Concurrent Validity of PROMIS and LD-SRS Scores in Pediatric Patients With Lower Limb Differences.

BACKGROUND: We sought to assess the concurrent validity of select Patient Reported Outcomes Measurement Information System (PROMIS) domains and Limb Deformity-Scoliosis Research Society (LD-SRS) scores. METHODS: We prospectively administered PROMIS-25 (including anxiety, depression, fatigue, pain interference, peer relationships, and physical function) and LD-SRS questionnaires to 46 consecutive pediatric patients with lower limb differences, presenting to a single surgeon for reconstruction. Concurrent validity between various subdomains of the 2 outcome measures was assessed through Pearson's correlation, with significance defined as P <0.05. The strength of correlation was interpreted by Evans criteria: absolute r value <0.20 indicating very weak correlation; 0.20 to 0.39, weak; 0.40 to 0.59, moderate; 0.60 to 0.79, strong; and 0.8 or greater indicating very strong correlation. RESULTS: The LD-SRS Pain, Function, and Mental Health domains most strongly correlated with the PROMIS pain interference (r=-0.79, P<0.001), physical function (r=0.74, P<0.001), and anxiety (r=-0.68, P <0.001) domains, respectively. In addition, LD-SRS pain strongly correlated with PROMIS physical function (r=0.61, P<0.001) and LD-SRS function with PROMIS pain interference (r=-0.72, P<0.001). All PROMIS domains significantly correlated with total LD-SRS scores. PROMIS pain interference (r=-0.79, P <0.001), physical function (r=0.67, P <0.001), and fatigue (r=-0.60, P <0.001) domains demonstrated the strongest correlations with the total LD-SRS score. CONCLUSIONS: The significant concurrent validity between LD-SRS and multiple PROMIS domains suggests considerable overlap, and perhaps redundancy, between these 2 outcome measures. Given the high degree of concordance and the advantage of computer adaptive testing (CAT) in mitigating administrative burden and survey fatigue, along with the ability to compare outcomes across a wider group of children with a variety of underlying diagnoses, select PROMIS domains may be a viable alternative to LD-SRS score for assessing patient-reported outcomes when treating pediatric patients with lower limb deformities. A larger, multi-center study including pediatric patients with lower limb differences from a diverse background, including age, etiology, native language, and ethnicity, would be helpful to externally validate our findings. LEVEL OF EVIDENCE: Level-I.

Reuse of Orthopaedic Equipment: Barriers and Opportunities.

¼ Reuse of orthopaedic equipment is one of many potential ways to minimize the negative impact of used equipment on the environment, rising healthcare costs and disparities in access to surgical care.¼ Barriers to widespread adoption of reuse include concerns for patient safety, exposure to unknown liability risks, negative public perceptions, and logistical barriers such as limited availability of infrastructure and quality control metrics.¼ Some low- and middle-income countries have existing models of equipment reuse that can be adapted through reverse innovation to high-income countries such as the United States.¼ Further research should be conducted to examine the safety and efficacy of reusing various orthopaedic equipment, so that standardized guidelines for reuse can be established.

Peer-reviewed publications in orthopaedic surgery from lower income countries: A comparative analysis.

INTRODUCTION: Musculoskeletal (MSK) disease is a substantial global burden, especially in lower income countries. However, limited research has been published on MSK health by scholars from these countries. We aimed to study the distribution of authorships, including trends in peer-reviewed orthopaedic publications based on each author's affiliated institution's country income status. METHODS: Based on a bibliometric search, 119 orthopaedic-related journals were identified using the Journal Citation Reports database. Details of all scientific articles published in these journals between 2012 and 2021 were used to study trends and association between each of the author's affiliated institution's country income status, using the World Bank Classification. RESULTS: Of the 133,718 unique articles, 87.6% had at least one author affiliation from a high-income country (HIC), 7.0% from an upper-middle income country (UMIC), 5.2% from a lower-middle income country (LMIC), and 0.2% from a low-income country (LIC). Overall, these articles were cited 1,825,365 times, with 92.5% of citations from HIC-affiliated authors and < 0.1% from LIC-affiliated authors. Over the 10-year study period, HIC-affiliated articles demonstrated the largest increase in the number of publications (9107-14,619), compared to UMIC-affiliated (495-1214), LMIC-affiliated (406-874), and LIC-affiliated articles (4-28). CONCLUSIONS: There are large and persistent disparities in orthopaedic research publications based on the country income status of the author's affiliated institution, especially in the higher impact orthopaedic journals. Efforts should be made to increase opportunities for scholars from LICs and LMICs to publish their research in high-impact orthopaedic journals.

Inter- and Intra-rater Reliability of the Checketts' Grading System for Pin-site Infections across All Skin Colours.

The Checketts' grading system (CGS) is the only classification that provides both a description of how to visually grade the infection and the appropriate course of treatment. There are no studies on the reliability of this system nor on whether skin colour can influence applicability. This study aims to determine the inter-rater and intra-rater reliability of the CGS to assess whether this scale could be used as a universal grading system across all skin colours. A survey consisting of 134 anonymised photographs of pin-site infections was sent out to orthopaedic surgeons specialising in limb lengthening and reconstruction and to patients or carers of individuals who had external fixators. For each photograph, the participants were asked to grade the infection using the CGS, rate their confidence in their chosen grade on a Likert scale and assign a treatment option. The participants were supplied with the CGS at the beginning of the survey, after the 45th and 90th photographs. The inter-rater reliability of the CGS between the surgeons, expressed as an intraclass correlation coefficient (ICC), was poor-to-moderate at both time points (ICC = 0.56 for baseline survey and ICC = 0.48 for follow-up). This was similar for the patient or caretaker group. There was a lower inter-rater reliability for grading of dark skin as opposed to light skin by surgeons but not for patients or caretakers. The inter-rater reliability of treatment decisions between the surgeons was poor at both time points (kappa = 0.30 and 0.22) with similar inter-rater reliability for dark (kappa = 0.26 and 0.23) compared with light skin (kappa = 0.29 and 2.6). This was similar for the patient or caretaker group. The surgeons' confidence (Table 4) in grading was low (median = 1). The patient or caretaker group's confidence in their grading was modest (median = 2). The reliability of the CGS as assessed here demonstrates poor-to-moderate inter-rater reliability which makes interpretation of published pin site infection rates using this scale difficult. The design of new grading systems will need to consider skin colour to reduce inequities in medical decision-making. How to cite this article: Groenewoud R, Chhina H, Bone J, et al. Inter- and Intra-rater Reliability of the Checketts' Grading System for Pin Site Infections across All Skin Colours. Strategies Trauma Limb Reconstr 2023;18(1):2-6.

Trends and Practices in Limb Lengthening: An 11-year US Database Study.

Aim: Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. Materials and methods: Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. Results: There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. Conclusion: There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. Clinical significance: Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis. How to cite this article: Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.

Pediatric Orthopaedic Observerships in North America for International Surgeons: A Qualitative Study Exploring Motivations, Relevance, and Alternate Learning Platforms.

BACKGROUND: Given the growing interest among international surgeons to participate in North American clinical observerships, it is essential to incorporate international surgeons' views to further enhance the program's applicability, value, and accessibility. In this qualitative follow-up study, we explored the motivations, relevance, and opinions about alternate learning platforms among the international surgeons who had participated in a pediatric orthopaedic clinical observership in North America. METHODS: Using a semistructured interview guide, international surgeons who had participated in a North American pediatric orthopaedic observership during 2009 to 2019 were interviewed until data saturation and inductive thematic saturation were reached. Twenty-one international surgeons representing 15 different countries (1 from a low-income country, 10 from a lower middle-income country, 8 from an upper middle-income country, and 2 from a high-income country) were interviewed. RESULTS: The most commonly cited motivations for doing a clinical observership were to advance clinical training and learn specific skills. The clinical and nonclinical skills gained during the observership, such as utilizing an integrated team approach and open communication style, were helpful to most interviewees; however, several respondents highlighted the critical need to adapt and modify surgical indications, techniques, and skills to suit their local environment and limited resource availability. Although respondents were interested in exploring virtual learning models to save time and expense, several preferred a hybrid model, including access to remote learning opportunities and sharing their own clinical experiences with the North American hosts. CONCLUSIONS: Identifying the visiting surgeon's motivation for participation can allow North American hosts to align their clinical exposure more closely with the unique needs and aspirations of the international surgeons and enable a more relevant exchange of clinical and nonclinical skills. Use of a blended learning model, including in-person and virtual learning platforms, and the missed opportunity of having the international surgeons share their clinical experiences and skills with their North American counterparts should be explored further.

3D Printing Technology in Pediatric Orthopedics: a Primer for the Clinician.

PURPOSE OF REVIEW: This article reviews the basics of 3D printing and provides an overview of current and future applications of this emerging technology in pediatric orthopedic surgery. RECENT FINDINGS: Both preoperative and intraoperative utilization of 3D printing technology have enhanced clinical care. Potential benefits include more accurate surgical planning, shortening of a surgical learning curve, decrease in intraoperative blood loss, less operative time, and fluoroscopic time. Furthermore, patient-specific instrumentation can be used to improve the safety and accuracy of surgical care. Patient-physician communication can also benefit from 3D printing technology. 3D printing is rapidly advancing in the field of pediatric orthopedic surgery. It has the potential to increase the value of several pediatric orthopedic procedures by enhancing safety and accuracy while saving time. Future efforts in cost reduction strategies, making patient-specific implants including biologic substitutes and scaffolds, will further increase the relevance of 3D technology in the field of pediatric orthopedic surgery.

Spontaneous self-expulsion of an oesophageal duplication cyst.

A case report of an oesophageal duplication cyst in an adult patient with chronic cough and presenting with a "coughed out lump". This is an unusual presentation highlighting the importance of considering congenital duplication cysts in patients with chronic cough and no obvious respiratory cause.

The Role of Scribes in Orthopaedics.

¼: The rapid increase in the use of electronic medical records (EMRs) has led to some unintended consequences that negatively affect physicians and their patients. ¼: The use of medical scribes may serve as a possible solution to some of the EMR-related concerns. ¼: Research has demonstrated an overall positive impact of having scribes on both physician and patient well-being, safety, and satisfaction. ¼: Adaptation of advances in technology, including remote and asynchronous scribing, use of face-mounted devices, voice recognition software, and applications of artificial intelligence may address some of the barriers to more traditional in-person scribes.

Orthopaedic trauma observerships in North America for international surgeons: the visitors' perspective.

International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented. Methods: A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed. Results: Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon. Conclusions: Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed. Level of Evidence: IV-Cross-Sectional Study.

Host Perspectives of High-Income Country Orthopaedic Resident Rotations in Low and Middle-Income Countries.

BACKGROUND: International orthopaedic resident rotations in low and middle-income countries (LMICs) are gaining popularity among high-income country (HIC) residency programs. While evidence demonstrates a benefit for the visiting residents, few studies have evaluated the impact of such rotations on the orthopaedic surgeons and trainees in LMICs. The purpose of this study was to further explore themes identified in a previous survey study regarding the local impact of visiting HIC resident rotations. METHODS: Using a semistructured interview guide, LMIC surgeons and trainees who had hosted HIC orthopaedic residents within the previous 10 years were interviewed until thematic saturation was reached. RESULTS: Twenty attending and resident orthopaedic surgeons from 8 LMICs were interviewed. Positive and negative effects of the visiting residents on clinical care, education, interpersonal relationships, and resource availability were identified. Seven recommendations for visiting resident rotations were highlighted, including a 1 to 2-month rotation length; visiting residents at the senior training level; site-specific prerotation orientation with an emphasis on resident attitudes, including the need for humility; creation of bidirectional opportunities; partnering with institutions with local training programs; and fostering mutually beneficial sustained relationships. CONCLUSIONS: This study explores the perspectives of those who host visiting residents, a viewpoint that is underrepresented in the literature. Future research regarding HIC orthopaedic resident rotations in LMICs should include the perspectives of local surgeons and trainees to strive for mutually beneficial experiences to further strengthen and sustain such academic partnerships.

Malunion of Pediatric Forearm Shaft Fractures: Management Principles and Techniques.

PURPOSE OF REVIEW: Clinically significant malunion of forearm diaphyseal fractures is an uncommon but potentially disabling condition amongst children and adolescents. We present the preoperative evaluation, including imaging, and discuss surgical indications and contemporary approaches to manage such patients, including an illustrative case. RECENT FINDINGS: While advances in three-dimensional (3D) simulation, modeling, and patient-specific instrumentation have expanded the surgical armamentarium, their impact on long-term outcomes compared to traditional methods remains unknown. Successful outcome following surgical correction of malunion following a both-bone forearm fracture can be achieved with careful patient selection, appropriate indications, and a well-planned surgical execution.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients.

BACKGROUND: Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research. METHODS: We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics. RESULTS: We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%). CONCLUSIONS: There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

What Factors Correlate With Length of Stay and Readmission After Limb Lengthening Procedures? A Large-database Study.

BACKGROUND: Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures. QUESTIONS/PURPOSES: (1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission? METHODS: Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses. RESULTS: Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only. CONCLUSION: When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Surgical Management of Foot and Ankle Deformities in Cerebral Palsy.

Children with cerebral palsy (CP) are at a high risk of developing foot and ankle deformities that can impact function, brace/shoe fit, and seating. The 3 commonly observed foot and ankle segmental malalignment patterns include equinus, planovalgus, and equinovarus. Assessment of foot deformities is multifaceted, requiring the collection and integration of data from a combination of sources that include the clinical history, standardized physical examination, observational and quantitative gait analysis, GMFCS classification, and radiographic findings. Surgical procedures are determined by identifying all segmental malalignments and assessing the contribution of dynamic or flexible soft-tissue imbalance, fixed soft-tissue imbalance, and skeletal deformities.

The Prevalence of Bullying Among Pediatric Orthopaedic Patients.

BACKGROUND: Bullying is destructive and pervasive. Although the literature suggests children with chronic health conditions are at higher risk of being bullied, there is minimal research regarding the prevalence of bullying among children with orthopaedic conditions. Our study aimed to assess the prevalence of bullying among pediatric orthopaedic outpatients and evaluate the association of orthopaedic conditions and use of orthopaedic devices with perceptions of bullying. METHODS: Patients in outpatient pediatric orthopaedic clinics, ages 10 to 17 and their parents were surveyed using the Child-Adolescent Bullying Scale-9. Basic demographic, information about the child's orthopaedic condition, and parent's perception of their child being subject to bullying were also collected. Children were asked if they had used any orthopaedic devices in the last 3 months, whether they were bullied because of their device, and if bullying affected their compliance with device use. The analysis utilized a t test or analysis of variance to compare mean Child-Adolescent Bullying Scale-9 scores across different groups. RESULTS: Among the 198 patients surveyed, 61% (N=121) perceived no-to-minimal exposure to bullying, 36% (N=72) moderate exposure, and 3% (N=5) severe exposure. Children ages 10 to 13 (N=100) and children ages 14 to 17 (N=98) reported similar rates of bullying (P=0.97). Higher rates of moderate to severe bullying were reported by patients with foot deformity (80%), multiple orthopaedic diagnoses (55%), chronic pain (39%), fracture/acute injury (37%), and scoliosis (33%). Moderate to severe bullying was reported by 37% of patients who wore a cast, 40% who wore a brace/orthotic, and 52% who used multiple orthopaedic devices. Parental concern that their child was being bullied was highly correlated with their child's bullying score (P=0.0002). CONCLUSIONS: More than one third of our pediatric orthopaedic outpatients (39%) experience moderate to severe levels of bullying, which is higher than the general population's reported rates of 20% to 35%. Exposure to bullying may be higher in certain diagnoses or with use of certain orthopaedic devices. Further research is needed to delineate who is at highest risk. LEVEL OF EVIDENCE: Level IV.

Pediatric Orthopaedic Observerships in North America for International Surgeons: Perceived Barriers and Opportunities for Visitors and Hosts.

BACKGROUND: Despite recommendations for high-income countries to partner with low-income and middle-income countries to expand surgical access, little is known about the barriers that are faced by international surgeons (ISs) who participate in short-term clinical observerships in North America and the barriers that are encountered by their North American (NA) hosts. METHODS: Surveys were distributed to ISs who participated in a pediatric orthopaedic observership in North America in 2009 to 2019 and their NA hosts to assess the perceived barriers that are faced by both partners and identify possible opportunities for improvement. RESULTS: Responses were received from 181 ISs and 46 NA hosts. The ISs reported facing a variety of barriers prior to, during, and after completion of their NA observerships, including financial burden, language and cultural barriers, and challenges with local accommodations and transportation. Only 49% of ISs reported that their NA hosts had sought feedback from them. Barriers noted by the NA hosts included financial burden, logistical challenges with hosting, language barriers, and lack of support from their co-faculty/staff. At least 43% of NA hosts reported that their observership program was unfunded. Based on the survey responses, potential areas that may enhance the observership experience include funding support, creating a centralized data bank of pediatric subspecialty opportunities that are available at each sponsoring institution, a pre-visit orientation for the visiting surgeon, improving inclusivity by addressing language and cultural barriers, improving access to observing surgical procedures, obtaining post-visit feedback, and creating a virtual community of international visitors and NA hosts for an ongoing exchange of ideas and resources. CONCLUSIONS: The ISs who participated in a pediatric orthopaedic clinical observership and their NA hosts identified limited funding as a major barrier. There are several opportunities for enhancing this unique learning experience and exploring the role of contextual remote learning for all participants. Additional studies are needed to investigate the value of clinical observerships for ISs, including the downstream impact of such opportunities on capacity-building, bidirectional learning, and improving patient care.

The Pulseless Supracondylar Elbow Fracture: A Rational Approach.

BACKGROUND: Supracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60-70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3-19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation. PURPOSE: While there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent. METHODS: Herein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience. RESULTS: We recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately. CONCLUSION: Much of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.