Faculty Bibliography

As the world continues to battle the COVID-19 pandemic, health care providers are committed to providing care not only to our patients but also to our community. Schools in New York City (NYC) went remote on March 15, 2020. This can prove detrimental to student development and education. Numerous leaders in education and public health have noted that the remote learning will further widen educational and income disparities in those from underserved and underrepresented areas. A group of orthopedic residents who attended NYC public schools and were current house staff at a major academic tertiary medical center in NYC developed and implemented a virtual high-school mentorship program. This program incorporated weekly lectures and discussions given by health care providers to students interested in health care from NYC public high schools. The goal of this program was to provide mentorship during the COVID pandemic to a high-school audience where greater than 80% of students are considered to be living below the poverty level. Although school is now back in session, these programs should be continued in person. It is the aim of the authors that other orthopedic residents and health care providers implement similar programs in their communities.

PURPOSE/OBJECTIVE:To identify current medical and psychosocial needs and to examine the effectiveness of healthcare transition program for adult-aged patients with neuromuscular conditions transitioning from pediatric to adult services. DESIGN AND METHODS/METHODS:At Neuromuscular Transition Clinic visit, 46 patients were evaluated and referred to adult-based providers, if did not currently have one, from an acquired list of interested clinicians. At mean follow-up of 22 months, 42 were interviewed by phone regarding referrals for Core Services (primary care, physiatry, dental care and gynecology), Medical Specialties and Rehabilitation Services. Mean age was 30 years with 62% males. Majority (74%) had cerebral palsy. Sixty percent were non-ambulatory. RESULTS:As per protocol, all were indicated to need Core Services. Eighty-three percent already had adult primary care provider. Most referrals were given for physiatry (62%), vocational training (100%), and occupational therapy (88%). At follow-up, visits were completed most frequently with adult provider for primary care (100%), occupational therapy (78%), and neurology (75%). Referred provider was seen 100% for physiatry, neurology, physical therapy, occupational therapy and vocational training. Of the total 125 referrals given across all services, 73 (58%) participants had completed a visit with an adult provider. CONCLUSIONS:As only about 60% transitioned to adult-based services after referral, healthcare transition remains challenging and requires tailoring of services according to patients' needs, staff and willing-and-available adult-based providers. PRACTICE IMPLICATIONS/CONCLUSIONS:Transitioning healthcare of patients with neuromuscular conditions from pediatric- to adult-based providers remains challenging. This clinical specialty requires tailoring of services based on patient's needs, and availability of adult-based providers and resources.

BACKGROUND/UNASSIGNED:In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office. OBJECTIVE/UNASSIGNED:Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting. CONCLUSION/UNASSIGNED:This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.

PURPOSE/OBJECTIVE:Tranexamic acid (TXA), a synthetic lysine analogue, has been used in orthopedic procedures to limit blood loss and prevent allogeneic blood transfusions. However, data are scarce on its use in hip reconstruction of patients with cerebral palsy (CP). This study examines the effect of TXA on patients with CP undergoing hip reconstruction with at least two osteotomies. METHODS:This is a single-center, retrospective study of patients with CP who underwent hip reconstruction with two or more osteotomies from January 2013 to April 2019. There were 43 patients, with a mean age of 9.9 years. Age, procedure, preoperative and postoperative hemoglobin/hematocrit, estimated blood loss (EBL), transfusions and length of stay were recorded. The patients were split into the following two groups: 24 patients who had received intraoperative TXA and 19 who had not. RESULTS:Age, EBL, mean preoperative and postoperative hemoglobin or hematocrit, preoperative to postoperative hematocrit drop, and length of stay were similar for the two groups (p > 0.05). The risk for intraoperative transfusion (21 vs. 17%), postoperative transfusion (26 vs. 8%), and any transfusion (42 vs. 21%) appeared to be greater in the group that did not receive TXA, but this difference did not achieve statistical significance. CONCLUSION/CONCLUSIONS:This pilot study shows patients with CP undergoing hip reconstruction with two or more osteotomies; the use of TXA, while not statistically significant, shows a trend toward a decreased need for allogeneic blood transfusion.

BACKGROUND:Women have long been underrepresented in orthopaedic surgery; however, there is a lack of quantitative data on the representation of women in orthopaedic academic program leadership. QUESTIONS/PURPOSES:(1) What is the proportion of women in leadership roles in orthopaedic surgery departments and residency programs in the United States (specifically, chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs)? (2) How do women and men leaders compare in terms of years in position in those roles, years in practice, academic rank, research productivity as represented by publications, and subspecialty breakdown? (3) Is there a difference between men and women in the chair or program director role in terms of whether they are working in that role at institutions where they attended medical school or completed their residency or fellowship? METHODS:We identified 161 academic orthopaedic residency programs from the Accreditation Council for Graduate Medical Education (ACGME) website. Data (gender, length of time in position, length of time in practice, professorship appointment, research productivity as indirectly measured via PubMed publications, and subspecialty) were collected for chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs in July 2020 to control for changes in leadership. Information not provided by the ACGME and PubMed was found using orthopaedic program websites and the specific leader's curriculum vitae. Complete data were obtained for chairs and program directors, but there were missing data points for vice chairs, assistant program directors, and division chiefs. All statistical analysis was performed using SPSS using independent t-tests for continuous variables and the Pearson chi-square test for categorical variables, with p < 0.05 considered significant. RESULTS:Three percent (4 of 153) of chairs, 8% (5 of 61) of vice chairs, 11% (18 of 161) of program directors, 27% (20 of 75) of assistant program directors, and 9% (45 of 514) of division chiefs were women. There were varying degrees of missing data points for vice chairs, assistant program directors, and division chiefs as not all programs reported or have those positions. Women chairs had fewer years in their position than men (2 ± 1 versus 9 ± 7 [95% confidence interval -9.3 to -5.9]; p < 0.001). Women vice chairs more commonly specialized in hand or tumor compared with men (40% [2 of 5] and 40% [2 of 5] versus 11% [6 of 56] and 4% [2 of 56], respectively; X2(9) = 16; p = 0.04). Women program directors more commonly specialized in tumor or hand compared with men (33% [6 of 18] and 17% [3 of 18] versus 6% [9 of 143] and 11% [16 of 143], respectively; X2(9) = 20; p = 0.02). Women assistant program directors had fewer years in practice (9 ± 4 years versus 14 ± 11 years [95% CI -10.5 to 1.6]; p = 0.045) and fewer publications (11 ± 7 versus 30 ± 48 [95% CI -32.9 to -5.8]; p = 0.01) than men. Women division chiefs had fewer years in practice and publications than men and were most prevalent in tumor and pediatrics (21% [10 of 48] and 16% [9 of 55], respectively) and least prevalent in spine and adult reconstruction (2% [1 of 60] and 1% [1 of 70], respectively) (X2(9) = 26; p = 0.001). Women program directors were more likely than men to stay at the same institution they studied at for medical school (39% [7 of 18] versus 14% [20 of 143]; odds ratio 3.9 [95% CI 1.4 to 11.3]; p = 0.02) and trained at for residency (61% [11 of 18] versus 42% [60 of 143]; OR 2.2 [95% CI 0.8 to 5.9]; p = 0.01). CONCLUSION:The higher percentage of women in junior leadership positions in orthopaedic surgery, with the data available, is a promising finding. Hand, tumor, and pediatrics appear to be orthopaedic subspecialties with a higher percentage of women. However, more improvement is needed to achieve gender parity in orthopaedics overall, and more information is needed in terms of publicly available information on gender representation in orthopaedic leadership. CLINICAL RELEVANCE:Proportional representation of women in orthopaedics is essential for quality musculoskeletal care, and proportional representation in leadership may help encourage women to apply to the specialty. Our findings suggest movement in an improving direction in this regard, though more progress is needed.

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.

INTRODUCTION/BACKGROUND:Maternity leave among orthopaedic surgeons is not well understood. This study seeks to quantify past and current maternal leave characteristics of female orthopaedic surgeons. METHODS:A survey was distributed to the members of the Ruth Jackson Orthopaedic Society and Women in Orthopaedics, an online group exclusive to female orthopaedic surgeons in practice or in training. The survey was open from April 2018 to October 2018 with access gained by way of a web-based link. Respondents were queried regarding demographics and maternity leave characteristics including age at conception, length of leave given/taken, and cost. RESULTS:A total of 801 surveys were completed with 452 surveys returning with information regarding past pregnancies. Of the 452 surgeons with children, the average leave offered was 4.6 ± 4.2 weeks for the first child, with 8.2 ± 7.4 weeks taken. A difference was observed (P < 0.001) between the amount of leave taken between residents (6.3 ± 5.0 weeks), fellows (8.3 ± 7.2 weeks), and practicing surgeons (9.6 ± 8.5 weeks). The average cost of the first leave was $40,932 ± 61,258. The average cost during training was different than during practice ($154 versus $45,350, P < 0.001). The length of leave offered (P = 0.05) and taken (P < 0.001) affects the cost, whereas delivery type, timing of stopping clinic, taking calls, and operating did not. Each additional week of leave offered saved a surgeon $2,583, and each additional week taken cost $3,252. DISCUSSION/CONCLUSIONS:Residents take shorter leaves than fellows and attendings. The cost of taking leave is substantial, and the cost during practice is higher than during training. The amount of leave taken is greater than the amount of paid leave offered.

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.

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

AIM/OBJECTIVE:To assess the accuracy of consumer available wrist-based and hip-based activity trackers in quantitatively measuring ambulation in children with cerebral palsy (CP). METHOD/METHODS:Thirty-nine children (23 males, 16 females; mean age [SD] 9y 7mo [3y 5mo]; range 4-15y) with CP were fitted with trackers both on their wrist and hip. Each participant stood for 3 minutes, ambulated in a hallway, and sat for 3 minutes. The number of steps and distance were recorded on trackers and compared to manually counted steps and distance. Pearson correlation coefficients were determined for the number of steps during ambulation from each tracker and a manual count. Mean absolute error (MAE) and range of errors were calculated for steps during ambulation for each tracker and a manual count and for distance for each tracker and hallway distance. RESULTS:For the number of steps, a weak inverse relationship (r=-0.033) was found for the wrist-based tracker and a strong positive relationship (r=0.991) for the hip-based tracker. The MAE was 88 steps for the wrist-based and seven steps for the hip-based tracker. The MAE for distance was 0.06 miles for the wrist-based and 0.07 miles for the hip-based tracker. INTERPRETATION/CONCLUSIONS:Only the hip-based tracker provided an accurate step count; neither tracker was accurate for distance. Thus, ambulation of children with CP can be accurately quantified with readily available trackers.