Comparing Relative Value Units for Intramedullary Limb Lengthening Procedures to Common Pediatric Orthopaedic Surgeries to Determine Adequate Compensation.

OBJECTIVE: Reimbursement for surgical procedures is determined by a computation of the relative value unit (RVU) associated with CPT codes. It is based on the amount of work required to provide a service, resources available, and level of expertise involved. Given the evolution of changes in the limb lengthening field, we wanted to evaluate whether the RVU values were comparable across different orthopaedic subspecialties. Consequently, this study compares the work relative value unit (wRVU) totals of 3 common pediatric orthopaedic surgeries-arthroscopic ACL reconstruction, spinal fusion for adolescent idiopathic scoliosis, and antegrade femoral intramedullary limb lengthening. METHODS: This was an IRB-approved, multicenter, retrospective chart review. Charts of subjects who had ACL reconstructions, including meniscal repairs; spinal fusion surgeries for adolescent idiopathic scoliosis (7 to 12 levels), including Ponte osteotomies, and femoral antegrade internal limb lengthening procedures, each completed by fellowship-trained orthopaedic surgeons were reviewed. Comparisons were carried out between several parameters, including mean duration per procedure, number of CPT codes billed per procedure, number of postoperative visits in the 90-day global period, and the wRVU for each procedure. RESULTS: Fifty charts (25 per center) per procedure were reviewed. The wRVU per hour was lowest in the antegrade femur lengthening group (P < 0.0001). The number of postoperative visits in the 90-day global postsurgery period was significantly higher in the antegrade femur lengthening group (P < 0.0001). Intramedullary limb lengthening also had the least number of CPT codes billed. CONCLUSIONS: RVUs per time are statistically lowest in the limb lengthening group and highest in the scoliosis group. The limb lengthening patient also requires significantly more visits and time in the postoperative period compared with the other groups. These extra visits during the global period do not add any RVU value to the lengthening surgeon and occupy clinic spots that could be filled with new patients. Based on these data, a review of the RVU values assigned to the limb lengthening codes may be necessary. LEVEL OF EVIDENCE: Level III-retrospective comparison study.

Prospective Multicenter Preliminary Validation of Limb Deformity-modified Scoliosis Instruments in Pediatric Patients With Limb Deformity.

INTRODUCTION: There are few disease-specific patient-reported outcome measures (PROMs) for use in pediatric limb deformity (LD), with authors instead relying on generic PROMs such as the Pediatric Outcomes Data Collection Instrument (PODCI) to assess treatment outcomes from the patient's perspective. The purpose of this study was to perform preliminary validation of 2 disease-specific PROMs in pediatric patients with LD. METHODS: LD modifications were created by substituting the word "limb" for "back" in the Early Onset Scoliosis Questionnaire (EOSQ, ages 10 and younger) and the Scoliosis Research Society (SRS, ages 11 to 18) survey, creating the LD-EOSQ and LD-SRS instruments. Children were preoperatively administered the age-appropriate LD-PROMs (n=34 LD-EOSQ; n=30 LD-SRS) and PODCI questionnaires. LD-PROMs were assessed for construct (convergent and discriminant) validity, floor and ceiling effects, content validity, and minimal clinically important difference. RESULTS: Both LD-EOSQ and LD-SRS demonstrated excellent preliminary convergent validity with similar PODCI domains and discriminant validity with demographic information, deformity data, and LLRS-AIM scores. There were minimal floor or ceiling effects. Content validity was achieved in 100% of LD-EOSQ surveys and more than 80% of LD-SRS surveys. Minimal clinically important difference was 0.4 for LD-EOSQ and 0.3 for LD-SRS. CONCLUSIONS: The LD-EOSQ for patients aged 10 and under and LD-SRS for patients aged 11 to 18 demonstrated preliminary validity and reliability in the pediatric LD population. These measures provide more information specifically related to familial impact in younger children and self-image and mental health in adolescents compared to the PODCI and should be further evaluated for use in these patients. LEVEL OF EVIDENCE: Level II-diagnostic. Prospective cross-sectional cohort design.

Access to care among patients with osteogenesis imperfecta during the COVID-19 pandemic.

In a cross-sectional study assessing the experiences of individuals with osteogenesis imperfecta accessing care during the COVID-19 pandemic, participants reported high rates of delays in accessing medical care and high utilization of telehealth. Considering the needs of individuals with complex medical conditions is important when improving access to care. PURPOSE: Individuals with osteogenesis imperfecta (OI) often have complex care needs requiring that they see a variety of specialists. The onset of the COVID-19 pandemic in March 2020 led to delays in medical care for many health conditions. The goal of this study was to describe the experiences of individuals with OI accessing medical care during this time. METHODS: Responses to an electronic survey distributed via the OI Foundation mailing list were collected from August 2020 until February 2021. Participants were instructed to compare their experiences in the months since the start of the pandemic with their experiences prior to this date. Data were analyzed using descriptive statistics and were compared across demographic groups using logistic regression and chi-squared tests. RESULTS: Surveys were completed by 110 participants. Most participants (72%) reported experiencing delays in accessing at least one care provider. The majority of participants reported less or similar amounts of bone pain (74.3%) and less or the same rate of fracture (88.6%) as before the start of the pandemic. CONCLUSION: While most study participants experienced delays in care, they did not report an increase in symptoms associated with OI. They also frequently utilized telehealth as a tool to see their providers. Future research should focus on the impact of changes in telehealth legislation on patients' ability to access care. As methods for care delivery evolve, the needs of people with OI and other rare diseases should be considered and prioritized.

Intraoperative Hardware Failure of the Fassier-Duval Rescue System in a Pediatric Patient with Osteogenesis Imperfecta.

The use of telescopic intramedullary rods for the treatment of lower extremity deformity in children with osteogenesis imperfecta has been well described. The reinforcement of these weakened weightbearing bones with intramedullary devices leads to improvements in mobility that progress into adulthood. Although the current telescopic intramedullary rod systems are an upgrade from earlier systems, they are still associated with high rates of reoperation and complication. We describe a unique complication encountered during a revision which involved the male retriever system for the Fassier-Duval rod (FDR) (Pega Medical, Quebec, CA) experienced intraoperatively. To our knowledge, this mechanism of failure has not been previously described in the literature.

Bilateral Recurrent, Atraumatic Anterior Knee Dislocations in a Pediatric Patient With Congenital Absence of the Anterior Cruciate Ligament.

An 8 yo 15 kg male child with an undiagnosed congenital syndrome presented with painful, recurrent atraumatic bilateral knee dislocations. Recurrent dislocations were reduced in the emergency department and were never associated with neurovascular compromise. Magnetic resonance imaging identified congenital agenesis of the anterior cruciate ligament (ACL) bilaterally. He underwent staged bilateral physeal-sparing ACL reconstructions with autograft iliotibial band and had no subsequent dislocations during 14 month follow-up. To our knowledge, this is the only reported case of atraumatic spontaneous bilateral knee dislocations in a patient with bilateral congenital absence of the ACL. This case describes a novel indication for physeal-sparing ACL reconstruction in a rare clinical entity.