyle fractures.

A 2012 publication regarding the surgical management of pediatric lateral humeral condyle fractures (PLHCF) found that leaving pins exposed produced an average savings of $3442 per patient compared to burying pins, with fewer complications. The primary objective of this present study was to determine the impact of this cost analysis on surgeons' treatment preferences at the same hospital. The secondary aim was to verify that leaving pins exposed continued to be a cost-effective and safe treatment strategy. We reviewed all PLHCF treated with open reduction and internal fixation at our institution between 2004 and 2017. The Clavien-Dindo Classification was used to grade complications. Variations in treatment course were evaluated using a chi-squared test to compare the proportions of buried and exposed pins, pre- and postcost analysis report publication. Two hundred forty-eight patients were included. The mean age was 5.9 years (range 1-12 years). In 174 (70%) cases, the pins were buried and in the remaining 30% the pins were exposed. Between 2004 and 2012, the majority of pins were buried (90%) compared to between 2013 and 2017, when the majority of pins were exposed (62%) (P < 0.001). There was no difference detected in complication rate (P = 0.75) or complication severity (P = 0.61) across groups. The demonstrated cost-effectiveness of exposing the pins in the treatment of PLHCF has had a statistically significant impact on surgeon behavior at our institution. Publishing cost analysis research can change physician practice to improve quality, safety and value of care delivery.

Early Career Experience of Pediatric Orthopaedic Fellows: What to Expect and Need for Their Services.

INTRODUCTION: A dramatic increase in the number of pediatric orthopaedic fellows being trained has led to concerns that there may be an oversupply of pediatric orthopaedists. The purpose of this study was to determine whether this perception is accurate and whether the practice expectations of recent pediatric fellowship graduates are being met by surveying recent pediatric fellowship graduates about their early practice experiences. METHODS: A 36-question survey approved by the Pediatric Orthopaedic Society of North America (POSNA) leadership was electronically distributed to 120 recent graduates of pediatric orthopaedic fellowships; 81 responses were ultimately obtained (67.5% response rate). RESULTS: Almost all (91%) of the respondents were very or extremely satisfied with their fellowship experience. Half of the respondents had at least 1 job offer before they entered their fellowships. After completion of fellowships, 35% received 1 job offer and 62.5% received ≥2 job offers; only 2.5% did not receive a job offer. Most reported a practice consisting almost entirely of pediatric orthopaedics, and 93.5% thought this was in line with their expectations; 87% indicated satisfaction with their current volume of pediatric orthopaedics, and 85% with the complexity of their pediatric orthopaedic cases. Despite the high employment percentages and satisfaction with practice profiles, nearly a third (28%) of respondents replied that too many pediatric orthopaedists are being trained. CONCLUSIONS: Positive messages from this survey include the satisfaction of graduates with their fellowship training, the high percentage of graduates who readily found employment, and the satisfaction of graduates with their current practice environments; this indicates that the pediatric orthopaedic job environment is not completely saturated and there are continued opportunities for graduating pediatric fellows despite the increased number of fellows being trained. Although not determined by this study, it may be that the stable demand for pediatric orthopaedic services is being driven by the expansion of the scope of practice as well as subspecialization within the practice of pediatric orthopaedics.

Uniplanar Versus Taylor Spatial Frame External Fixation For Pediatric Diaphyseal Tibia Fractures: A Comparison of Cost and Complications.

BACKGROUND: The purpose of this study was to compare the outcomes and cost variations between uniplanar (UNI) and Taylor Spatial Frame (TSF) external fixation for unstable pediatric tibial diaphyseal fractures. METHODS: We performed an IRB approved, retrospective review of 44 diaphyseal tibial fractures in 42 children treated with external fixation (16 TSF and 28 UNI) between 2003 and 2011, at a single level 1 pediatric trauma center. Data on demographic, clinical, radiographic, treatment cost, and complication differences were analyzed between the 2 groups. The Student t tests, Fisher's exact tests, χ trend tests, logistic regression, and a cost analysis comparison was used to assess the differences. RESULTS: The mean age in both groups was 13 years (range: 6 to 18 y TSF, 9 to 17 y UNI). The mean follow-up was 8 months (TSF) and 13 months (UNI). According to the AO classification, there were 28 type A, 13 type B, and 3 type C fractures with no significant difference between the 2 groups (P=0.69). Total time in the fixator was not different between the 2 groups (UNI 14 wk, TSF 12 wk, P=0.10), but time to union was less in the TSF group (UNI 16 wk, TSF 13 wk, P<0.01). There were no differences in the final radiographic alignment between the groups. The UNI group experienced more complications (7 pin-site infections and 9 reoperations) compared with 4 pin-site infections and 2 reoperations in the TSF group. A cost analysis revealed significant differences in equipment cost (UNI frame=$5074 vs. TSF frame=$10,675; P<0.0001); however, after corrected cost analysis with calculated return to the operating room for complications, there was no difference in cost of treatment (UNI treatment=$20,113 vs. TSF treatment=$19,138). CONCLUSIONS: Despite an initial equipment cost difference between UNI and TSF frames, corrected cost analysis reveals equivalent costs for care delivery. Therefore, TSF can be considered as a cost-conscious device for the treatment of unstable pediatric tibial diaphyseal fractures. LEVEL OF EVIDENCE: Level III-retrospective comparative cohort study.

Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

PURPOSE: The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF). METHODS: A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied. RESULTS: A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %. CONCLUSIONS: Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

Overcoming the funding challenge: the cost of randomized controlled trials in the next decade.

Randomized controlled trials (RCTs) represent the gold standard of evidence-based medicine. However, over the last several decades, the cost associated with conducting RCTs has increased dramatically. Several factors contribute to higher costs associated with clinical trials. This paper describes important barriers to conducting surgical RCTs, identifies funding sources available to finance RCTs, and suggests strategies to maintain cost-efficient study practices as we move into the next decade.