Faculty Bibliography

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/METHODS:Level III.

BACKGROUND:The purpose of this study was to identify and characterize challenges and benefits to the use of tele-medicine for the treatment of pediatric orthopedic patients during and after the COVID-19 pandemic. METHODS:A novel survey was sent to all faculty members at an academic pediatric orthopedic practice in New York City regarding their use of telemedicine in response to the COVID-19 pandemic. RESULTS:Faculty members performed 227 unique tele-health visits with pediatric orthopedic patients over a 7-week period in early 2020, and this formed the basis for responses to the survey. The results of the faculty survey suggest that telemedicine has substantial clinical benefits for pediatric orthopedic surgeons and our patients that extend beyond the COVID-19 pandemic. Providers recognize the limits of conducting physical exams over telemedicine and should always use clinical judgment when evaluating patients, par-ticularly trauma patients who may require prompt referral for additional care. CONCLUSIONS:The ability to provide pediatric orthopedic care through telemedicine has allowed us to safely evaluate and treat pediatric patients with musculoskeletal problems in New York City and its environs despite the COVID-19 pandemic. The efficient evaluation of both new and exist-ing pediatric orthopedic patients via telehealth is viable. Physical examination is the most challenging aspect of the physician-patient encounter to replicate virtually. Targeted educational efforts for patients and their families before the visit about what to expect and how to prepare improves efficiency with virtual pediatric orthopedic visits. Efforts to limit disparities in access to telemedicine will be needed to allow all pediatric orthopedic patients to participate in telemedicine equitably.

Purpose: To determine the reliability of performing ultrasound enhanced physical examination of infant hips amongst different types providers. The technique of ultrasound enhanced physical examination of the hip allows one of four possible outcomes: normal, dysplastic, unstable and dislocated. It can also be reported in binary form as having either a normal or abnormal outcome.
Method(s): 227 infants underwent ultrasound enhanced physical examination of the hip by one of two different examiners; one was an experienced clinician (considered the gold standard for this study) and the other was one of 3 different providers: a pediatric orthopedic fellowship trained surgeon with 4 years of experience, a fifth year orthopedic surgery resident and a pediatrician with 3 years of experience. All of the second examiners were trained by the senior examiner in a one-on-one training session lasting 2 hours. The examinations were performed on the same day but independent of each other. The results were then analyzed by a third independent blinded reviewer, who was familiar with the technique, to determine agreement amongst the examiners. Inter and intra observer reliability was measured with intraclass correlation coefficient (ICC) using one-way ANOVA, where a result of 1 represents perfect agreement and 0 represents no agreement.
Result(s): Of the 227 patients (454 hips) there were 18 dislocations, 24 unstable hips and 63 dysplastic hips (as graded by the gold standard examiner). The ICC between the gold standard and the other examiners for all hips was 0.915 (p=0.001). When adjusting for only a binary outcome of "normal" versus "abnormal" hips the ICC was 0.97 (p=0.001).
Conclusion(s): With a 2 hour one-on-one training session, ultrasound enhanced physical examination of the hip was easy to learn and perform and proved to be reliable and have low variability, especially when reported as a binary outcome of normal or abnormal. Clinicians will be able to incorporate ultrasound to their physical examination to improve the diagnostic accuracy of hip dysplasia, it is a simple technique to learn and is reliable

Methods of diagnosing and monitoring pediatric musculoskeletal infections are rapidly evolving. Key serologic tests are typically used in screening patients with suspected infections, and remain an integral part of the initial work-up. Synovial studies from arthrocentesis in possible septic arthritis, and source-specific cultures have been the foundation of our treatment algorithm. Given the prevalence of soft tissue abscesses and osteoarticular infections, advanced imaging is an advantageous tool. More affordable use and expanded access to MRI has made it a valuable adjunct to clinical picture and existing tests in order to comprehensively visualize the extent of musculoskeletal infections in children. Ongoing validation for criteria to help determine the patients that stand to benefit the most from MRI, even when surgical intervention may be delayed, remains of significant clinical interest. Given the rates of culture-negative infections, and the need for timely diagnosis, new diagnostic techniques are always being considered. The search for more accurate biomarkers, and technology such as Whole genome sequencing (WGS) and next-generation sequencing (NGS) that can rapidly identify pathogens of all types of phyla based on a small sample of DNA, has promising clinical implications. While once novel and prohibitively expensive, these tests are now being applied in university and tertiary care centers in certain scenarios. Applying these techniques to pediatric musculoskeletal will require a large change in lab workflow and training. However, the benefits of acquiring diagnostic information along with will make them a superior tool in our arsenal of diagnostic tests.

Ultrasonography is a valuable tool that can be used in many capacities to evaluate and treat pediatric orthopaedic patient. It has the capability to depict bone, cartilaginous and soft-tissue structures, and provide dynamic information. This technique can be readily applied to a wide range of pediatric conditions, including developmental dysplasia of the hip, congenital limb deficiencies, fracture management, joint effusions, and many other musculoskeletal pathologies. There are many benefits of implementing ultrasonography as a regular tool. It is readily accessible at most centers, and information can be quickly obtained in a minimally invasive way, which limits the need for radiation exposure. Ultrasonography is a safe and reliable tool that pediatric orthopaedic surgeons can incorporate into the diagnosis and management of a broad spectrum of pathology.

The purpose of this study is to determine the highest-cited articles on developmental dysplasia of the hip (DDH) and analyze their bibliometric characteristics. We searched the Web of Science (WoS) for articles with the highest number of citations on DDH and recorded their number of citations in WoS, Scopus, and Google Scholar (GS). We ranked and selected the top 100 cited articles. The average number of citations in WoS was 148 (range 66-638). The most-cited article in all databases was Crowe's total hip replacement cohort on DDH. The Journal of Bone and Joint Surgery American Volume (n = 35) had the most articles in the list, and the United States (n = 46) contributed with the most articles. The University of Bern had the most publications (n = 8). Most studies were therapeutic (n = 45) or diagnostic (n = 29). Hip preservation and arthroplasty investigations have had an increment in citations in recent decades. We provide an historical perspective on research conducted on DDH. A majority of the articles were observational and therapeutic. All databases had good correlation in the number of citations.

The purpose of this study is to analyze trends in the epidemiology of paediatric stress fractures. The New York Statewide Planning and Research Cooperative System database was queried for stress fractures in children between the ages of 6 and 18 years. After checking for monotonicity of the data, Spearman's correlation coefficient was calculated. Multivariate regressions were used to test for associations between demographic variables and risk of stress fracture. Analysis of 11 475 386 outpatient visits between 2000 and 2015 showed that the annual incidence of paediatric stress fractures increased from 1.37 cases per 100 000 outpatient visits in 2006 to 5.32 per 100 000 visits in 2015 (ρ = 0.876, P < 0.01). The mean age at the time of injury was 14.4 ± 2.8 years. Children younger than 14 years accounted for 33.6% of the cohort. Age, male sex, white ethnicity, and private insurance were statistically significant predictors of stress fractures in a multivariate model. This study is the first to document an increase in the annual incidence of paediatric stress fractures.