Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Operative Reduction for Developmental Dysplasia of the Hip: Epidemiology Over 16 Years.

BACKGROUND: The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations. METHODS: The Healthcare Utilization Project Kids' Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates. RESULTS: An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018). CONCLUSIONS: The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH. LEVEL OF EVIDENCE: Level III.

What's New in Pediatric Hip?

BACKGROUND: Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip. METHODS: We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line. RESULTS: A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information. CONCLUSIONS: DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions. LEVEL OF EVIDENCE: Level V.

Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial.

BACKGROUND: Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures. METHODS: Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort. RESULTS: A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort. CONCLUSIONS: Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Klippel-Feil Syndrome: Clinical Presentation and Management.

¼: Klippel-Feil syndrome (KFS) is a rare multisystem constellation of findings with congenital cervical fusion as the hallmark. The etiology is not fully understood. ¼: Recent studies have indicated that KFS is more prevalent than previously described. ¼: Hypermobility in the nonfused segments may lead to adjacent segment disease and potential disc herniation and myelopathy after minor trauma. ¼: Most patients with KFS are asymptomatic and can be managed nonoperatively. Surgical treatment is reserved for patients presenting with pain refractory to medical management, instability, myelopathy or radiculopathy, or severe adjacent segment disease. ¼: Patients with craniocervical abnormalities and upper cervical instability should avoid contact sports as they are at increased risk for spinal cord injury after minor trauma.

Thoracic Curve Correction Ratio: An Objective Measure to Guide against Overcorrection of a Main Thoracic Curve in the Setting of a Structural Proximal Thoracic Curve.

Purpose: The correction of double thoracic (Lenke 2) curves has been associated with higher rates of postoperative shoulder imbalance that may compromise long-term outcomes following spinal deformity correction. A number of methods have been proposed to mitigate this risk, though no accepted standard measurement exists. The purpose of this study is to validate a novel quantitative method of determining the relative curve correction magnitude in double thoracic curves. Methods: Retrospective data from a multi-center database of patients undergoing surgical correction of left-proximal thoracic, right-main thoracic Lenke 2 curves were analyzed. A novel measurement tool, the Thoracic Curve Correction Ratio (TCCR), was applied for the purposes of validation against historical data. Results: A total of 305 patients with complete two-year follow-up data were included. The TCCR, or the ratio of postoperative percent correction of the thoracic curves divided by the ratio of the preoperative curve magnitudes, displayed a significant negative correlation (Pearson R = −0.66; p < 0.001) with T1 tilt at two years postoperatively. Conclusions: The TCCR could be added as an important factor in the preoperative planning process and intraoperative assessment in order to reduce postoperative T1 tilt. While T1 tilt remains an imperfect surrogate measure for clinical shoulder balance, it serves as one of many potential measures that the surgeon may evaluate quantitatively and radiographically.

Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery.

STUDY DESIGN: Retrospective case control study. OBJECTIVE: To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. SUMMARY OF BACKGROUND DATA: No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. METHODS: Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. RESULTS: Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). CONCLUSION: Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship.

BACKGROUND: Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture. METHODS: Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics. RESULTS: Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex. CONCLUSIONS: Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outpatient Pediatric Orthopedic Surgery.

Outpatient surgery refers to a surgical procedure that is performed without an overnight stay in a hospital. Outpatient surgery is associated with decreased individual and societal costs while achieving equivalent health outcomes and excellent patient satisfaction. Successful outpatient pediatric surgery is predicated on appropriate patient selection, adequate pain control, thorough preoperative education, and close clinical follow-up. Continuous research in quality, value, and patient safety are needed to ensure that this practice continues in as safe and efficient a manner as possible.