Faculty Bibliography

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.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients <10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p < 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p < 0.001) and mortality (OR: 2.05 [1.65-2.54], p < 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p < 0.001) and extLOS (OR: 2.83 [2.48-3.22], p < 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

Background and Objective(s): Commercially available activity tracking devices present the opportunity to quantify functional changes in ambulatory status of patients with cerebral palsy (CP). The purpose of this study was to assess the accuracy of a waist-based and a wrist-based wearable device for tracking steps and walking distance of children with CP in a controlled setting. Study Design: Prospective cohort study. Study Participants & Setting: Participants were 27 children, mean age of 9.6 years (range, 4-15), with CP and a Gross Motor Function Classification System (GMFCS) score between I and III. Thirteen children were diagnosed with hemiplegia (48%), 13 with diplegia (48%), and 1 with quadriplegia (4%). Seventeen were classified as GMFCS I (63%), 3 as II (11%), and 7 as III (26%). Fourteen children wore ankle-foot orthoses (52%), one wore HKAFO (4%) and 12 wore no orthotics (44%). Four patients used Lofstrand crutches (15%), two used posterior rollators (7%), and 21 patients used no assistive devices (78%). Materials/Methods: Each participant was outfitted with both a waist-based activity tracker, FitBitTM One, and a wrist-based tracker, FitBitTM Flex. They ambulated at a self-selected speed for 670 feet in a hallway. Orthotics and assistive devices were utilized as per the child's normal routine. Number of steps and distance were collected from both trackers. A researcher simultaneously used a tally counter to manually count total number of steps. Pearson correlation coefficients were determined for number of steps from each tracker and the manual count. Mean absolute percent error (MAPE) was calculated for steps for each tracker and the manual count, and for the distance from each tracker and the hallway distance. Results: For number of steps, a strong positive correlation was found between the waist tracker and the manual count (r=0.997), whereas a weak positive correlation was found between wrist tracker and manual count (r=0.223). MAPE for steps was 1% for the waist tracker and 12% for the wrist tracker. For distance, MAPE was 56% for the waist tracker and 41% for the wrist tracker. Conclusions/Significance: The waist-based activity tracker provided an accurate step count. Neither waist-based nor wristbased tracker was accurate for distance measurement. Thus, the walking ability of ambulatory children with CP can be accurately quantified with a readily available inexpensive activity tracker. This has the potential to enable clinicians to assess the effects of various treatments on the real-world activity level of patients with CP

Foot and ankle deformities in cerebral palsy can be effectively treated with surgery. Surgery should be considered in patients with significant deformity and those who have pain or difficulty with orthotic and shoe wear. Equinus contracture of both gastrocnemius and soleus can be treated with open tendoachilles lengthening; ankle valgus with medial epiphysiodesis. Equinovarus is more commonly seen in hemiplegic patients and this deformity can usually be treated with tendon transfers. Triple arthrodesis is an option in children with severe degenerative changes. It is important to address all aspects of the child's pathology at the time of surgical correction.

BACKGROUND: The purpose of this study was to evaluate the necessity of early postoperative radiographs after pinning of supracondylar humerus fractures by determining both the percentage of patients who displayed change in fracture fixation and whether these changes affected their outcome. METHODS: A series of 643 consecutive patients who underwent operative management of Gartland type II and III fractures at our institution between January 2002 and December 2010 were reviewed. Demographic data were obtained through chart review, including age, sex, extremity, fracture type, and mechanism. Intraoperative fluoroscopic images were compared with postoperative radiographs to identify changes in fracture alignment and pin placement. RESULTS: A total of 643 patients (320 females, 323 males) with a mean age of 6.1 years (range, 1.1 to 16.0) were reviewed. Fifty-seven percent of fractures were classified as type II and 43% were type III. The overall complication rate was 8.8% (57/643). Pin backout or fracture translation was seen in 32 patients (4.9%) at the first postoperative visit. All of these patients sustained type III fractures. One of these patients required further operative management. Patients with changes in pin or fracture alignment did not demonstrate a statistically significant difference in time to first postoperative visit (P=0.23), days to pin removal (P=0.07), or average follow-up time (P=0.10). Fracture severity did not correlate with change in alignment (P=0.952). No postoperative neurological complications were observed in patients with alignment changes. CONCLUSIONS: Mild alignment changes and pin migration observed in postoperative radiographs after pinning of supracondylar humerus fractures have little effect on clinical management parameters or long-term sequelae. Radiographs can therefore be deferred until the time of pin removal provided adequate intraoperative stability was obtained. LEVEL OF EVIDENCE: Level IV.