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PURPOSE OF REVIEW: Myths, widely held but false or unproven beliefs, exist in pediatric orthopedics, with the most common examples related to flexible flatfeet, in-toeing/out-toeing, W-sitting, and toe-walking. Concerns regarding these findings and suggested treatments, unfounded in science, may be passed along verbally or published through various media, without citation. The current review investigates these myths and provides up to date recommendations on diagnosis and treatment (or lack of necessary treatment) for these common pediatric orthopedic findings. RECENT FINDINGS: Orthotics used in childhood do not alter foot development for flexible flatfeet. W-sitting is not associated with developmental dysplasia of the hip, and there is no scientific evidence to support that it leads to contractures, hip dislocations, or functional deficits. SUMMARY: Misinformation about normal variants of growth in childhood and suggested treatments are rampant and can be found published through various media without citation, as supportive scientific studies do not exist or existing studies refute the claims. Flexible flatfeet, in-toeing/out-toeing, W-sitting, and toe-walking typically improve throughout childhood without intervention. Physical therapy, orthotics and bracing have not been proven effective. Treatment is required in rare scenarios and should be directed by the orthopedic surgeon.
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Pé Chato , Ortopedia , Criança , Humanos , Postura Sentada , Dedos do Pé , CaminhadaRESUMO
The electronic medical record (EMR) can reveal preferences of clinicians regarding imaging services. We sought to evaluate viewing habits for reports and images of musculoskeletal (MSK) studies by ordering clinicians. We hypothesized that MSK reports are important to clinical management, especially for advanced imaging modalities. We tracked the image and report access of all MSK studies ordered in September 2016 over 8 months using logs of the EMR (Epic Systems, Verona, WI), and by an independent analysis of the institutional PACS (Picture Archiving and Communication Systems) (Carestream Health, Rochester, NY). The time stamps were extracted for when images and reports were viewed. We categorized MSK studies by modality and provider department. We also compared the rates of viewing reports and images among different modalities and departments using the chi-square test. Of the 8143 viewed MSK studies, 7842 (96.3%) reports (with/without images) and 3916 (48.1%) imaging data (with/without reports) were viewed. Viewing reports alone occurred in 4227 (51.9%) studies. CT and MRI reports alone views occurred more often in comparison to radiographs ([482/706; 68.3%] for CT and [981/1713; 57.3%] for MRI vs. [2764/5724; 48.3%] for radiography, p < 0.001). Orthopedists ordered the highest number of MSK studies and viewed reports 99.2% (3216/3242) of the time, including a 54.6% (1770/3242) rate of viewing reports alone and a 44.6% (1446/3242) rate of viewing both reports and images. They viewed images without reports in 0.8% (27/3242) of cases. MSK reports were viewed significantly more frequently than the images across all modalities and all relevant specialties.
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Radiologia , Sistemas Computacionais , Registros Eletrônicos de Saúde , Humanos , Radiografia , Sistemas de Informação em RadiologiaRESUMO
Purpose: As stakeholders seek to improve patient outcomes while maintaining cost-effectiveness in an increasingly expensive healthcare system, metrics such as patient satisfaction are becoming more important. This present study sought to identify factors associated with and independently predictive of better surgical satisfaction two years following hand and wrist surgery. Methods: Patients undergoing hand and wrist surgery at an urban outpatient institution were enrolled preoperatively into a surgical registry and assessed two years postoperatively. Patient satisfaction with surgery was measured at two years postoperatively with the Surgical Satisfaction Questionnaire (SSQ-8). Bivariate analysis determined associations between postoperative satisfaction and patient demographics, injury specifiers, medical history, and multiple patient-reported outcomes (PROs). Multivariable analysis determined independent predictors of two-year postoperative satisfaction following hand and wrist surgery. Results: Better surgical satisfaction was associated with having never smoked, no preoperative opioid use, lack of an accompanying legal claim, lack of a workers compensation claim, no clinical history of depression/anxiety, less comorbidities, and higher preoperative expectations.Various PROs relating to function, pain, activity, and general health at both baseline and two years demonstrated associations with postoperative satisfaction. Multivariable analysis confirmed that never smoking, lack of a legal claim, and better preoperative Brief Michigan Hand Questionnaire scores were independently predictive of better surgical satisfaction two years following hand and wrist surgery. Conclusion: At two years following hand and wrist surgery, better patient satisfaction was best predicted by never smoking, no related legal claim, and better baseline Brief Michigan Hand Questionnaire scores. Level of evidence: III.
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OBJECTIVES: The purpose of this study was to define the rate of preoperative opioid use among patients undergoing hip arthroscopy, ascertain which clinical factors are associated with opioid use, and assess the effect of preoperative opioid usage on preoperative patient-reported outcome (PRO) measures. METHODS: A single institution orthopedic registry was retrospectively analyzed for patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) syndrome with or without labral tear between 2015 and 2022. Patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Scores (NPS), and Musculoskeletal Outcomes Data Evaluation and Management System expectations domain preoperatively. Patients' charts were reviewed to determine demographic factors and identify any active opioid prescription within 6 weeks before surgery. Bivariate analysis was used to determine associations between preoperative opioid use and baseline PROs. Statistically significant bivariate associations were further tested by multivariate analysis to determine independent predictors. RESULTS: A total of 123 patients were included (age 39.7 â± â12.0 years; 87 females; body mass index 27.4 â± â5.7 kg/m2). There were 21 patients (17%) using opioids preoperatively. Prior orthopedic or other surgery and lower education level were associated with preoperative opioid use. Patients with preoperative opioid use scored statistically significantly worse compared with those without preoperative opioid use on baseline PROMIS Physical Function (38.6 vs 40.5, p â= â0.01), Pain Interference (65.9 vs 60.2, p â= â0.001), Fatigue (60.7 vs 51.6, p â= â0.005), Social Satisfaction (38.2 vs 43.2, p â= â0.007), and Depression (54.2 vs 48.8, p â= â0.01). Preoperative opioid use was also associated with statistically significantly worse preoperative NPS for both the operative hip (6.3 vs 4.6, p â= â0.003) and whole body (3.0 vs 1.4, p â= â0.008). Preoperative opioid use was an independent predictor of worse baseline PROMIS Pain Interference, Fatigue, Social Satisfaction, and NPS for the operative hip. CONCLUSION: Patients using opioids preoperatively had worse baseline PROs for physical function, pain, social satisfaction, and depression than those not using opioids preoperatively. When controlling for confounding variables, preoperative opioid use was independently predictive of worse baseline pain, fatigue, and social satisfaction. LEVEL OF EVIDENCE: Level III, prognostic study.
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Analgésicos Opioides , Artroscopia , Impacto Femoroacetabular , Medidas de Resultados Relatados pelo Paciente , Humanos , Feminino , Analgésicos Opioides/uso terapêutico , Masculino , Adulto , Artroscopia/métodos , Estudos Retrospectivos , Impacto Femoroacetabular/cirurgia , Pessoa de Meia-Idade , Período Pré-Operatório , Medição da Dor , Articulação do Quadril/cirurgia , Sistema de Registros , Cuidados Pré-Operatórios/métodos , Dor Pós-Operatória/tratamento farmacológicoRESUMO
BACKGROUND: The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores. METHODS: This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores. RESULTS: Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI. CONCLUSION: Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.
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A 12-year-old boy presented to the pediatric emergency department with a 5-day history of atraumatic, progressively worsening right hip pain and inability to ambulate. He was afebrile and had elevated inflammatory markers (Erythrocyte Sedimentation Rate [ESR]: 42 mm/hr, C-Reactive Protein [CRP]: 6.6 mg/dL) with a normal white blood cell count of 6050 cells/mm3. Given the clinical concern for septic arthritis, joint aspiration of the right hip was done and demonstrated a bloody appearance with a WBC count of 54,999 cells/mm3 and RBC count of 7,000 cells/mm3. MRI of the right hip demonstrated an intra-articular mass suggestive of tenosynovial giant cell tumor/pigmented villonodular synovitis. Subsequent biopsy and excision of the mass confirmed the diagnosis. The acute presentation of tenosynovial giant cell tumor with features mimicking septic arthritis is uncommon. This rare presentation of an already uncommon diagnosis should be considered in a child with an equivocal presentation for severe hip pain because misdiagnosis may lead to unnecessary or inadequately planned surgical treatment of the condition.
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Artrite Infecciosa , Tumor de Células Gigantes de Bainha Tendinosa , Sinovite Pigmentada Vilonodular , Artrite Infecciosa/diagnóstico , Artrite Infecciosa/cirurgia , Sedimentação Sanguínea , Criança , Tumor de Células Gigantes de Bainha Tendinosa/diagnóstico por imagem , Tumor de Células Gigantes de Bainha Tendinosa/cirurgia , Humanos , Masculino , DorRESUMO
INTRODUCTION: Healthcare regulators and patients are increasingly interested in financial transparency between physicians and the industry because of concerns of bias. METHODS: Disclosures for every first and last author with a medical degree from the United States associated with a poster or podium presentation at the American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting were identified. Author characteristics were collected. AAOS disclosures were then compared with disclosures from the Open Payments Database to determine whether any inconsistencies existed. RESULTS: In total, 2,503 AAOS presenters were identified, and 1,380 authors met the inclusion criteria. Using AAOS disclosures as the standard comparator, 482 authors (35%) had an inconsistency in any category between AAOS disclosures and the Open Payments Database. Inconsistency rates for each category were 8% for royalties, 10% for speaker's fee, 15% for paid consultant, 16% for research, 14% for stocks, and 1% for other financial support. DISCUSSION: Although the inconsistency rate for each category has improved over the years, the overall inconsistency rate between physician-reported disclosures at a recent AAOS Annual Meeting and industry-reported relationships reported in the Open Payments Database was still 35%.
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Cirurgiões Ortopédicos , Médicos , Conflito de Interesses , Revelação , Humanos , Indústrias , Estados UnidosRESUMO
OBJECTIVE: To compare outcome metrics of digital breast tomosynthesis (DBT) breast cancer screening with full-field digital mammogram (FFDM); specifically, to compare recall rates by the type of recalled finding, and to assess if screening with DBT versus FFDM changes biopsy recommendations and if the likelihood of malignancy varied by lesion type, if detected on DBT or FFDM screening mammogram. METHODS: The outcomes of 22,055 FFDM and DBT screening mammograms were retrospectively reviewed. The exams were performed at an academic institution between August 2015 and September 2016. Performance of screening with FFDM versus DBT was compared in terms of recall rate and percentage of recalled lesions resulting in a cancer diagnosis, with subset analyses performed for specific mammographic findings. RESULTS: The recall rate was 10.6% for FFDM and 8.0% for DBT (p < 0.001). Architectural distortion was more likely to be recalled on DBT screening than FFDM (p = 0.002), and was associated with an increased likelihood of malignancy (p = 0.008). Asymmetries were less likely to be recalled on DBT than FFDM (p < 0.001) screening mammogram, but more likely to be recommended for biopsy when detected on DBT. Calcifications more frequently required short-term follow-up or biopsy on both DBT and FFDM. CONCLUSIONS: DBT screening confers an advantage in detection of architectural distortion representing malignancy. Recall rate of asymmetries are reduced with screening DBT, probably due to reduction of tissue superimposition. Calcifications pose a particularly difficult diagnostic challenge for breast imagers, regardless of screening mammogram type.
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Neoplasias da Mama , Mamografia , Mama/diagnóstico por imagem , Neoplasias da Mama/diagnóstico por imagem , Detecção Precoce de Câncer , Feminino , Humanos , Programas de Rastreamento , Estudos RetrospectivosRESUMO
RATIONALE AND OBJECTIVES: Our objective was to identify factors impacting false positive recalls in screening mammography. MATERIALS AND METHODS: We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features. RESULTS: A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index. CONCLUSION: FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.
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Neoplasias da Mama/diagnóstico , Mama/diagnóstico por imagem , Detecção Precoce de Câncer , Mamografia/métodos , Programas de Rastreamento/métodos , Adulto , Biópsia , Índice de Massa Corporal , Densidade da Mama , Reações Falso-Positivas , Feminino , Humanos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: The radiology report serves as the primary means of communication between radiologist and clinician. However, the value clinicians place on imaging and reports is variable, with many images of studies or their reports never being viewed. This has implications on the perceived value of the radiologist in the imaging chain. We hypothesized that neurologists, neurosurgeons, and otolaryngologists would view neuroradiology images most frequently and neuroradiology reports least frequently of all medical specialties. MATERIALS AND METHODS: Ordering data were collected on all neuroradiology studies over a 1-month period. Imaging study date and time stamps were obtained for (1) when imaging study orders were placed, (2) when the patient underwent the imaging study, (3) when the imaging studies were viewed, and (4) when the radiology reports were accessed and by whom. Each data point included provider names, locations, departments, and level of training. RESULTS: There were 7,438 imaging neuroradiology studies ordered. Overall, 85.7% (6,372) of reports and 53.2% (3,956) of imaging studies were viewed and 13.1% (977) of studies had neither images nor reports viewed. Inpatient neurosurgeons and neurologists viewed both imaging and reports significantly more than primary care specialties (P < .001). In the outpatient setting, this trend stayed true for neurosurgeons though was not true for neurologists (P < .001). Outpatient study imaging and reports were both viewed the least (48.6%), and inpatient study reports were viewed the most (95.2%; P < .001). CONCLUSION: Viewing of imaging and reports varies with neurosurgeons viewing neuroradiology studies more than all other medical specialties. Overall, the reports were viewed significantly more than the images, suggesting that the radiologist and his or her interpretation are more valuable than the study's images. The radiologists' value, as measured by reports viewed, was maximal with obstetricians and gynecologists and psychiatry clinicians.
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Acesso à Informação , Documentação/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Comunicação Interdisciplinar , Neurorradiografia , Radiologistas/estatística & dados numéricos , Sistemas de Informação em Radiologia/estatística & dados numéricos , Humanos , Revisão da Utilização de Recursos de SaúdeRESUMO
PURPOSE: We examined the impact of an MR scanner in the emergency department (ED) on ED length of stay (LOS), hospital (H) LOS, hospital admission rate, hospitalization costs, and ED re-presentation rate of patients presenting with stroke-like symptoms (SLS). We hypothesized that the ED MR would increase efficiency of patient care. METHODS: The number of MRIs performed in the ED vs. inpatient setting, EDLOS, HLOS, hospitalization charges, admission rate, discharge diagnoses, and 30-60-day ED re-presentation rates were determined for ED patients with SLS six months before (2011) and after (2012) ED MR installation. RESULTS: 362 and 448 patients with SLS presented to the ED, and 196 and 176 patients were admitted in 2011 and 2012 respectively. In 2011, 36 (18.4%) admitted patients, and, in 2012, 68 (38.6%) had MRIs in the ED, p<0.001. In 2011, 74 (37.8%) admitted patients were diagnosed with ischemic stroke, compared to 92 (52.3%) in 2012, p=0.007. HLOS was longer and charges higher for patients with stroke. No patients returned with a confirmed diagnosis of CVA or TIA within 0-60days after being discharged from the ED with negative MR. CONCLUSIONS: With the ED MR, more admitted patients 1) got scanned in the ED and 2) were diagnosed with stroke. Because this led to more patients on the stroke service actually suffering from strokes (and not other diagnoses), the overall HLOS and charges of patients presenting with SLS were not reduced by ED MR screening. Discharge after a negative ED MR did not incur risk of TIAs or strokes over the ensuing 60days. Therefore, not only does a dedicated MR scanner in the ED aid in the acute diagnosis of a CVA or other neurologic disorder, but it does so without the risk of under-diagnosing TIAs or evolving strokes in the presence of a negative MRI.