AOA Critical Issues Symposium: Promoting Health Equity.

ABSTRACT: Promoting equitable health care is to ensure that everyone has access to high-quality medical services and appropriate treatment options. The definition of health equity often can be misinterpreted, and there are challenges in fully understanding the disparities and costs of health care and when measuring the outcomes of treatment. However, these topics play an important role in promoting health equity. The COVID-19 pandemic has made us more aware of profound health-care disparities and systemic racism, which, in turn, has prompted many academic medical centers and health-care systems to increase their efforts surrounding diversity, equity, and inclusion. Therefore, it is important to understand the problems that some patients have in accessing care, promote health care that is culturally competent, create policies and standard operating procedures (at the federal, state, regional, or institutional level), and be innovative to provide cost-effective care for the underserved population. All of these efforts can assist in promoting equitable care and thus result in a more just and healthier society.

Technology-Assisted Hip and Knee Arthroplasty in Orthopaedic Residency Training: A National Survey.

INTRODUCTION: The adoption of technology-assisted total joint arthroplasty (TA-TJA) is increasing; however, the extent to which TA-TJA is used among orthopaedic trainees is unknown. The purpose of this study was to assess the current use of TA total knee arthroplasty (TKA) and total hip arthroplasty (THA) by orthopaedic residents and to evaluate resident perceptions toward TA-TJA in their surgical training. METHODS: In this cross-sectional study, an anonymous electronic survey was sent to all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program coordinators to distribute to their PGY-2 to PGY-5 residents. The survey consisted of 24 questions, including resident demographics, utilization of TA-TJA in their training, and perceptions regarding TA-TJA. RESULTS: A total of 103 orthopaedic residents completed the survey, of whom 68.0% reported using TA-TJA at their institution. Of the residents using TA-TJA, 28.6% used TA for total TKA only, 71.4% used TA for both TKA and THA, and none used TA solely for THA. One-third of residents (33.3%) use TA for more than half of all TKAs conducted, whereas 57.0% use TA for <10% of all THAs conducted. Approximately half of all residents (49.5%) thought that training in TA-TJA should be required during residency, with no significant differences between junior and senior level residents ( P = 0.24). Most (82.0%) thought that trainees should be required to learn conventional TJA before learning TA-TJA. 63.0% thought that technology had a positive effect on their primary TJA training experience; however, 26.0% reported concern that their training conducting conventional TJA may be inadequate. DISCUSSION: This study demonstrates that most orthopaedic residents currently conduct TA-TJA and highlights notable differences in TJA training experiences. These results provide a platform for future work aimed at further optimizing TJA training in residency, particularly as technology continues to rapidly evolve and utilization of TA-TJA is projected to grow exponentially. LEVEL OF EVIDENCE: N/A, survey-based study.

The pathophysiology and treatment of musculoskeletal fibrosis.

Fibrosis continues to challenge the regeneration and repair of the Orthopaedic tissues in states of injury or disease. The mechanism behind developmental fibrosis has been widely investigated in the last few decades. However, the current efficacy of treatment for existing fibrous scars remains insufficient from both basic research and clinical perspectives. Scarred fibrotic tissue impedes the physical function of affected local tissues and organs and may also be associated with abnormal pain conduction or tissue reinjury. It is necessary to discover the functional treatment for fibrous scars as this pathology is medically demanding to effected patients. The current article will review the mechanisms behind fibrosis formation and the treatment potential in the field of the musculoskeletal system, especially in the pathology and treatment of injured skeletal muscle and the development of osteoarthritis.

Pediatric Supracondylar Humerus Fractures Can Be Safely Treated by Orthopaedic Surgeons With and Without Pediatric Fellowship Training.

BACKGROUND: The purpose of this study was to compare the outcomes of pediatric patients who were surgically treated for a supracondylar humerus fracture by pediatric fellowship-trained orthopaedic surgeons (PFT) to the outcomes of those surgically treated by orthopaedic surgeons without pediatric fellowship training (NPFT). We hypothesized that there would be no differences in patient outcomes. METHODS: A retrospective review of pediatric patients who underwent surgical treatment for a supracondylar humerus fracture with closed reduction and percutaneous pinning (CRPP) or open reduction and percutaneous pinning (ORPP) at a regional level 1 trauma center over a 5-year period was performed. Exclusion criteria were inadequate follow up or absence of postoperative radiographs. RESULTS: A total of 201 patients met the inclusion criteria. Pediatric-fellowship trained orthopaedic surgeons treated 15.9% of patients. There was no statistically significant difference in carrying angle, Baumann's angle, or lateral rotation percentage at final follow up between PFT and NPFT groups. There was no permanent neurovascular compromise in either group. Patients treated by NPFT were more likely to return to the operating room for pin removal. CONCLUSION: In this study, there was no difference in radiographic outcomes for patients with supracondylar humerus fractures surgically treated by either group. This suggests that pediatric supracondylar humerus fractures may be appropriately treated in communities without a pediatric-fellowship trained orthopaedic surgeon without compromised outcomes.Level of Evidence: III.

Assessing the Impact of the Pediatric Orthopaedic Society of North America (POSNA) Visiting Scholar Program.

BACKGROUND: The primary objective of the Pediatric Orthopaedic Society of North America (POSNA)-Children's Orthopaedics in Underserved Regions (COUR) Visiting Scholar Program is to engage emerging leaders from low-income and middle-income countries (LMICs) in POSNA educational offerings. This study aims to outline the educational and leadership activities pursued by the alumni of the POSNA-COUR Visiting Scholars Program. We hypothesized that there may be a discrepancy between visiting scholar interest level and actual participation in key follow-up educational and leadership activities. METHODS: A 32-question online survey developed by the POSNA-COUR committee was electronically delivered to the POSNA-COUR visiting scholarship recipients from 2007 to 2019. The survey inquired about scholars' educational background, clinical practice, and academic interests. Respondents also reported educational, research, and leadership activities that occurred following program participation. RESULTS: Fifty-seven percent (44/77) of the previous scholars participated in the survey. Sixty-eight percent reported that >75% of their practice was comprised of pediatric patients. The COUR scholarship afforded 15 scholars the opportunity to attend their first educational conference in North America. The majority (86%) of respondents consulted POSNA members on care-related issues, 52% organized a POSNA member's visit to their country, and 13% have become members of POSNA. Scholars shared their knowledge with colleagues through lectures (73%), demonstration of surgical skills (63%), mentorship (59%), hosting local courses (43%), and research (14%). There was a significant discrepancy between interest and actual participation in research (98% vs. 16%, P<0.0001), hosting a regional course (98% vs. 43%, P<0.0001), and becoming a member of POSNA (96% vs. 13%, P<0.0001). CONCLUSIONS: The POSNA-COUR Visiting Scholar Program is effective at providing beneficial educational opportunities to orthopaedic surgeons from LMICs. There is, however, a significant discrepancy between reported scholar interest and actual engagement in leadership endeavors including: research, organization of regional courses, and POSNA membership. The impact of the POSNA-COUR visiting scholar program can be enhanced through collaboration with scholarship alumni in these key areas. LEVEL OF EVIDENCE: Level IV-case series.

Guided Growth with Hemiplateau Elevation as an Alternative to Epiphysiodesis for Treatment of a Young Patient with Advanced Infantile Blount Disease: A Case Report.

CASE: Infantile Blount disease results from deceleration of growth by the proximal posteromedial tibial physis causing tibia vara. In advanced disease stages, surgical treatment is indicated. Owing to the young age and advanced Langenskiöld stage in this patient, a novel technique was performed combining lateral proximal physeal tethering with medial hemiplateau elevation osteotomy to correct the articular surface and unload the medial proximal tibial physis. CONCLUSION: Together, these procedures allow for correction of alignment while preserving growth potential. This technique was successful in correcting tibia vara due to infantile Blount disease while allowing continued growth in a 5-year-old patient.

Juvenile Idiopathic Arthritis for the Pediatric Orthopedic Surgeon.

Juvenile idiopathic arthritis includes conditions characterized by joint inflammation of unknown etiology lasting longer than 6 weeks in patients younger than 16 years. Diagnosis and medical management are complex and best coordinated by a pediatric rheumatologist. The mainstay of therapy is anti-inflammatory and biologic medications to control pain and joint inflammation. Orthopedic surgical treatment may be indicated for deformity, limb length inequality, or end-stage arthritis. Evaluation of the cervical spine and appropriate medication management in consultation with a patient's rheumatologist are essential in perioperative care. Preoperative planning should take into account patient deformity, contracture, small size, osteopenia, and medical comorbidities.

Surgical Reconstruction Technique of Two Patients With Tarsal Type Preaxial Polydactyly: Two True Prehalluces.

Polydactyly of the foot occurs in 1.7 cases per 1000 live births, comprising 45% of congenital abnormalities of the foot. Most reported cases of polydactyly of the foot are postaxial, and 15% are preaxial; of those, tarsal type preaxial polydactyly (a true prehallux) occurs in only 3% of cases. Because of this rarity, there is minimal literature available to guide management or surgical reconstruction. Two newborns presented with similar tarsal type preaxial polydactylies in the context of multiple congenital anomalies at a single institution. Patient 1 presented at birth with an accessory digit arising medially from the right foot at the medial malleolus. Two weeks later, genetically unrelated, patient 2 presented at birth with an accessory digit arising medially from the right foot at the talus. Both patients underwent resection of the extra digit and reconstruction including transfer of the accessory anterior tibial tendon arising from the preaxial extra digit to the remaining first ray. Two years after surgery, both patients are walking well with preserved dorsiflexion strength. Given the rarity of true prehallux cases, reported surgical treatment and outcomes are lacking. This case demonstrates the management of 2 patients to better guide future patient care. Although nonsurgical treatment with shoewear modification is an option, surgical reconstruction facilitated wearing typical shoes while preserving ambulatory ability. Both patients in this series had an accessory anterior tibial tendon. Surgical transfer of the tendon prevented loss of dorsiflexion strength and foot drop postoperatively.

Lower Extremity Surgical Treatment to Improve Function in a Patient with Gollop-Wolfgang Complex: A Case Report.

CASE: Gollop-Wolfgang Complex (GWC) includes congenital absence of the tibia with ipsilateral distal femur bifurcation associated with hand/foot ectrodactyly. A 20-month-old male presented with GWC, including left bifid distal femur with ipsilateral tibial hemimelia and absent extensor mechanism, hypoplastic bilateral thumbs, and right foot tarsal-type preaxial polydactyly. Left through-knee amputation preserving growth and contralateral polydactyly reconstruction were performed. Complications of wound infection and dehiscence were successfully treated. Patient is 44 months old and ambulating with left knee disarticulation prosthesis and right supramalleolar orthosis. CONCLUSIONS: Through-knee amputation and prosthetic fitting provides limb function for GWC patients with tibial hemimelia lacking an extensor mechanism.

Pedicle Screw Insertion: a Novel Approach to Enhance Anatomic Knowledge and Student Engagement.

A procedure experience was incorporated into the anatomy lab to advance knowledge of the spine and enhance student engagement (Nutt et al., Clin Teach 9(3):148-151, 2012). The spine lab was modified to include a scoliosis case with a pedicle screw placement simulation exercise. The experience has been a success for both undergraduate medical students and resident facilitators.

Reliability of measurements of clavicle shaft fracture shortening in adolescents.

BACKGROUND: A relative indication for surgical treatment of midshaft clavicle fractures is shortening ≥2.0 cm. A standard method for determining shortening with routine clavicle radiographs has not been established. This study evaluated the interobserver and intraobserver reliability when measuring shortening of midshaft clavicle fractures in adolescents. METHODS: We identified all clavicle radiographs of simple midshaft clavicle fractures in adolescents from 2006 to 2010. Thirty-two radiographs were chosen following a power analysis for 7 observers. Each film was measured twice by each evaluator using 2 separate methods. Method 1 was the evaluator's method of choice to determine shortening on the digital radiographs. Method 2 was standardized. Intraclass correlation coefficient and confidence intervals (CI) were calculated to determine interrater reliability, and average differences between the 2 time points with 95% CI were calculated to determine intrarater reliability. RESULTS: Interrater reliability for method 1 was 0.771 (95% CI, 0.655-0.865) and 0.743 (95% CI, 0.604-0.851) at the 2 time points for fair agreement. Interrater reliability for method 2 was 0.741 (95% CI, 0.629-0.842) and 0.685 (95% CI, 0.554-0.805) at the 2 time points, for fair and poor agreement, respectively. Neither method was statistically superior to the other. For method 1, the SD for the measurements averaged 3.1 mm. For method 2, the average SD was 3.0 mm. Intrarater reliability for method 1 was 2.62 mm average difference between the 2 time points (95% CI, 2.24-3.00), and for method 2 it was 3.34 mm average (95% CI, 2.88-3.80). Method 2 had a significantly greater difference at the 2 time points than method 1 (P=0.027). CONCLUSIONS: There is only fair agreement among observers when measuring the shortening of clavicle fractures in adolescents on digital clavicle radiographs by either method described. However, as the average difference among measurers was only 3 mm, this is unlikely to influence clinical decision making. A lack of standardization of measurement in previous studies on clavicle fracture treatment may not represent a significant problem. LEVEL OF EVIDENCE: Level III diagnostic study.

Utility of electrodiagnostic testing and computed tomography myelography in the preoperative evaluation of neonatal brachial plexus palsy.

OBJECT: The rate of neonatal brachial plexus palsy (NBPP) remains 0.4%-4% despite improvements in perinatal care. Among affected children, the extent of brachial plexus palsy differs greatly, as does the prognosis. Controversial elements in management include indications and timing of nerve repair as well as type of reconstruction in patients in whom function will ultimately not be recovered without surgical intervention. Differentiating preganglionic (avulsion) from postganglionic (rupture) lesions is critical because preganglionic lesions cannot spontaneously recover motor function. Distinguishing between these lesions at initial presentation based on clinical examination alone can be difficult in infants. The purpose of the present study was to determine the sensitivity of preoperative electrodiagnostic studies (EDSs) and CT myelography (CTM) in determining the presence of nerve root rupture and avulsions in infants with NBPP. METHODS: After receiving institutional review board approval, the authors conducted a retrospective review of patients referred to the Neonatal Brachial Plexus Program between 2007 and 2010. Inclusion criteria included children who underwent brachial plexus exploration following preoperative EDSs and CTM. The CTM scans were interpreted by a staff neuroradiologist, EDSs were conducted by a single physiatrist, and intraoperative findings were recorded by the operating neurosurgeon. The findings from the preoperative EDSs and CTM were then compared with intraoperative findings. The sensitivities and 95% confidence intervals were determined to evaluate performance accuracy of each preoperative measure. RESULTS: Twenty-one patients (8 male amd 13 female) met inclusion criteria for this study. The sensitivity of EDSs and CTM for detecting a postganglionic rupture was 92.8% (CI 0.841-0.969) and 58.3% (CI 0.420-0.729), respectively. The sensitivity for EDSs and CTM for preganglionic nerve root avulsion was 27.8% (CI 0.125-0.509) and 72.2% (CI 0.491-0.875), respectively. In cases in which both CTM and EDSs gave concordant results, the sensitivity for both modalities combined was 50.0% (CI 0.237-0.763) for avulsion and 80.8% (CI 0.621-0.915) for rupture. Overall, EDSs were most useful in identifying ruptures, particularly in the upper plexus, whereas CTM was most sensitive in identifying avulsions in the lower plexus. CONCLUSIONS: Knowledge of the spinal nerve integrity is critical for early management of patients with NBPP. Surgical management, in the form of nerve repair/reconstruction, and optimal prognostication of NBPP depend on the accurate diagnosis of the level and type of lesion. Both EDSs and CTM scans must always be interpreted in the context of a comprehensive evaluation of the patient. They provide supplemental information (in addition to the physical examination) for early detection of nerve root rupture and avulsion injuries, aiding surgical decision making and preoperative planning for NBPP. Continued advances in imaging, EDSs, and microsurgical nerve repair techniques will allow surgeons to achieve greater success for functional recovery in management of NBPP.

Arthroscopic posterior cruciate ligament reconstruction in a skeletally immature patient: a new technique with case report.

Pediatric intrasubstance posterior cruciate ligament (PCL) injuries are rare but present a significant treatment challenge. Untreated instability may lead to further knee injury, including meniscal or chondral damage. Surgical intervention risks damage to the physis, growth arrest, and angular deformity. We present the case of a skeletally immature 11-year-old boy with a high-grade intrasubstance PCL injury reconstructed using an all-arthroscopic tibial inlay technique modified to minimize risk of physeal injury. The femoral tunnels were placed entirely within the epiphysis, and the tibial physis was minimally crossed with a small drill hole and suture material. At 17 months' follow up, the patient had returned to full activity, including sports. He had a grade 1 posterior drawer and no posterior sag. Radiographs showed no degenerative changes. Both the proximal tibial and distal femoral physes were widely patent with no angular deformity. The patient had a 1-cm leg length discrepancy, with the operative limb being longer. This technical note with a case report describes a novel physeal-sparing reconstruction of the PCL in a pediatric patient with open physes.