Faculty Bibliography

UNLABELLED:Children with cerebral palsy (CP) undergoing orthopaedic surgery require thorough preoperative evaluation to enhance outcomes and minimize risks. This comprehensive review covers various considerations. Each part of the preoperative assessment is explained, emphasizing the importance of a tailored approach to address the specific needs and complexities of children with CP. Anesthesia considerations include the pulmonary, cardiovascular, and gastrointestinal systems to reduce perioperative complications. Neurological issues, such as seizure management and medication interactions, are detailed, along with respiratory problems like aspiration and poor airway clearance, gastrointestinal concerns, nutritional status, and bowel management. Vascular considerations focus on planning access and volume resuscitation before major orthopaedic procedures. Skin-related issues, including pressure ulcers and wound healing, require preventive strategies and careful postoperative care. Other factors addressed include urinary tract problems, deep vein thrombosis risks, blood loss management, pain control, anesthesia challenges, and psychological effects. This review highlights the importance of teamwork, patient-centered care, and thorough planning to ensure the best possible outcomes for children with CP undergoing orthopaedic surgery. KEY CONCEPTS/UNASSIGNED:(1)Children with cerebral palsy (CP) who are preparing for orthopaedic surgery need a thorough preoperative assessment.(2)A thorough preoperative assessment is crucial to make sure that any surgical procedure is customized to the child's specific functional needs and that the risks and benefits are thoughtfully evaluated.(3)Multidisciplinary care and focusing on patient-centered outcomes are crucial when deciding to pursue orthopaedic surgery in this high-risk population.(4)Effective communication with the child's caregivers and health care team is vital to ensure coordinated care and a clear plan for both preoperative and postoperative management.

BACKGROUND:Children and adolescents are vulnerable to the ongoing opioid overdose epidemic in the United States. To minimize pediatric patients' exposure to opioids, efforts are underway to reduce opioid prescriptions after closed reduction and percutaneous pinning (CRPP) for supracondylar humerus fractures. Standardized pain management protocols preferentially using opioid-free analgesics are reported to be effective in managing postoperative pain and limiting the utilization of opioids. This study compares retrospective data collected before and after the implementation of a standardized postoperative pain management protocol at a large academic children's hospital. The primary aim of this study was to compare opioid prescription patterns during the 2 periods. The secondary aim of the study was to determine the effect of the protocol on minimizing prescription errors. METHODS:This Institutional Review Board-approved study was a retrospective review of pediatric patients who underwent CRPP for supracondylar humerus fractures between January 2019 and December 2021. A control cohort of patients treated before the implementation of a department-approved pain management protocol was compared with a cohort of patients treated after the implementation of a standardized postoperative pain management protocol. We compared the number of opioid prescriptions provided to patients before and after the implementation of the protocol. Descriptive statistics and chi-square analyses were used to evaluate prescribing patterns. RESULTS:After the implementation of the standardized pain medication control protocol, we observed a successful decrease in pediatric patients receiving postoperative opioids from 49.6% to 13.6% and in opioid prescribing errors from 38.6% to 12.5%. In addition, there was reduced variability in the type of narcotics prescribed. After the protocol's implementation, the most common combination of medication prescribed for postoperative pain control was acetaminophen and ibuprofen (69.5%). The chi-square test demonstrated no significant association between postoperative opioid prescription and fracture classification or length of stay. CONCLUSION/CONCLUSIONS:Opioid prescription patterns for postoperative pain management after CRPP for supracondylar humerus fractures were highly variable before the introduction of a standardized pain management protocol. The introduction of the standardized guideline effectively decreased the number of opioids prescribed at discharge, resulted in fewer opioid prescribing errors, and reduced variability in prescribing patterns among providers. LEVEL OF EVIDENCE/METHODS:Level IV-retrospective case series.

The aim of this study was to provide a review for orthopedic surgeons on the care of para athletes. The article focuses on common patient populations that present to orthopedic surgeons, including individuals with spinal cord injuries and related disorders, limb deficiencies, and neuromuscular conditions. The most common types of injuries affecting these para athletes will be discussed, as well as strategies for injury prevention and treatment. This review article also dives into the historical origins of para sports and discusses how treatment can potentially influence classification levels for para athletes. Orthopedic surgeons should encourage their patients with disabilities to participate in para sports, understand the types of injuries they may be at risk of based on disability and sports-specific factors, and work to help keep para athletes successfully competing in the sports they love.

INTRODUCTION/BACKGROUND:Children with cerebral palsy (CP) have high rates of foot deformity. Accurate assessment of foot morphology is crucial for therapeutic planning and outcome evaluation. This study aims to evaluate the reliability of a novel photo-based Modified Foot Posture Index (MFPI) in the evaluation of foot deformity in children with CP. METHODS:Thirteen orthopaedic surgeons with neuromuscular clinical focus from 12 institutions evaluated standardized standing foot photographs of 20 children with CP, scoring foot morphology using the MFPI. Raters scored the standardized photographs based on five standard parameters. Two parameters assessed the hindfoot: curvature above and below the malleoli and calcaneal inversion/eversion. Three parameters assessed the midfoot and forefoot: talonavicular congruence, medial arch height, and forefoot abduction/adduction. Summary MFPI scores range from -10 to +10, where positive numbers connote planovalgus, whereas negative numbers connote a tendency toward cavovarus. Intra- and interrater reliability were calculated using a 2-way mixed model of the intraclass correlation coefficient (ICC) set to absolute agreement. RESULTS:Feet spanned the spectrum of potential pathology assessable by the MFPI, including no deformity, mild, moderate, and severe planovalgus or cavovarus deformities. All scored variables showed high intrarater reliability with ICCs from 0.891 to 1. ICCs for interrater reliability ranged from 0.965 to 0.984. Hindfoot total score had an ICC of 0.979, with a 95% CI, 0.968-0.988 (P<0.001). The forefoot total score had an ICC of 0.984 (95% CI, 0.976-0.991, P<0.001). Mean total score by the MFPI was 3.67 with an ICC of 0.982 (95% CI, 0.972-0.990, P<0.001). CONCLUSIONS:The photo-based MFPI demonstrates high intra- and interrater reliability in assessing foot deformities in children with CP. Its noninvasive nature and ease of use make it a promising tool for both clinical and research settings. MFPI should be considered as part of standard outcomes scores in studies regarding the treatment of CP-associated foot deformities. LEVEL OF EVIDENCE/METHODS:Level V.

Although gait is one of the most globally ubiquitous concepts-traversing all geographic, cultural, and language barriers-it is often seen as an overwhelming and confusing concept. This review describes the phases and components of gait to help the clinician identify what is normal, evaluate what is not normal, and understand some common pathologic gait patterns seen in the different orthopedic subspecialties.

BACKGROUND/UNASSIGNED:Optimal management of post-operative pain is a critical component of orthopedic surgical care. There is a heightened awareness of narcotic prescribing habits given the current "opioid epidemic." The lack of standardized protocols has led to increased errors, delayed access to prescribed medications, and excessive narcotic prescribing.The purpose of this study is to assess the current trends in opioid use and document the prescribing patterns in the pediatric population before and after the implementation of a standardized protocol at our Institution. METHODS/UNASSIGNED:A multimodal postoperative pain pathway was developed and implemented throughout a large, academic, pediatric orthopedic division. The pathway utilized opioid and non-opioid pain medications and educational handouts with descriptions of the different classes of pain medication and specific dosing regimens.A query of electronic medical records was completed to identify all patients under the age of 18 that underwent inpatient orthopedic surgery from January 2016 to June 2018. Based on surgical dissection and anticipated postoperative pain, procedures were grouped into low complexity and high complexity. The average amount of opioids administered to the patients during their stay in the hospital was converted to morphine milligram equivalents (MME). The average MME was plotted, and the trends were analyzed. RESULTS/UNASSIGNED:455 inpatients met the inclusion criteria. Opioid pain medication administration was significantly higher in the high-complexity group compared to the low-complexity group. Implementing the multimodal pain pathway significantly reduces opioid administration in both groups without an increase in length of stay. CONCLUSION/UNASSIGNED:.

The process of giving and receiving feedback in orthopaedic surgery training programs is distinctly unique from any other job. Trainees are required to meet certain milestones, and faculty are responsible for the caliber of surgical skills of their graduating trainees, yet there are rarely standardized practices and guidance for providing real-time feedback. Furthermore, institutional educational programs for faculty on giving meaningful feedback are lacking. The purpose of this article was to understand how feedback is defined, how to appropriately involve the learner in the process to foster active engagement rather than destructive thinking, and to characterize important principles that can elevate one's learning and self-reflection to the fullest potential.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

BACKGROUND:Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS:Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS:After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 (P<0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P<0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P=0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P<0.01). CONCLUSION/CONCLUSIONS:A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

➤/UNASSIGNED:Sports participation can improve gait, muscle strength, and functional abilities in patients with a wide variety of disabilities. Para athletes are also at substantial risk for injury during sports participation. ➤/UNASSIGNED:Ambulant athletes with cerebral palsy are at risk for soft-tissue injuries about the knee as well as foot and ankle injuries. Wheelchair athletes are at risk for osteoporotic fractures and shoulder girdle injuries. Limb-deficient athletes are prone to low back pain and overuse injuries of the contralateral extremity. ➤/UNASSIGNED:Para athletes are vulnerable to abuse during sports participation, and physicians should promptly report any possible abuse or mistreatment. ➤/UNASSIGNED:Orthopaedic surgeons should understand disability and sport-specific risk factors for injury in para athletes in order to initiate early management and injury prevention protocols.