Are Generative Pretrained Transformer 4 Responses to Developmental Dysplasia of the Hip Clinical Scenarios Universal? An International Review.

OBJECTIVE: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings. METHODS: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care. RESULTS: GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 ( P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores ( P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions ( P = 0.034). CONCLUSIONS: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation. LEVEL OF EVIDENCE: Level IV.

A Comparison Between 3 Functional Hip Scores for Evaluation of the Pediatric Hip.

BACKGROUND: This investigation aimed to determine the degree of correlation among 3 functional scales for evaluating the hip in pediatric patients and determine the correlation between measures of global function and outcome. METHODS: We performed a prospective study of 173 consecutive patients (M age = 13 ± 3 y) being followed for developmental dysplasia of the hip (n = 122, 71%), slipped capital femoral epiphysis (n = 31, 18%), or Legg-Calve-Perthes disease (n = 20, 12%). We evaluated patients clinically, and we compiled scores for the Iowa Hip Score (IHS), Harris Hip Score (HHS), and Children's Hospital Oakland Hip Evaluation Scale (CHOHES). Patients concomitantly completed the Pediatric Outcomes Data Collection Instrument (PODCI) at the same clinic visit. We assessed Global Functioning Scale the and the Sports and Physical Functioning Core Scale of the PODCI. We determined the degree of correlation between the functional hip scales and between each scale and the PODCI scales using Spearman rank correlation coefficients. RESULTS: The correlations between the IHS, HHS, and CHOHES scores were robust (IHS and HHS ρ = 0.991; IHS and CHOHES ρ = 0.933; HHS and CHOHES ρ = 0.938; all P < 0.001). The correlation between the Global Functioning Scale of the PODCI and the 3 hip scores was ρ = 0.343 for the IHS, ρ = 0.341 for the HHS, and ρ = 0.352 for the CHOHES (all P < 0.001). The correlation between the sports and physical functioning core scale of the PODCI and the 3 hip scores was ρ = 0.324 for the IHS, ρ = 0.329 for the HHS, and ρ = 0.346 for the CHOHES (all P < 0.001). CONCLUSIONS: In a pediatric population with diverse hip pathology, there was a very strong correlation between scores on the IHS, HHS, and CHOHES. However, none of these 3 most commonly used hip scores correlated strongly with the global functioning scale or sports and physical functioning core scale of the PODCI. The most frequently used scores to determine the outcome of pediatric patients with hip pathology correlate strongly with each other but do not necessarily relate to global functional results. LEVEL OF EVIDENCE: Level IV.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study.

BACKGROUND: It is estimated that 11% to 60% of unilateral slipped capital femoral epiphysis (SCFE) patients will develop contralateral pathology, usually within 18 months after the first event. Despite this, prophylactic fixation remains controversial, and there is significant variability in surgeon preferences. Thus, this study aimed to determine which factors predict surgeon preferences for prophylactic contralateral pinning in SCFE patients. METHODS: We designed a survey for pediatric orthopedic surgeons to collect data on (1) surgeon and hospital characteristics, (2) individual preference for contralateral SCFE pinning in three disparate hypothetical scenarios, and (3) personal risk-aversion traits. The questionnaire was distributed across the United States by the POSNA Evidence-Based Orthopaedics Committee. All POSNA members were eligible to respond. We performed analyses to evaluate the role of patient risk factors in hypothetical surgical decision-making and to determine if surgical training, hospital characteristics, and geographic region influenced prophylactic pinning in a surgeon's real-life practice. RESULTS: A total of 126 POSNA members responded to the survey. In the last year, a median of 6.5 SCFE patients was seen per surgeon (1243 patients total). A median of 10% of those patients underwent prophylactic contralateral fixation. In multiple analyses, surgeons were influenced by body mass index, open triradiate cartilage, patient race, various endocrine abnormalities, and specific radiographic measurements when deciding to fix the contralateral side prophylactically. Moreover, in multivariate regression, more years in practice and a hospital size of 500+ beds predicted fewer prophylactic fixation procedures (all P <0.05). Surgeons practicing in the South Atlantic, New England, and Mountain regions of the United States estimated the highest rate of contralateral pinning. CONCLUSIONS: This study's findings suggest that multiple factors influence surgeons' decisions to prophylactically fix the contralateral side in SCFE patients. Surgical training, hospital characteristics, and geographical regions played a role in decision-making. LEVEL OF EVIDENCE: N/A.

Effect of a Protocol to Reduce Radiographic Imaging in Pediatric Patients With Suspected Fractures.

BACKGROUND: Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS: Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS: After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 ( P <0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P <0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P =0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P <0.01). CONCLUSION: A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Chitosan Nanoparticles as Oral Drug Carriers.

The use of nanoparticles as drug delivery systems has increased in importance in the last decades. Despite the disadvantages of difficulty swallowing, gastric irritation, low solubility, and poor bioavailability, oral administration stands out as the most widely used route for therapeutic treatments, though it may not always be the most effective route. The effect of the first hepatic pass is one of the primary challenges that drugs must overcome to carry out their therapeutic effect. For these reasons, controlled-release systems based on nanoparticles synthesized from biodegradable natural polymers have been reported to be very efficient in enhancing oral delivery in multiple studies. Chitosan has been shown to have an extensive variability of properties and roles in the pharmaceutical and health fields; of its most important properties are the ability to encapsulate and transport drugs within the body and enhance the drug interaction with the target cells, which improves the efficacy of the encapsulated drugs. The physicochemical properties of chitosan give it the ability to form nanoparticles through multiple mechanisms, which will be addressed in this article. The present review article focuses on highlighting the applications of chitosan nanoparticles for oral drug delivery.

The Art of Negotiation: Avoiding Positional Bargaining and Getting to Yes.

Effective negotiation is a crucial part of almost every aspect of life. One should never consider conflict a "zero-sum" game; negotiation is necessary. This paper first explains how negotiation is a part of pediatric orthopaedic practice, highlights some of the reasons negotiations break down, and discusses ways to avoid these breakdowns by applying proven techniques.

What is the Interobserver Reliability of an Ultrasound-enhanced Physical Examination of the Hip in Infants? A Prospective Study on the Ease of Acquiring Skills to Diagnose Hip Dysplasia.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common disorder found in newborns. The consequences of DDH can be mitigated with early diagnosis and nonoperative treatment, but existing approaches do not address the current training deficit in making an early diagnosis. QUESTION/PURPOSE: Can ultrasound be taught to and used reliably by different providers to identify DDH in neonates? METHODS: This was a prospective observational study of a series of neonates referred for an evaluation of their hips. An experienced clinician trained three second examiners (a pediatric orthopaedic surgeon, an orthopaedic resident, and a pediatrician) in performing an ultrasound-enhanced physical examination. The 2-hour training process included video and clinical didactic sessions aimed to teach examiners to differentiate between stable and unstable hips in newborns using ultrasound. The experienced clinician was a pediatric orthopaedic surgeon who uses ultrasound regularly in clinical practice. Materials required for training include one ultrasound device. A total of 227 infants (454 hips) were examined by one of the three second examiners and the experienced clinician (gold standard) to assess reliability. Of the 454 hips reviewed, there were 18 dislocations, 24 unstable hips, and 63 dysplastic hips, and the remainder had normal findings. The cohort was composed of a series of patients younger than 6 months referred to a specialty pediatric orthopaedic practice. RESULTS: Ultrasound-enhanced physical examination of the hip was easily taught, and the results were reliable among different levels of providers. The intraclass correlation coefficient between the gold-standard examiner and the other examiners for all hips was 0.915 (p = 0.001). When adjusting for only the binary outcome of normal versus abnormal hips, the intraclass correlation coefficient was 0.97 (p = 0.001). Thus, the agreement between learners and the experienced examiner was very high after learners completed the course. CONCLUSION: After a 2-hour course, physicians were able to understand and reliably examine neonatal children using ultrasound to assess for DDH. The success of the didactic approach outlined in this study supports the need for ultrasound-enhanced examination training for the diagnosis of DDH in orthopaedic surgery and pediatric residency core curriculums. Training programs would best be supported through established residency programs. Expansion of training more residents in the use of ultrasound-enhanced physical examinations would require a study to determine its efficacy. This finding highlights the need for further research in implementing ultrasound-enhanced physical examinations on a broader scale. LEVEL OF EVIDENCE: Level II, diagnostic study.

Is There a Benefit to Weaning Pavlik Harness Treatment in Infantile DDH?

BACKGROUND: Following successful treatment of developmental hip dysplasia with a Pavlik harness, controversy exists over the benefit of continued harness use for an additional "weaning" period beyond ultrasonographic normalization versus simply terminating treatment. Although practitioners are often dogmatic in their beliefs, there is little literature to support the superiority of 1 protocol over the other. The purpose of this study was to compare the radiographic outcomes of 2 cohorts of infants with developmental hip dysplasia treated with Pavlik harness, 1 with a weaning protocol and 1 without. METHODS: This was a comparative review of patients with dislocated/reducible hips and stable dysplasia from 2 centers. All patients had pretreatment ultrasounds, and all started harness treatment before 3 months of age. On the basis of power analysis, a sufficient cohort of hips were matched based on clinical examination, age at initiation, initial α angle, and initial percent femoral head coverage. Patients from institution W (weaned) were weaned following ultrasonographic normalization, whereas those from institution NW (not weaned) immediately ceased treatment. The primary outcome was the acetabular index at 1 year of age. RESULTS: In total, 16 dislocated/reducible and 16 stable dysplastic hips were matched at each center (64 total hips in 53 patients). Initial α angle and initial femoral head coverage were not different between cohorts for either stable dysplasia (P=0.59, 0.81) or dislocated/reducible hips (P=0.67, 0.70), respectively. As expected, weaned hips were treated for significantly longer in both the stable dysplasia (1540.4 vs. 1066.3 h, P<0.01), and dislocated/reducible cohorts (1596.6 vs. 1362.5 h, P=0.01). Despite this, we found no significant difference in the acetabular index at 1 year in either cohort (22.8 vs. 23.1 degrees, P=0.84 for stable dysplasia; 23.9 vs. 24.8 degrees, P=0.32 for Ortolani positive). CONCLUSIONS: Despite greater total harness time, infants treated with additional Pavlik weaning did not demonstrate significantly different radiographic results at 1 year of age compared with those who were not weaned. However, differences in follow-up protocols between centers support the need for a more rigorous randomized controlled trial. LEVEL OF EVIDENCE: Level III.

Has There Been a Change in the Age of Presentation of Patients With DDH After the Implementation of a Dedicated Ultrasound-screening Program?

BACKGROUND: We sought to determine if the age of patients presenting to a tertiary subspecialty hospital dedicated to pediatric orthopaedics has changed over the last 21 years and determine if a dedicated ultrasound-screening program implemented in 2006 made any difference. METHODS: We reviewed the hospital charts for 9299 patients diagnosed with developmental dysplasia of the hip (DDH) and determined the age at the time of presentation; this was a consecutive series of all patients presenting between 1998 and 2019. We determined the diagnosis and age from the chart, 8011 were female (86.15%), and 1288 were male (13.85%). The left hip was affected in 4588 cases (49.34%), the right hip in 1824 cases (19.62%), and there were 2887 bilateral cases (31.05%). RESULTS: Over the 21 years, the mean age of presentation was 2.36 years (range, 0.1 to 17 y). In 1998, the mean age was 2.49 years (range, 0.1 to 16 y). In 2006, a dedicated ultrasound-screening clinic was instituted. The mean age decreased to 1.70 years in 2019 (range, 0.1 to 14 y). The mean age at presentation decreased significantly from 2.65 years, between 1998 and 2005, to 2.19 between 2006 and 2019 (P=0.0067). CONCLUSIONS: The implementation of a dedicated ultrasound-screening protocol was significantly correlated with a decrease in the mean age of diagnosis of DDH. The results of treatment of DDH are known to be better the sooner the diagnosis is made. Given that the age of presentation remains a challenge, especially in developing countries, a dedicated ultrasound-screening program is one step to improve our ability to detect DDH in patients at a younger age. LEVEL OF EVIDENCE: Level IV-diagnostic.

Modified Oxford Bone Scores Are Reduced in Patients With Slipped Capital Femoral Epiphysis Compared With Healthy Controls.

BACKGROUND: The etiology and pathogenesis of slipped capital femoral epiphysis (SCFE) are attributable to abnormalities of the proximal femoral epiphysis. This study aimed to examine if there is a difference in the bone age of patients diagnosed with SCFE compared with patients without hip pathology. METHODS: We identified a consecutive series of patients treated for SCFE between December 2012 and December 2019 from a departmental database. Retrospective chart review was performed to collect demographic information and patient medical history. We then obtained a control group of statistically similar patients based on age and sex. These patients did not have hip pathology or medical comorbidities that could alter their bone age. The modified Oxford bone score (mOBS) was calculated for both groups by 3 blinded reviewers. We excluded patients with unstable slips, endocrine disorders, and inadequate imaging. RESULTS: We identified 60 patients with stable idiopathic SCFE during the study period; 45 met inclusion criteria and were included in the final analysis. There were 27 males and 18 females. The average age of patients with SCFE was higher in males than females (12.6 vs. 11.1, P<0.01). Patients in the comparison cohort did not differ significantly from the SCFE cohort in terms of age (11.6 vs. 12.0, P=0.06) or sex (P=0.52). The comparison group's median mOBS was significantly higher than the SCFE group (22.5 vs. 20.5, P<0.01). The difference in the mOBS between male and female patients in the SCFE group approached significance (20.0 vs. 21.0, P=0.05). The weighted κ coefficient was 0.93. CONCLUSIONS: Patients with SCFE have a decreased bone age compared with patients without hip pathology. Male patients with SCFE were more likely to be older compared with female patients. LEVEL OF EVIDENCE: Level IV-retrospective study.

What Are the Rate and Risk Factors for Developing a Complication With the Pavlik Method for the Treatment of Hip Dysplasia?

BACKGROUND: The Pavlik method for the treatment of developmental dysplasia of the hip (DDH) has been proven successful for over 85 years. The high success rate and reproducibility have made it the mainstay of treatment. METHODS: We performed a retrospective cohort study of patients with DDH treated with the Pavlik method between September 2016 and August 2018 with at least 24 months of follow up in a single academic center. We excluded patients with neuromuscular conditions, teratologic dislocations, and arthrogryposis. We identified and included a total of 307 patients in the analysis. There were 66 patients with dysplasia, 97 with instability, and 144 with a dislocation. Data collected included age at initiation of the Pavlik method, diagnosis (isolated dysplasia, subluxation, or dislocation), duration of treatment, follow up duration and any complication. At final follow up, anteroposterior radiographs of the pelvis were used to determine the Severin classification. RESULTS: Major complications were proximal femoral growth disturbance (5.8%) and femoral nerve palsy (0.98%). Multivariate analysis showed that an initial diagnosis of a dislocated hip (odds ratio, 2.20; P<0.01), was significantly associated with developing a complication. At final follow up, we found Severin type I or II radiographic findings in 100% of patients with dysplasia, 95% of patients with instability and 54% of patients with dislocation (P=0.001). CONCLUSIONS: Complications are not entirely uncommon when the Pavlik method is used for the treatment of DDH. The overall rate of major complications was 7%. The Pavlik method is safe, and independent risk factors for complications were being over 5 months of age and having a dislocated hip at initial presentation. LEVEL OF EVIDENCE: Level IV-cohort study.

Isolated Trochanteric Descent and Greater Trochanteric Apophyseodesis Are Not Effective in the Treatment of Post-Perthes Deformity.

BACKGROUND: Greater trochanteric apophyseodesis and isolated trochanteric descent seek to prevent abductor weakness in patients with a hip deformity because of Legg-Calvé-Perthes disease; however, no studies have evaluated radiographic findings or abductor strength in children treated with these procedures. QUESTIONS/PURPOSES: (1) Do children with Waldenström Stage III Legg-Calvé-Perthes disease treated with either isolated greater trochanteric descent or isolated greater trochanteric apophyseodesis achieve improved radiographic findings (Stulberg classification or neck-shaft angle) compared with those who underwent no surgical treatment? (2) Do children treated with one of those procedures achieve greater abductor strength than those who did not have surgery? METHODS: Between 2006 and 2010, we treated 89 children with Waldenström Type III Legg-Calvé-Perthes disease (reossification). Of these, 27.9% (12 patients) underwent greater trochanteric descent, 25.6% (11 patients) underwent greater trochanteric apophyseodesis, and 46.5% (20 patients) did not have surgery. During that time, the decision to perform either apophyseodesis or trochanteric descent was made by the surgeon based on the subjective appearance of remaining growth from the greater trochanter. Nonsurgical management was chosen by the parents of the patients after the risks and benefits of surgery were discussed. During greater trochanteric descent, the greater trochanter was osteotomized and fixed distally with two 7.0-mm screws. During greater trochanteric apophyseodesis, the physis was identified fluoroscopically, and the lateral half of the growth plate was drilled. Nonoperative treatment involved serial clinical and radiographic evaluations every 3 to 6 months. All children in all groups were available for follow-up at a minimum of 6 years. The median follow-up durations for children undergoing greater trochanteric descent, greater trochanteric apophyseodesis, and control cohorts were 6.6 years (range 6.0-8.2 years), 6.5 years (range 6.1-9.2 years), and 7.4 years (range 6.0-9.1 years), respectively. On presentation, each patient's affected hip was classified according to the Stulberg classification by the operating surgeon and an orthopaedic surgeon not involved in the child's care. The neck-shaft angle was measured for each patient before surgery and at the final follow-up examination. Abductor strength was assessed by a pediatric orthopaedic fellow and a physical therapist with the patient in the lateral decubitus position. Each patient was given a muscle strength score on a scale of 0 to 10 points, per a modification of the Medical Research Council scale to allow for a narrower range. We had 80% power to detect an 8° difference in the neck-shaft angle between the greater trochanteric apophyseodesis and nonoperative management cohorts. A sample size of 6.8 patients per cohort would be necessary to detect the above endpoint. RESULTS: With the numbers available, we found no differences among the groups in the proportion of patients with Stulberg Class 2 femoral heads (two of 12 patients in the isolated trochanteric descent group, three of 11 in the isolated trochanteric apophyseodesis group, and two of 20 who did not undergo surgery; p = 0.46). Likewise, there were no differences among the three groups in terms of the neck-shaft angle at a minimum of 6 years of follow-up (122° ± 6°, 119° ± 7°, and 126° ± 8° in the isolated trochanteric descent, isolated trochanteric apophyseodesis, and nonoperative groups, respectively). There were no differences among the groups in term of the median abductor strength test result: seven of 10 (range 6-8), six of 10 (range 6-8), and six of 10 (range 6-10; p = 0.34). CONCLUSION: Because neither isolated greater trochanteric descent nor greater trochanteric apophyseodesis alone had an effect on hip morphology or abductor strength in children with sequellae of Legg-Calvé-Perthes disease, we conclude these types of extraarticular surgery are ineffective. Therefore, we no longer perform isolated trochanteric descent or apophyseodesis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Microneedles as Enhancer of Drug Absorption Through the Skin and Applications in Medicine and Cosmetology.

The microneedles technology has found applications in many health-related fields. For example, their application in drugs and vaccines delivery as well, as the determination of biomarkers, has been reported. They also have a place in the dermatology and cosmetic areas such as the treatment of wounds from burns, scars, acne, depigmentation, and alopecia will be shown. Microneedles are used in therapeutic applications and are manufactured using materials such as metal (steel, titanium, nickel), polymer (oly-glycolic acid (PGA), poly-lactide-co-glycolide acid (PLGA), poly-L-lactic acid (PLA), chitosan), glass, silicon, ceramic, carbohydrates (trehalose, sucrose, mannitol). Examples of application of microneedles and their advantages and disadvantages are discussed. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

How Often Does Femoroacetabular Impingement Occur After an Innominate Osteotomy for Acetabular Dysplasia?

BACKGROUND: Femoroacetabular impingement is increasingly recognized as a cause of hip pain but its incidence after an innominate osteotomy for the correction of acetabular dysplasia has not been determined. This information would be essential for the orthopaedic surgeon because it has the potential to produce a poor outcome in the long term when trying to balance acetabular instability and overcorrection. QUESTIONS/PURPOSES: The purposes of our study were (1) to determine the frequency with which clinically relevant femoroacetabular impingement (FAI) occurs after an innominate osteotomy for the treatment of acetabular dysplasia; (2) to determine risk factors for the development of FAI; and (3) to compare postoperative radiographic and clinical outcomes in patients having undergone an innominate osteotomy for the correction of acetabular dysplasia both with and without FAI. METHODS: This was a retrospective review of 154 hips (132 patients) that had undergone an innominate osteotomy for acetabular dysplasia and were evaluated at a minimum followup of 10 years (mean = 12 years). Mean age at the time of surgery was 3 years, 114 hips had a concomitant open reduction, and 54 hips also had femoral shortening. One hundred eight hips had a Salter osteotomy and 46 had a Pemberton osteotomy. Radiographs were analyzed to determine the lateral center-edge angle (CE angle) and the presence of a crossover sign. The diagnosis of FAI was established when the CE angle was greater than 40°, there was a positive crossover sign, and the patient had groin pain when flexing the hip less than 90°. Comparisons between nonparametric variables were performed with a Mann-Whitney's U test. Categorical variables were compared with a chi-square test. Change in acetabular index (correction) was dichotomized considering 20° of correction as the cutoff point. Association is presented as odds ratio (95% confidence interval), and logistic regression was performed. RESULTS: According to our criteria, 18 of 154 hips had FAI (12%). Of the 18 patients with FAI, 10 had undergone a Pemberton osteotomy (10 of 46 [22%]) and eight a Salter osteotomy (eight of 108 [7%]). A change in the postoperative acetabular index greater than 20° was associated with a greater likelihood of developing FAI. The mean postoperative acetabular index was lower for the group with FAI, for whom it was 20°, compared with the group without FAI, for whom it was 27° (p = 0.04). The mean Iowa Hip Score for the group with FAI was 85, whereas for those without FAI, it was 93 (p = 0.03). CONCLUSIONS: FAI is not common after an innominate osteotomy for the treatment of acetabular dysplasia; however, overcorrection is related to a higher incidence. When FAI is present, it can affect the outcome. Overcorrection should be avoided when performing an innominate osteotomy for the treatment of acetabular dysplasia because it can create iatrogenic FAI and have an adverse effect on outcome. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

BACKGROUND: Little information exists concerning the variability of presentation and differences in treatment methods for developmental dysplasia of the hip (DDH) in children < 18 months. The inherent advantages of prospective multicenter studies are well documented, but data from different centers may differ in terms of important variables such as patient demographics, diagnoses, and treatment or management decisions. The purpose of this study was to determine whether there is a difference in baseline data among the nine centers in five countries affiliated with the International Hip Dysplasia Institute to establish the need to consider the center as a key variable in multicenter studies. QUESTIONS/PURPOSES: (1) How do patient demographics differ across participating centers at presentation? (2) How do patient diagnoses (severity and laterality) differ across centers? (3) How do initial treatment approaches differ across participating centers? METHODS: A multicenter prospective hip dysplasia study database was analyzed from 2010 to April 2015. Patients younger than 6 months of age at diagnosis were included if at least one hip was completely dislocated, whereas patients between 6 and 18 months of age at diagnosis were included with any form of DDH. Participating centers (academic, urban, tertiary care hospitals) span five countries across three continents. Baseline data (patient demographics, diagnosis, swaddling history, baseline International Hip Dysplasia Institute classification, and initial treatment) were compared among all nine centers. A total of 496 patients were enrolled with site enrolment ranging from 10 to 117. The proportion of eligible patients who were enrolled and followed at the nine participating centers was 98%. Patient enrollment rates were similar across all sites, and data collection/completeness for relevant variables at initial presentation was comparable. RESULTS: In total, 83% of all patients were female (410 of 496), and the median age at presentation was 2.2 months (range, 0-18 months). Breech presentation occurred more often in younger (< 6 months) than in older (6-18 months at diagnosis) patients (30% [96 of 318] versus 9% [15 of 161]; odds ratio [OR], 4.2; 95% confidence interval [CI], 2.3-7.5; p < 0.001). The Australia site was underrepresented in breech presentation in comparison to the other centers (8% [five of 66] versus 23% [111 of 479]; OR, 0.3, 95% CI, 0.1-0.7; p = 0.034). The largest diagnostic category was < 6 months, dislocated reducible (51% [253 of 496 patients]); however, the Australia and Boston sites had more irreducible dislocations compared with the other sites (ORs, 2.1 and 1.9; 95% CIs, 1.2-3.6 and 1.1-3.4; p = 0.02 and 0.015, respectively). Bilaterality was seen less often in older compared with younger patients (8% [seven of 93] versus 26% [85 of 328]; p < 0.001). The most common diagnostic group was Grade 3 (by International Hip Dysplasia Institute classification), which included 58% (51 of 88) of all classified dislocated hips. Splintage was the primary initial treatment of choice at 80% (395 of 496), but was far more likely in younger compared with older patients (94% [309 of 328] versus 18% [17 of 93]; p < 0.001). CONCLUSIONS: With the lack of strong prognostic indicators for DDH identified to date, the center is an important variable to include as a potential predictor of treatment success or failure.

The safety and efficacy of a transarticular pin for maintaining reduction in patients with developmental dislocation of the hip undergoing an open reduction.

BACKGROUND: Redislocation after an open reduction for develpmental dislocation of the hip is relatively common. The purpose of this study was to determine if the use of a transarticular pin (TAP) is safe and effective in maintaining reduction. METHODS: A total of 578 patients (645 hips) were reviewed after an open reduction, mean age at the time of surgery was 2.1 years. In 621 cases a smooth Kirschner wire was placed across the joint. The rates of redislocation, avascular necrosis (AVN), and other complications were determined. AVN was classified according to Kalamchi et al. Outcome was determined at a minimum of 6 years using the Severin classification. RESULTS: Redislocation occurred in 27 cases (4.1% rate), 24 had a TAP (3.8%) and 3 did not (12.5%). AVN was observed in 127 cases (19.7%), it was type I in 73 cases, type II in 38 cases, type III in 14 cases, and type IV in 2 cases; AVN was seen in 123 cases which had a TAP (19.8%) and 4 cases which did not (16.7%). Analyzing pin placement: when it was in the inferior third of the neck the rate of AVN was 15.2% (32/211), in the middle third it was 21.7% (71/326), and in the superior third it was 28.6% (24/84). According to the Severin classification for the hips with a TAP, 496 were type I or II (79.8%), 113 were type III (18.2%), 10 were type IV (1.6%), and 2 were type V (0.3%); in the group without a TAP 19 cases were type I or II (79.2%), 4 were type III (16.7%), and 1 was type IV. CONCLUSIONS: The use of a TAP was effective in maintaining reduction and was not associated with significant morbidity. Placing the pin in the inferior third of the neck was associated with the lowest rate of AVN. LEVEL OF EVIDENCE: Level IV--therapeutic.

Feasibility and safety of perfusion MRI for Legg-Calvé-Perthes disease.

BACKGROUND: Recent studies have suggested that perfusion magnetic resonance imaging (pMRI) using gadolinium contrast and a subtraction technique can provide useful prognostic information in Legg-Calvé-Perthes disease (LCPD) and allow earlier stratification for outcome. There are, however, sparse data available regarding the feasibility and safety of these studies in children. The purpose of this study was to collect this information across multiple centers using pMRI for LCPD. METHODS: We retrospectively reviewed a consecutive series of patients with confirmed or suspected LCPD who had undergone pMRI at 1 of 5 large tertiary-care children's hospitals in the United States, UK, and Mexico. Demographic information, type of contrast administered, and requirement for sedation or anesthesia were noted. Records were scrutinized for adverse events associated with the pMRI protocol. RESULTS: Over the study period, 165 patients underwent 298 pMRI studies. The median age at the time of imaging was 8.6 years (range, 2.5to 16.9 y). A total of 252 scans (85%) were performed for a known diagnosis of LCPD, whereas 46 were performed for a suspected diagnosis. Ninety-two of the 298 (31%) pMRIs required sedation, 48 (16%) required general anesthesia, and 122 (41%) were facilitated by video goggles only. The remaining 36 patients (12%) had their studies performed without additional measures. The ages of patients requiring sedation (mean, 7.2±2.4 y) and anesthesia (mean, 7.7±2.3 y) were significantly younger than those patients requiring neither (mean, 10.2±2.3 y, P<0.001). Four patients (1.3%) reported nausea or vomiting as a result of sedation. Two patients (0.7%) had complications from intravenous cannulation (pull out, difficult access). One child (0.3%) had nausea/vomiting as a result of contrast administration. There were no serious adverse events as a result of the pMRI protocol; specifically none of nephrogenic systemic fibrosis, anaphylaxis, or death. CONCLUSIONS: pMRI is a safe and feasible imaging technique for LCPD. Almost half of our patients required either sedation or general anesthesia to complete the study. LEVEL OF EVIDENCE: IV (case series).

Trends in Medicare Reimbursement for Common Pediatric Orthopedic Procedures: From 2000 to 2022.

Objective We aimed to evaluate trends in government monetary reimbursement (Medicare) for 10 of the most commonly performed pediatric orthopedic procedures from 2000 to 2020. Methods Utilizing the Centers for Medicare and Medicaid Services website, we collected data for 10 of the most commonly performed pediatric orthopedic surgical procedures and their variations. The reimbursement data for each procedure was taken from the Current Procedural Terminology (CPT) code, which was collected from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services (Baltimore County, MD). The reimbursement values were adjusted for inflation to the 2022 US dollar (USD) using the changes to the Consumer Price Index. The compound annual growth rates (CAGRs) and total percentage changes in reimbursement were calculated for all the procedures and put into relative value units. Results Reimbursement for 20 of the 22 total procedures decreased by 32.65% from 2000 to 2022 after adjusting for inflation. Achilles tenotomy with local anesthesia saw the greatest decrease (-54.38%), whereas the procedure revision of spinal fusion saw the highest increase (26.00%) in mean adjusted reimbursement during this study period. Adjusted reimbursement decreased by an average of 2.08% on a yearly basis. Conclusion This study is the first to take an in-depth view and evaluate trends in procedural Medicare reimbursement for pediatric orthopedic surgery. When adjusted for inflation, Medicare reimbursement for 20 of 22 included procedures has steadily decreased from 2000 to 2022. There needs to be an increased awareness and consideration of these trends as they will be important for policymakers, hospitals, and surgeons to ensure continued access to meaningful surgical pediatric orthopedic care in the United States.

Incidence of Upper Extremity Neuropathies at a Single Tertiary Care Institution in the United States: Trends in Recent Years, Including the COVID-19 Pandemic.

OBJECTIVE: This study examined trends in upper extremity (UE) neuropathies at a large urban tertiary care center in the Northeastern United States over the past five years, including the period of the COVID-19 pandemic. METHOD: A retrospective medical record review was conducted from 2018 to 2022. We collected data from unique patient records identified using International Classification of Diseases, Tenth Revision (ICD-10) codes for UE neuropathies. We characterized subjects by age, demographics, and duration of symptoms.  Results: This study included 288 pediatric patients and 51,997 adult patients newly diagnosed with UE neuropathy. Most patients were aged 55+; 0.4% of all patients diagnosed with UE neuropathy were children. Across all ages, there was an overall increase in UE neuropathy diagnoses in the past five years, with the most noticeable increases from 2018 to 2019 (+5,761 diagnosed individuals, or +122%) and from 2020 to 2021 (+2,769 diagnosed individuals, or +28.8%). CONCLUSION: Our institution's UE neuropathy diagnoses have increased in the past five years. Of note, there was a significantly increased rate of UE neuropathy diagnoses from 2020 to 2021. This increase coincides with the COVID-19 pandemic, which is leading to a changing environment for many Americans. These societal changes will likely become indelible after the pandemic; safety practices should be enacted to avoid these debilitating neuropathies.

Positive outcome reporting in orthopaedic literature.

Aims: Perthes' disease (PD) is a relatively rare syndrome of idiopathic osteonecrosis of the proximal femoral epiphysis. Treatment for Perthes' disease is controversial due to the many options available, with no clear superiority of one treatment over another. Despite having few evidence-based approaches, many patients with Perthes' disease are managed surgically. Positive outcome reporting, defined as reporting a study variable producing statistically significant positive (beneficial) results, is a phenomenon that can be considered a proxy for the strength of science. This study aims to conduct a systematic literature review with the hypothesis that positive outcome reporting is frequent in studies on the treatment of Perthes' disease. Methods: We conducted a systematic review of all available abstracts associated with manuscripts in English or with English translation between January 2000 and December 2021, dealing with the treatment of Perthes' disease. Data collection included various study characteristics, surgical versus non-surgical management, treatment modality, mean follow-up time, analysis methods, and clinical recommendations. Results: Our study included 130 manuscripts. Overall, 110 (85%) reported positive (beneficial) results, three (2%) reported negative results, and 17 (13%) reported no significant difference. Despite only 10/130 studies (8%) having a testable hypothesis, 71 (55%) recommended the use of their studied treatment methods for the patients, five (4%) made recommendations against the use of the studied treatment modality, and 54 (42%) did not make any recommendations. Conclusion: The overall rate for positive outcomes among included manuscripts regarding different treatment methods for Perthes' disease (85%) is higher than the 74% positive outcome rate found among studies for other surgically treated disorders and significantly higher than most scientific literature. Despite the lack of testable hypotheses, most manuscripts recommended their studied treatment method as a successful option for managing patients solely based on the reporting of retrospective data.