Publications by authors named "Apurva S Shah"

74 Publications

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

J Pediatr Orthop 2021 Jul;41(6):389-394

Division of Orthopaedic.

Background: Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

Methods: This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

Results: A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

Conclusion: Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001825DOI Listing
July 2021

Open Reduction and Suture Fixation of Acute Sternoclavicular Fracture-Dislocations in Children.

JBJS Essent Surg Tech 2020 Jul-Sep;10(3). Epub 2020 Sep 18.

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Background: Acute sternoclavicular fracture-dislocation is associated with high-energy trauma and is being increasingly recognized in children. These injuries are associated with compression of mediastinal structures and can be life-threatening. The management of acute sternoclavicular fracture-dislocation includes closed reduction or open surgical stabilization; however, limited success is reported with closed reduction. To our knowledge, there are no detailed descriptions of open reduction and suture fixation of acute sternoclavicular fracture-dislocation in children.

Description: Following diagnosis of acute sternoclavicular fracture-dislocation, the timing of surgical treatment is determined according to several patient and surgical factors. Among patients with hemodynamic instability, respiratory compromise, or evidence of asymmetric perfusion, surgical treatment is needed on an emergency basis. In the absence of these factors, surgical treatment can be performed on an urgent basis. It is important to communicate with vascular or thoracic surgeons prior to proceeding to the operating room because of the rare case in which advanced surgical access or vascular repair is required. In the operating room, general anesthesia and large-bore intravenous access are required. Patients are positioned supine on a radiolucent table, and a small bump is placed between the scapulae to elevate the medial aspect of the clavicle. The contralateral sternoclavicular joint and medial aspect of the clavicle should be prepared into the sterile field, as well as both sides of the groin in case vascular access is needed. A 6 to 8-cm incision is centered on the medial aspect of the clavicle, extending to the manubrium. Standard dissection to the clavicle is performed, and care is taken to maintain the integrity of the sternoclavicular ligament complex. Circumferential dissection of the medial clavicular metaphysis is usually required in order to mobilize the dislocated fragment. Reduction of the physeal fracture usually requires axial traction and extension of the ipsilateral shoulder with the aid of a reduction clamp on the medial clavicular metaphysis. In some cases, a Freer elevator can be placed between the metaphysis and epiphysis to shoehorn the clavicle from posterior to anterior. Once reduced, the fracture-dislocation is usually stable; however, the reduction is augmented with suture fixation. The sternoclavicular joint capsule should be repaired if disrupted, and the incision should be closed in layers. Postoperatively, the arm is placed in a sling, and range of motion is commenced at 4 weeks.

Alternatives: Alternative management of acute sternoclavicular fracture-dislocation includes closed reduction, plate fixation, and ligament reconstruction.

Rationale: In our experience, closed reduction is often unsuccessful, which is consistent with the experiences reported by other authors. In addition, suture fixation is sufficient and plate fixation is not required because this injury is relatively stable following reduction. Lastly, ligament reconstruction with use of autograft or allograft may be indicated but is more relevant in chronic cases with injury or attenuation of the sternoclavicular ligament complex. Open reduction allows for direct visualization of the fracture reduction, and suture fixation allows for increased stability without the need for hardware or secondary surgical procedures.

Expected Outcomes: We expect patients to achieve full range of motion and strength without any joint instability as reported by Waters et al..

Important Tips: There is an inherent risk of vascular injury with open reduction and suture fixation. This risk is mitigated with perioperative planning and consultation with vascular or thoracic surgeons. General surgeons should always be available when these procedures are performed in case of vascular issues or emergencies.It is sometimes difficult to reduce the dislocation, but additional maneuvers allow for controlled reduction of the displaced clavicle, such as using a Freer elevator and serrated clamp.Assessing fracture reduction can be difficult intraoperatively. Including the contralateral sternoclavicular joint in the sterile surgical field can be helpful in assessing fracture reduction and osseous contour.
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http://dx.doi.org/10.2106/JBJS.ST.19.00074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154393PMC
September 2020

Open reduction of radial neck fractures in children: injury severity predicts the radiographic and clinical outcomes.

J Shoulder Elbow Surg 2021 May 18. Epub 2021 May 18.

Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address:

Background: Radial neck fractures are the third most common elbow fracture in children. Open reduction may be required if closed or mini-open techniques are not successful in reducing the fracture. Previous reports on open reduction have noted poor outcomes and complications with this treatment approach. However, it is unknown whether it is the open procedure itself or the severity of the initial injury that leads to the poor results. The purpose of this study was to evaluate the correlation between intraoperative findings at the time of open reduction of radial neck fractures and the clinical and radiographic outcomes.

Methods: Data from patients who underwent open reduction for an acute radial neck fracture between January 2009 and December 2018 were abstracted and reviewed. Patients undergoing open treatment for a nonunion or malunion and those with inadequate follow-up were excluded. Demographic data, injury characteristics, treatment strategies, intraoperative findings, and clinical and radiographic outcomes were assessed.

Results: Twenty-two patients met the inclusion criteria. Of these patients, 14 were girls. The mean age was 9.7 ± 3 years, and the mean follow-up period was 15.8 months. Fifteen patients had a Judet grade IV displacement. Fair or poor outcomes were observed in 12 patients (55%). Ten reoperations were recorded during the study period. Age, weight, and associated injuries were not predictive of poor outcomes. Intraoperative findings of soft-tissue stripping and radial head comminution were the only significant predictors of fair or poor clinical outcomes (P < .001) and subsequent radiographic changes including fragmentation and collapse of the radial head and arthritic changes (P < .001). The quality of reduction and the choice of hardware were not significantly associated with either clinical or radiographic outcomes.

Conclusion: Our findings support the notion that the outcomes of open reduction of radial neck fractures are most closely correlated with the injury severity, with the intraoperative findings of complete soft-tissue stripping or comminution of the radial head fragment being significant predictors of poor clinical and radiographic outcomes. The choice of hardware and the quality of reduction achieved at the time of surgery have less significance than injury severity.
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http://dx.doi.org/10.1016/j.jse.2021.04.037DOI Listing
May 2021

Opioid Prescriptions After Pediatric Orthopedic Surgery: Analyzing Rates of Unfilled Prescriptions.

J Pediatr Orthop 2021 May 13. Epub 2021 May 13.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco Department of Pediatric Orthopedics, UCSF Benioff Children's Hospital Oakland, Oakland, CA Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY Perelman School of Medicine at the University of Pennsylvania Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Background: The prevalence of nonmedical use of prescription opioids among American teenagers is staggering. Reducing the quantity of postoperative opioid prescriptions can help address this epidemic by decreasing the availability of opioids. As the fourth most common opioid prescribers, orthopaedic surgeons are primed to lead efforts to reverse this crisis. The purpose of this study was to determine patient factors associated with filling opioid prescriptions after pediatric orthopaedic surgery and to recommend potential methods to limit excess opioid prescriptions.

Methods: This retrospective cohort study included 1413 patients who were prescribed opioids upon discharge after an orthopaedic surgical procedure at a single urban children's hospital from 2017 to 2018. The state's Prescription Drug Monitoring Program was used to determine which patients filled their opioid prescriptions. Comparisons of demographic, clinical, and surgical factors were made between patients that filled their opioid prescription upon discharge and those that did not. Statistical analysis included λ2, Mann-Whitney U, and binary logistic regression for significant factors from bivariate analysis.

Results: Nine percent (n=127) of patients did not fill their opioid prescriptions after discharge. Those who filled and did not fill prescriptions were similar in terms of sex, ethnicity, race, insurance type, and age at surgery (P>0.05). Patients who did not fill their opioid prescriptions received significantly fewer opioids during their postoperative hospital course (5.3 vs. 7.7 mg oxycodone, P=0.01). Not receiving oral oxycodone during postoperative hospitalization (odds ratio=2.16, 95% confidence interval: 1.49-3.14) and undergoing upper extremity surgery (odds ratio=2.00, 95% confidence interval: 1.37-2.91) were independently associated with not filling opioid prescriptions after surgery in the multivariate analysis.

Conclusions: This study identified a subset of pediatric orthopaedic surgery patients who were prescribed opioids upon discharge but did not fill those prescriptions. Factors that increased the likelihood that patients did not fill their prescriptions upon discharge included fewer postoperative hospital course opioids, no oral oxycodone, and surgery on the upper extremity. Future studies must be performed to help decrease the number of opioids prescribed unnecessarily.

Level Of Evidence: Level III-prognostic cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001859DOI Listing
May 2021

A Gender Gap in Publishing? Understanding the Glass Ceiling in Pediatric Orthopaedic Surgery.

J Pediatr Orthop 2021 May 3. Epub 2021 May 3.

Division of Orthopedic Surgery, Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Background: Women are underrepresented across most surgical specialties and especially in the field of orthopaedic surgery. Despite pediatric orthopaedic surgery being one of the most gender diverse subspecialties in orthopaedics, women may still face barriers to academic advancement. Research presentations at national meetings and publication record are important drivers of advancement in the field of academic orthopaedic surgery. The aim of this study is to assess whether research abstracts authored by women are less likely to be published than abstracts authored by men.

Methods: Abstracts from research podium presentations given at the Pediatric Orthopaedic Society of North America annual meetings from 2006 to 2020 were reviewed to assess research quality and determine basic study characteristics. For each abstract, author gender was determined through a search of institutional websites and professional networking websites for gender-specific pronouns. Resulting publications corresponding to the 2006 to 2018 were identified using a systematic search of PubMed and Google Scholar databases. Kaplan-Meier inverse survival analysis with log rank test were used to determine differences in publication rates based on whether the last (senior) author was female versus male. Multivariate, binary logistic regression was performed to assess factors predictive of eventual publication.

Results: One thousand five hundred and eighty-one of 1626 (97.2%) of abstracts from 2006 to 2020 had an identifiable last author gender, with 17.8% (281/1581) female. No differences in study quality were identified across genders including sample size, level of evidence, or impact factor of journal if leading to publication. Women were more likely to author abstracts in foot, ankle, or lower extremity surgery [17.8% (50/281) vs. 12.9% (168/1300), P=0.032] and less likely to author abstracts focusing on the hip [11.0% (31/281) vs. 17.1% (222/1300), P=0.012]. Abstracts with women as the last author were significantly less likely to be published compared with abstracts with men as the last author [59.6% (143/240) vs. 67.9% (783/1154), P=0.013]. Multivariate analysis demonstrated that last author female gender was predictive of a lower likelihood of publication (odds ratio: 0.684, 95% confidence interval: 0.513-0.912, P=0.010). Women were less likely to be the last author of abstracts presented by study groups [2.1% (6/281) vs. 5.5% (71/1300), P=0.019].

Conclusion: In pediatric orthopaedic surgery, abstracts authored by women are less likely to reach publication, despite no identifiable differences in study quality. Reasons for this discrepancy must be explored including insufficient mentorship, exclusion from study group participation, or potential bias against female researchers in the field of orthopaedic surgery.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001843DOI Listing
May 2021

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children.

J Hand Surg Am 2021 Apr 19. Epub 2021 Apr 19.

Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Electronic address:

Purpose: Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort.

Methods: A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores.

Results: A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores.

Conclusions: Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function.

Type Of Study/level Of Evidence: Diagnostic II.
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http://dx.doi.org/10.1016/j.jhsa.2021.02.026DOI Listing
April 2021

Refilling Opioid Prescriptions After Pediatric Orthopaedic Surgery: An Analysis of Incidence and Risk Factors.

J Pediatr Orthop 2021 Mar;41(3):e291-e295

Perleman School of Medicine, University of Pennsylvania.

Background: Understanding which pediatric patients seek opioid refills is crucial as prescription opioid use in childhood is associated with an increased risk of future opioid misuse. Orthopaedic surgeons are optimally positioned to lead the charge in addressing the opioid epidemic. The aim of this study was to describe the incidence of and risk factors associated with requiring opioid refills after pediatric orthopaedic surgery in children.

Methods: This retrospective case-control study included 1413 patients aged 0 to 18 years that underwent orthopaedic surgery at a single tertiary care children's hospital and were prescribed opioids at discharge. Using the state Prescription Drug Monitoring Program (PDMP) database, we determined which patients filled additional opioid prescriptions within 6 months following an orthopaedic procedure. Comparisons were made between patients that sought additional opioids and those that did not use bivariate analysis and binomial logistic regression.

Results: In total, 31 (2.2%) patients sought additional opioid prescriptions a median 41 days postoperatively (range, 2 to 184). Nearly half of these patients obtained refills from providers outside of our institution, suggesting that previous reports using hospital records may underestimate its prevalence. Factors associated with requiring opioid refills included receiving hydromorphone [odds ratio (OR)=3.04, P=0.04] or methadone (OR=38.14, P<0.01) while inpatient, surgery on the axial skeleton (OR=5.42, P=0.01) or lower extremity (OR=2.49, P=0.04), and nonfracture surgery (OR=3.27, P=0.01). Patients who obtained additional opioids received significantly more opioids during their inpatient recovery (32.9 vs. 11.1 morphine equivalents, P<0.01).

Conclusions: Approximately 2% of children and families obtain additional opioids within 6 months of orthopaedic surgery. The volume of opioids during inpatient hospitalization may predict the need for opioid prescription refills after discharge. Clinicians should maximize efforts to achieve pain control with multimodal analgesia and opioid alternatives, and use caution when administering high-dose opioids during postoperative hospitalization.

Level Of Evidence: Level III-prognostic.
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http://dx.doi.org/10.1097/BPO.0000000000001736DOI Listing
March 2021

Pediatric scaphoid fracture: diagnostic performance of various radiographic views.

Emerg Radiol 2021 Jun 15;28(3):565-572. Epub 2021 Jan 15.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.

Purpose: The purpose of this study was to systematically investigate the performance of different radiographic views in the identification of scaphoid fractures in children.

Methods And Materials: This case-control study compared 4-view radiographic examinations of the wrist between children with scaphoid fracture and age- and sex-matched children without fractures performed between January 2008 and July 2019. After randomization, each examination was reviewed 3 times, at least 1 week apart, first using each view separately and later using multiple views without (3-view) and with the posteroanterior (PA) scaphoid view (4-view), to determine the presence or absence of a scaphoid fracture. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with inter-rater agreement.

Results: The study group of 58 children (48 boys and 10 girls; mean age 13.1 ± 2.1 years) included 29 with scaphoid fractures (8 corner, 9 distal pole, 10 waist, and 2 proximal pole) and 29 without fractures. Multiple views had higher sensitivity (3-view, 93.0%; 4-view, 96.5%) for fracture identification when compared to individual views (41.0-89.6%). The oblique view was 100% specific for the identification of a scaphoid fracture, but it lacked sensitivity. The PA scaphoid view had the highest sensitivity (89.6%) and NPV (90%) when compared to other individual views and its inclusion in the 4-view examinations produced the highest inter-rater agreement (93%, κ = 0.86).

Conclusion: Multiple radiographic views of the wrist with the inclusion of a PA scaphoid view (4-view) produced the highest sensitivity, NPV, and inter-rater agreement for the identification of a scaphoid fracture in children.
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http://dx.doi.org/10.1007/s10140-020-01897-9DOI Listing
June 2021

Symptomatology and racial disparities among children undergoing universal preoperative COVID-19 screening at three US children's hospitals: Early pandemic through resurgence.

Paediatr Anaesth 2021 03 2;31(3):368-371. Epub 2020 Dec 2.

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

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http://dx.doi.org/10.1111/pan.14074DOI Listing
March 2021

Socioeconomic Deprivation and Its Adverse Association with Adolescent Fracture Care Compliance.

JB JS Open Access 2020 Apr-Jun;5(2):e0064. Epub 2020 Jun 2.

Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Background: Socioeconomic deprivation increases fracture incidence in adolescents, but its impact on fracture care is unknown. The area deprivation index (ADI), which incorporates 17 factors from the U.S. Census, measures socioeconomic deprivation in neighborhoods. This investigation aimed to determine the impact of socioeconomic deprivation and other socioeconomic factors on fracture care compliance in adolescents.

Methods: This study included patients who were 11 to 18 years of age and received fracture care at a single urban children's hospital system between 2015 and 2017. Demographic information (sex, race, caregiver status, insurance type) and clinical information (mechanism of injury, type of treatment) were obtained. The ADI, which has a mean score of 100 points and a standard deviation of 20 points, was used to quantify socioeconomic deprivation for each patient's neighborhood. The outcome variables related to compliance included the quantity of no-show visits at the orthopaedic clinic and delays in follow-up care of >1 week. Risk factors for suboptimal compliance were evaluated by bivariate analysis and multivariate logistic regression.

Results: The cohort included 457 adolescents; 75.9% of the patients were male, and the median age was 16.1 years. The median ADI was 101.5 points (interquartile range, 86.3 to 114.9 points). Bivariate analyses demonstrated that higher ADI, black race, single-parent caregiver status, Medicaid insurance, non-sports mechanisms of injury, and surgical management are associated with suboptimal fracture care compliance. Adolescents from the most socially deprived regions were significantly more likely to have delays in care (33.8% compared with 20.1%; p = 0.037) and miss scheduled orthopaedic visits (29.9% compared with 7.1%; p < 0.001) compared with adolescents from the least deprived regions. ADI, Medicaid insurance, and initial presentation to the emergency department were independent predictors of suboptimal care compliance, when controlling for other variables.

Conclusions: Socioeconomic deprivation is associated with an increased risk of suboptimal fracture care compliance in adolescents. Clinicians can utilize caregiver and insurance status to better understand the likelihood of fracture care compliance. These findings highlight the importance of understanding differences in each family's ability to adhere to the recommended follow-up and of implementing measures to enhance compliance.
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http://dx.doi.org/10.2106/JBJS.OA.19.00064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418910PMC
June 2020

Universal Screening for COVID-19 in Children Undergoing Orthopaedic Surgery: A Multicenter Report.

J Pediatr Orthop 2020 Nov/Dec;40(10):e990-e993

Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: The COVID-19 pandemic has substantially altered the typical process around performing surgery to ensure protection of health care workers, patients, and their families. One safety precaution has been the implementation of universal preoperative screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study examines the results of universal screening on children undergoing orthopaedic surgery.

Methods: This is a retrospective cohort study evaluating the incidence and symptomatology of COVID-19 in all patients presenting for orthopaedic surgery at 3 pediatric tertiary care children's hospitals during the COVID-19 pandemic (March to June 2020). All patients underwent universal screening with a nasopharyngeal swab to detect presence of SARS-CoV-2. Bivariate and multivariate logistic regression analysis was performed to identify risk factors for positive COVID-19 screening.

Results: In total, 1198 patients underwent preoperative screening across all 3 institutions and 7 (0.58%) had detection of SARS-CoV-2. The majority of patients (1/7, 86%) were asymptomatic. Patients that tested positive were significantly more likely to be Hispanic (P=0.046) and had greater number of medical comorbidities (P=0.013), as scored on the American Society of Anesthesiologists (ASA) physical status score. A known COVID-19 positive contact was found to be a significant risk factor in the multivariate analysis (P=0.004).

Conclusions: Early results of universal preoperative screening for COVID-19 demonstrates a low incidence and high rate of asymptomatic patients. Health care professionals, especially those at higher risk for the virus, should be aware of the challenges related to screening based solely on symptoms or travel history and consider universal screening for patients undergoing elective surgery.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000001657DOI Listing
October 2020

Outcomes After Surgical Fixation of Posterior Sternoclavicular Physeal Fractures and Dislocations in Children.

J Pediatr Orthop 2021 Jan;41(1):11-16

Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Acute sternoclavicular fractures and dislocations (SCFDs) are a rare but important injury in pediatric patients. SCFDs are either true dislocations, or more commonly, physeal fractures in children. The reduction is advised given the proximity to surrounding vascular structures, and some authors advocate for routine fixation given rates of redisplacement after closed reduction. The purpose of the current study was to provide validated long-term functional outcome data following open reduction and surgical fixation of pediatric SCFDs, as well as provide injury and demographic information.

Methods: This is a retrospective observational study with a subset of patients reporting functional outcomes. Patients under the age of 18 that had surgically managed acute posterior SCFD from 1990 to 2018 were included. A retrospective chart review was performed to obtain demographic, clinical, and surgical details. Patients with a minimum of 6-month follow-up were contacted to assess outcomes. Functional outcomes of interest included QuickDash, Visual Analog Scale pain rating, Single Assessment Numeric Evaluation of shoulder function, and PROMIS Upper Extremity questionnaire. Statistical analysis included descriptive statistics.

Results: A total of 37 patients that sustained an acute posterior SCFD during the study period were included. The average age at the time of injury was 15.2±2.1 years and 89% were male. Patient-reported outcomes were obtained for 14 patients with a mean follow-up of 4.5 years. The mean QuickDash score was 5.1/100 with 0 being normal, and the mean Visual Analog Scale pain rating was 0.7/10. The mean Single Assessment Numeric Evaluation score was 96% with 100% being completely normal. The mean PROMIS score was 55 with 50 being the mean of the relevant reference population. Approximately 29% (4/14 patients) stated that their injury negatively affected their ability to participate in sports.

Conclusions: There is a paucity of literature on functional outcomes after surgical management of pediatric acute posterior SCFD. Functional outcomes after surgery were satisfactory in this cohort with most patients being able to perform major activities of daily living. Additional future studies with larger cohorts and comparative groups are needed to better understand outcomes in this population.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001691DOI Listing
January 2021

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

J Pediatr Orthop 2020 Nov/Dec;40(10):e927-e931

Department of Orthopaedic Surgery and Biomechanical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN.

Background: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment.

Methods: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging.

Results: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention.

Conclusions: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD.

Level Of Evidence: Level III-therapeutic case control study.
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http://dx.doi.org/10.1097/BPO.0000000000001649DOI Listing
February 2021

Institutional Variation in Surgical Rates and Costs for Pediatric Distal Radius Fractures: Analysis of the Pediatric Health Information System (PHIS) Database.

Iowa Orthop J 2020 ;40(1):75-81

Boston Children's Hospital, Department of Orthopaedics, Boston, MA.

Background: Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database.

Methods: The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children's hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year.

Results: The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution.

Conclusions: In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care..
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368512PMC
February 2021

Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial.

J Med Internet Res 2020 07 29;22(7):e17750. Epub 2020 Jul 29.

Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, United States.

Background: Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain.

Objective: This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries.

Methods: Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups.

Results: A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).

Conclusions: In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference.

Trial Registration: ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.
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http://dx.doi.org/10.2196/17750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458063PMC
July 2020

Team Approach: Management of Brachial Plexus Birth Injury.

JBJS Rev 2020 07;8(7):e1900200

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00200DOI Listing
July 2020

Growth Disturbance Following Intra-articular Distal Radius Fractures in the Skeletally Immature Patient.

J Pediatr Orthop 2020 Nov/Dec;40(10):e910-e915

Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.

Introduction: The purpose of this study was to characterize the incidence of growth disturbance following intra-articular distal radius fractures in skeletally immature patients and to assess early radiographic and functional outcomes.

Methods: A retrospective investigation of pediatric patients with intra-articular distal radius fractures between 1997 and 2012 at a single institution was performed. Pathologic fractures and fractures in patients with closed physes were excluded. In total, 28 patients (24 males, 4 females), with a mean age of 13.8 years and mean follow-up of 31.7 months, met inclusion criteria. Fractures were categorized according to the Salter-Harris classification, and all radiographs were assessed for evidence of physeal disturbance. Information regarding treatment and early clinical results were obtained from a medical record review. Functional outcomes using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Modified Mayo Wrist Score (MMWS) were collected. Fisher exact test was used to compare the incidence of physeal arrest in the study population to previously published rates of physeal arrest in extra-articular fractures involving the distal radius. Because the data were not parametrically distributed, the Mann-Whitney-Wilcoxon test was used to compare those who did and did not develop physeal arrest.

Results: Of the 28 patients, 9 (32%) sustained Salter-Harris III fractures and 19 (68%) sustained Salter-Harris IV fractures. Growth disturbance occurred in 12 (43%) patients, comprised of 3 Salter-Harris III fractures and 9 Salter-Harris IV fractures; 7 of these patients underwent surgical intervention to address deformity. All 4 children age 10 years or younger had growth arrests that underwent subsequent procedures for a skeletal rebalancing of the wrist. No significant differences in DASH or MMWS were seen in the short term between patients who did or did not have physeal arrest.

Conclusions: Intra-articular distal radius fractures in skeletally immature patients have a considerably higher rate of physeal growth arrest than extra-articular physeal fractures. Following acute management aimed at restoring and preserving anatomic physeal and articular alignment, follow-up radiographs should be obtained to evaluate for physeal arrest in skeletally immature children. Patients and families should be counseled regarding the high rate of growth disturbance and the potential need for deformity correction in the future, particularly in younger children.

Level Of Evidence: IV-case series.
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http://dx.doi.org/10.1097/BPO.0000000000001626DOI Listing
February 2021

Incidence of COVID-19 in Pediatric Surgical Patients Among 3 US Children's Hospitals.

JAMA Surg 2020 08;155(8):775-777

The Children's Hospital of Philadelphia, Division of Orthopaedic Surgery, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1001/jamasurg.2020.2588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273313PMC
August 2020

Evaluation and Management of Preaxial Polydactyly.

Curr Rev Musculoskelet Med 2020 Aug;13(4):545-551

Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Purpose Of Review: To provide a current review of the embryology, classification, evaluation, surgical management, and clinical outcomes related to preaxial polydactyly.

Recent Findings: Recent studies include a proposed embryologic link between preaxial polydactyly and other congenital abnormalities, an evaluation of long-term postsurgical outcomes, and an examination of important predictors for postsurgical outcomes. Preaxial polydactyly, while relatively uncommon, is a complex congenital hand abnormality that requires careful preoperative classification and proper surgical intervention timing to yield optimal outcomes.
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http://dx.doi.org/10.1007/s12178-020-09644-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340718PMC
August 2020

Where Have All the Fractures Gone? The Epidemiology of Pediatric Fractures During the COVID-19 Pandemic.

J Pediatr Orthop 2020 Sep;40(8):373-379

Division of Orthopaedics, The Children's Hospital of Philadelphia.

Background: During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics.

Methods: This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019.

Results: In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P<0.001). The presenting age for all fractures decreased during the pandemic (7.5±4.3 vs. 9.4±4.4 y, P<0.001) because of decreased fracture burden among adolescents. There were also a decrease in the number of fractures requiring surgery (2.2±1.8/d vs. 0.8±0.8/d, P<0.001). During the pandemic, there was an increase in the proportion of injuries occurring at home (57.8% vs. 32.5%, P<0.001) or on bicycles (18.3% vs. 8.2%, P<0.001), but a decrease in those related to sports (7.2% vs. 26.0%, P<0.001) or playgrounds (5.2% vs. 9.0%, P<0.001). There was no increase in time-to-presentation. Patients with distal radius torus fractures were more likely to receive a velcro splint during the pandemic (44.2% vs. 25.9%, P=0.010).

Conclusions: Pediatric fracture volume has decreased 2.5-fold during the COVID-19 pandemic, partially because of cessation of organized sports and decreased playground use. In endemic regions, lower trauma volume may allow redeployment of orthopaedic surgeons and staff to other clinical arenas. Given the rising proportion of bicycling injuries, an emphasis on basic safety precautions could improve public health. An observed increase in the prescription of velcro splints for distal radius fractures highlights an opportunity for simplified patient care during the pandemic.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001600DOI Listing
September 2020

Infections of the Upper Extremity: New Developments and Challenges.

Instr Course Lect 2019 ;68:141-152

Hand infections are common in all patient populations. However, because of variability in presentation and severity, they can be challenging to correctly diagnose and complex to manage. It is important to be aware of special populations such as children, individuals who are immunocompromised, those with diabetes, and intravenous drug users who may have uncommon pathogens or unusual types of infection. Atypical or rare bacterial and fungal infections, even in an immunocompetent host, can be equally challenging to manage. In each of these scenarios, it is critical to be familiar with associated conditions to avoid mismanagement and initiate an appropriate team-based approach for care involving surgery and consultation with an infectious disease specialist.
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February 2020

Predicting Radial Head Instability in Multiple Hereditary Exostoses (MHE): A Multicenter Analysis of Risk Factors.

J Pediatr Orthop 2020 Aug;40(7):e656-e661

Department of Orthopaedics, Children's Hospital of Philadelphia.

Background: Forearm deformity occurs in one third of patients with multiple hereditary exostoses (MHE). Conservative and surgical treatment are aimed at preventing radial head subluxation and/or dislocation. Dislocation has been associated with isolated distal ulnar lesions, radial bowing, and ulnar shortening. Risk factors for radial head subluxation have not been clearly elucidated. This study aimed to identify risk factors for all radial head instability in MHE, to optimize early detection and prevent frank dislocation.

Methods: This multicenter retrospective case-control investigation included MHE patients with forearm lesions seen between 2000 and 2017 at 2 tertiary care children's hospitals. Demographic, clinical factors, radiographic measures, and surgical history were quantified. Comparisons were made between forearms that developed radial head instability versus those that remained stable and between those that progressed to radial head subluxation versus those that progressed to dislocation.

Results: This study included 171 forearms in 113 patients with MHE, who presented at a mean age of 8.0 years with a median follow-up time of 6.0 years. Nine forearms progressed to radial head subluxation (mean age: 10.2 y), and 24 forearms had radial head dislocation (mean age: 9.9 y). Five subluxations and 3 dislocations occurred despite preventative surgery. Initial radial bowing (7.2% vs. 8.5%, P=0.04), ulnar variance (-5.8% vs. 11.0%, P<0.001), and ulnar shortening (-2.5 vs. 9.1 mm, P=0.04) were predictive of radial head instability. Distal ulnar lesions and more severe ulnar variance (-5.8 vs. -10.6, P<0.001) and shortening (-2.5 vs. 13.2 mm, P=0.02) were associated with an increased risk of radial head subluxation. No significant differences were identified between forearms that progressed to subluxation versus those that progressed to dislocation.

Conclusions: Distal ulnar lesions and radiographic measures can be used to determine the risk of radial head instability in MHE. Ulnar variance and shortening are early identifiable risk factors for radial head subluxation that can help guide monitoring and treatment. Radial bowing may be a late predictor of instability.

Level Of Evidence: Level III-prognostic.
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http://dx.doi.org/10.1097/BPO.0000000000001515DOI Listing
August 2020

Determining the Prevalence and Costs of Unnecessary Referrals in Adolescent Idiopathic Scoliosis.

Iowa Orthop J 2019 ;39(1):57-61

The University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, Iowa City, IA USA.

Background: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs.

Methods: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology.

Results: Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs.

Conclusions: Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system. III.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604530PMC
February 2020

Early Predictors of Microsurgical Reconstruction in Brachial Plexus Birth Palsy.

Iowa Orthop J 2019 ;39(1):37-43

Boston Children's Hospital, Department of Orthopaedic Surgery, Boston, MA.

Background: Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction.

Methods: Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed.

Results: 365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%.

Conclusions: In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention. Prognostic Level I.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604547PMC
February 2020

Collection of Common Knee Patient-reported Outcome Instruments by Automated Mobile Phone Text Messaging in Pediatric Sports Medicine.

J Pediatr Orthop 2020 Feb;40(2):e91-e95

Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Patient-reported outcome (PRO) instruments measure health status in a variety of domains. With the proliferation of mobile phones, delivering PROs across patient-friendly platforms (eg, apps, text messaging) may increase completion rates, particularly among children. The purpose of this study was to validate the collection of common knee PROs in sports medicine with text messaging by correlating text-messaging responses with paper delivery in adolescents.

Methods: Patients presenting to a hospital-based pediatric orthopaedic sports medicine clinic with a knee injury were enrolled prospectively. Paper versions of the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and the Pediatric Functional Activity Brief Scale (Pedi-Fab Scale) were completed during initial clinic visits. Over the next 72 hours, patients completed the text message delivery of the Pedi-IKDC and Pedi-Fab Scale. Correlations between paper and text message delivery of the 2 PROs were assessed.

Results: Ninety-one patients (mean age: 16.0±2.0 y; 48% females) enrolled in the text-messaging study, with 55 (60.4%) completing the Pedi-Fab Scale, 48 (52.7%) completing the Pedi-IKDC, and 39 (42.9%) completing both PROs. The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-Fab Scale was 0.95 (P<0.001; 95% confidence interval, 0.91-0.97). The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-IKDC was 0.96 (P<0.001; 95% confidence interval, 0.93-0.98). Average Pedi-Fab scores on paper (M=12.7) and mobile phone (M=12.3) were not significantly different (P=0.52). Similarly, average Pedi-IKDC scores on paper (M=68.8) and mobile phone (M=67.7) were not significantly different (P=0.41). Average completion time for the text delivered Pedi-Fab and Pedi-IKDC were 102±224 and 159±155 minutes, respectively. High school enrollment (P=0.025), female sex (P=0.036), and race (P=0.002) were significantly associated with text completion of Pedi-IKDC.

Conclusions: Text message delivery using mobile phones permits valid assessment of Pedi-IKDC and Pedi-Fab scores in adolescents. Questionnaire delivery by automated text messaging allows asynchronous response and may increase compliance and reduce the labor cost of collecting PROs.

Level Of Evidence: Level III-prospective cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001403DOI Listing
February 2020

Simulation Training of Orthopaedic Residents for Distal Radius Fracture Reductions Improves Radiographic Outcomes.

J Pediatr Orthop 2020 Jan;40(1):e6-e13

Division of Orthopaedics, The Children's Hospital of Philadelphia.

Background: Most distal radius fractures can be treated with closed reduction and casting in pediatric patients. These skills are traditionally developed treating real patients, however, there is growing interest in the use of simulation training to supplement traditional learning strategies.

Methods: Seventy-eight children with distal radius fractures that underwent closed reduction and casting by novice orthopaedic surgery residents were retrospectively reviewed. Radiographic measures of patients treated by simulation-trained residents were compared with patients treated by residents without simulation training.

Results: Patients treated by simulation-trained residents had less residual angulation in the anteroposterior radiograph (3.7 vs. 6.3 degrees, P=0.006) and translation on the lateral (14% vs. 21%, P=0.040) and anteroposterior radiograph (10% vs. 16%, P=0.029). Patients treated by simulation-trained residents also had lower rates of redisplacement (50% vs. 79%, P=0.016).

Conclusions: Loss of reduction is common, particularly when novice trainees perform their first independent reductions. Residents who underwent simulation training had lower rates of loss of reduction, thus simulation training has potential as a supplement to the traditional apprentice model of medical education.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001387DOI Listing
January 2020

Operative Time and Cost Vary by Surgeon: An Analysis of Supracondylar Humerus Fractures in Children.

Orthopedics 2019 May 12;42(3):e317-e321. Epub 2019 Mar 12.

Operative time is a critical driver of cost in orthopedics and an important target for improving value in health care. This study used an archetypal pediatric orthopedic procedure to identify surgeon-dependent variability in operative time. The authors reviewed patients 12 years or younger treated with closed reduction and percutaneous pinning for extension-type supracondylar humerus fractures. Variability in operative time across surgeons was assessed. Surgeon experience at the time of the procedure and case volume (quarterly) were evaluated to explain variations in operative time. A total of 1472 patients were reviewed (57% Gartland type II and 43% type III fractures). Procedures were performed by 12 fellowship-trained pediatric orthopedists with 2 weeks to 32.8 years of experience. For individual surgeons, the mean operative time ranged from 20.4 to 33.7 minutes for type II fractures and from 31.0 to 46.8 minutes for type III fractures. There was significant variation across surgeons in mean operative time and cost (P<.001). Analysis showed no significant effect of surgeon experience or quarterly case volume. Surgeons' mean operative time for type II fractures was strongly positively correlated with their mean operative time for type III fractures (r=0.74). Mean operative time and cost for supracondylar humerus fracture closed reduction and percutaneous pinning vary significantly between surgeons, but this variation is not explained by experience or volume. Surgeons who required more time for type II fractures were also slower for type III fractures. Because of the high per minute cost of the operating room, surgeon variability significantly impacts cost. Identification and modification of sources of variation in surgeon behavior will allow for reduction in the cost of surgical care. [Orthopedics. 2019; 42(3):e317-e321.].
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http://dx.doi.org/10.3928/01477447-20190307-02DOI Listing
May 2019

Long-Term Clinical and Radiographic Follow-Up of Preaxial Polydactyly Reconstruction.

J Hand Surg Am 2019 Mar 7;44(3):244.e1-244.e6. Epub 2018 Jul 7.

Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.

Purpose: The purpose of the study was to determine the long-term results of preaxial polydactyly reconstruction through evaluating strength, range of motion, pain, arthritis, and functional outcomes.

Methods: Patients having preaxial polydactyly reconstruction 15 to 60 years ago completed the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT). Aggregate scores were compared with those of the general population. Patients completed a clinical evaluation comprising grip strength, pinch strength, side pinch strength, and range of motion. Mean strength and range of motion were compared with the contralateral extremity. Patients had radiographs of the reconstructed thumb to evaluate for arthritis.

Results: Twenty-five patients, comprising 27 surgical reconstructions, completed patient-reported outcomes questionnaires, and 13 reconstructions underwent clinical and radiographic evaluation. The median follow-up was 36 years. The most common Flatt-Wassel classification was type IV. The mean DASH score was 3.7, similar to the general population mean of 10.1 (SD, 14.5). The mean PROMIS UE CAT score was 51.5, similar to the general population mean of 50 (SD, 10.0). The mean pinch strength, side pinch strength, and grip strength did not differ significantly from the contralateral extremity. There was significantly decreased range of motion at the interphalangeal joint. No patient had pain in the thumb or hand on clinical evaluation. A minority of patients developed radiographic evidence of interphalangeal joint arthritis (15.4%). Nearly half of patients, 46.2%, had angular deformity.

Conclusions: Preaxial polydactyly reconstruction patients have functional outcomes similar to the general population, despite decreased range of motion at the interphalangeal joint. Patients have maintained pinch strength, side pinch strength, and grip strength. Radiographic findings of arthritis were seen in 15% of patients at follow-up but none of these patients had associated pain. Late angular deformity developed in nearly half of patients, and this highlights the importance of close follow-up until skeletal maturity.

Type Of Study/level Of Evidence: Therapeutic IV.
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March 2019

Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, Hospitalization Cost, and Length-of-Stay.

J Pediatr Orthop 2019 Jul;39(6):e447-e451

Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: There is a need for improved opioid stewardship in orthopedic surgery through multimodal analgesia strategies. Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning (CRPP) for displaced supracondylar humerus (SCH) fracture may decrease pain, reduce opioid requirements, and decrease hospitalization costs.

Methods: Retrospective case-control investigation of children (aged, 1 to 14) treated with CRPP for closed, modified Gartland type III extension-type SCH fractures at a single children's hospital between 2011 and 2017. Patients that received ketorolac perioperatively (cases) were randomly matched 1:2 by sex and age (±1 y) with patients that did not receive ketorolac (controls). Data abstraction included demographic and perioperative details including inpatient Wong-Baker FACES pain ratings and analgesic requirements. Analysis included 2-tailed Mann-Whitney U and χ tests.

Results: In total, 342 patients were studied including 114 cases and 228 controls. Age (mean, 6.2±2.4 y), sex ratio (M:F, 1.28:1), operative time, and number of pins used were equivalent between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7±1.9) than in controls (1.4±2.6, P=0.017), as well as at 30 to 120 minutes postoperatively (1.1±2.3 and 1.7±2.8, respectively, P=0.036), as seen in Figure 1. Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0±0.6) than control patients (1.2±0.5, P=0.003). Mean postoperative length-of-stay (LOS) was 50.0% longer for control patients (20.4±11.3 h) than the ketorolac patients (13.6±8.8 h, P<0.001). Ketorolac administration was associated with 40.4% lower inpatient hospitalization cost compared to control patients, providing a 33.8 times return on investment. There was no difference in the 90-day complication rate between patient groups (P=0.905).

Conclusions: The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Perioperative ketorolac is also associated with reduced LOS following CRPP for supracondylar humerus fractures and offers significant cost savings opportunities.

Level Of Evidence: Level 3-Therapeutic: Case-Control Study.
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July 2019
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