Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians.

OBJECTIVE: To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States. STUDY DESIGN: An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated. RESULTS: We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers. CONCLUSIONS: The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19.

CONTEXT: The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004-2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19. OBJECTIVE: Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period. DESIGN: Retrospective cohort study. SETTING: This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016-June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic. PATIENTS OR OTHER PARTICIPANTS: Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified. MAIN OUTCOME MEASURE(S): Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses. RESULTS: A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant. CONCLUSIONS: Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

Evidence-based Medicine in Pediatric Orthopaedics: Evidence-based Practice Committee Summary of Levels of Evidence, Clinical Practice Guidelines, Appropriate Use Criteria, and Best Practice Guidelines.

The concept of evidence-based medicine has evolved over the past 2 decades, and has become a cornerstone to clinical decision-making in virtually every aspect of medicine. With a commitment to providing its members with high-quality evidence-based guidelines, the American Academy of Orthopaedic Surgeons has instituted concerted efforts since 2006 to develop clinical practice guidelines (CPGs) and appropriate use criteria (AUCs) for certain orthopaedic conditions. Many of these CPGs and AUCs detail the management of pediatric orthopaedic conditions. By the same token, members of the Pediatric Orthopaedic Society of North America (POSNA) Evidence Based Practice Committee have been publishing succinct evaluations of randomized controlled trials in pediatric orthopaedic surgery to create an evidence-based repository for quick reference to available high-level evidence as well as resource to identify gaps in the current research and identify opportunities for future investigation. In instances where higher-level evidence needed to develop CPGs is not available to address a critically important clinical question, consensus recommendations from experts in the field have been obtained to develop best practice guidelines (BPGs). The purpose of this review is to provide readers with a deeper understanding of the key principles of evidence-based medicine and methodologies used for the development of CPGs, AUCs, and BPGs.

Incidence of Meniscal Entrapment and Associated Knee Injuries in Tibial Spine Avulsions.

BACKGROUND: Tibial spine avulsions (TSA) have historically been treated as isolated injuries. Data on associated injuries are limited with existing literature reporting wide ranging incidences. The purpose of this multicenter study was to (1) describe the incidence of meniscal entrapment and associated knee injuries in TSA and to (2) compare surgical and magnetic resonance image (MRI) findings for these injuries. Our hypothesis is that tibial spine injuries are not usually isolated injuries, and other meniscal, ligament, and cartilage injuries may be present. METHODS: MRI and surgical reports for patients with a diagnosis of a tibial spine fracture were retrospectively reviewed. Type of fracture was recorded as noted in the reports along with concomitant meniscal entrapment and osteochondral, ligamentous, and meniscal injury. Images and reports were reviewed by an orthopaedic surgeon at each respective institution. RESULTS: A total of 163 patients were included in this study. MRI was done for 77 patients and surgery was performed in 144 cases. Meniscal entrapment was found in 39.9% of all patients. MRI diagnosed meniscus, osteochondral, and non-anterior cruciate ligament ligamentous injury was found in 31.2%, 68.8%, and 32.4% of cases, respectively. Surgically diagnosed meniscus, chondral, and non-anterior cruciate ligament ligamentous injury was found in 34.7%, 33.3%, and 5.6% of patients, respectively. CONCLUSIONS: TSA fractures are associated with significant risk for concomitant knee injuries including meniscal tear, bone contusion, and chondral injury. Incidence of meniscal entrapment found during surgery was high, in spite of low incidence of positive findings by MRI. LEVEL OF EVIDENCE: Level IV-retrospective case series.

The Anterolateral Ligament of the Knee: An Inconsistent Finding in Pediatric Cadaveric Specimens.

BACKGROUND: The anterolateral ligament (ALL) of the knee has been identified as a structure that limits internal rotation, and thus, affects the pivot shift mechanism. It has previously been reported in a high percentage of adult subjects. The purpose of the current study was to evaluate whether the ALL could be identified on pediatric cadaveric knee specimens and compare these findings to previously published reports. METHODS: Eight skeletally immature cadaver knee specimens were examined through gross dissection: ages 3 months, 4 months, 1 year, 2 years, 3 years, 3 years, 8 years, and 10 years. There were 3 male and 5 female (7 right, 1 left) specimens. The presence or absence of the ALL was documented in each specimen, through dissection, intermittent internal and external rotation of the tibia, and anterior translation of the tibia, to produce tension of the lateral collateral tissues and joint capsule. These dissections were performed by a group of fellowship-trained orthopaedic surgeons. RESULTS: The iliotibial band, entire lateral joint capsule, lateral collateral ligament, and popliteus were readily identified in each specimen. In 7 specimens, a distinct ALL structure was not identified during dissection. The ALL was identified in 1 of 8 specimens (1-year-old female, right knee). The ALL was further delineated under applied internal rotational stress. CONCLUSIONS: Previous research has suggested that this ligament is present in the majority of adult specimens. This finding was not reproduced in the current study of pediatric cadaveric specimens, where only one of 8 specimens had an identifiable ALL. This suggests that this ligament may develop later in life, after physiological loads are applied to the joint capsule. Further research in both adult and pediatric knees needs to be conducted to further elucidate the development of this ligament, and the role of this structure in knee stability. CLINICAL RELEVANCE: The ALL is a knee ligament that has been described in adults. However, it is unclear whether this structure is present or fully developed in younger populations. The current study sought to identify the ALL in pediatric cadaver knee specimens, identifying this structure in only one of 8 specimens. The findings of this study suggest that the ALL may be an inconsistent structure in the pediatric population.

Surgeon practices regarding infection prevention for pediatric spinal surgery.

BACKGROUND: A postoperative spinal infection has significant financial and emotional impact on the patient, family, and health care system. The purpose of this study is to understand approaches used by pediatric spinal surgeons with regard to infection prevention. METHODS: A survey was electronically distributed to 277 POSNA/SRS members. A total of 123 responses were obtained (44%). Eighty-one percent of participating surgeons were in academic practices. Among responders, 82% have been in practice for >10 years, and only 5% have been in practice <5 years. RESULTS: Sixty-four percent of surgeons responded that they knew their infection rate over the last year, and average reported rates were 1.3% and 5.3% in idiopathic and neuromuscular patients, respectively. The surgeon estimated rates were 0.5% and 4.4% in similar populations for those who did not exactly know their infection rates. Preoperatively, 50% of surgeons suggest chlrorhexidine use at home. Preoperative labs to stratify risk are obtained in 54% of neuromuscular patients and 9% of all patients. MRSA swabs and urine cultures are used variably preoperatively. IV antibiotic use before incision commonly includes not only cephalosporins (>80%), but also frequently involves vancomycin. Forty-seven percent of neuromuscular patients receive gram-negative coverage, whereas only 11% of idiopathic patients do. Skin preparation methods are highly variable among responding physicians. Vancomycin powder is used with the bone graft in 24% of all patients, with gentamycin and vancomycin used variably in idiopathic and neuromuscular patients. Policies limiting scrub wear out of the hospital and traffic in the operating room, the use of UV lights or negative pressure ventilation, and use of drains were also variable. CONCLUSION: There is significant variability in the current practices of surgeons who perform spinal deformity surgery with regard to infection prevention. Such variability most likely results from a lack of good evidence and may reflect suboptimal care. This data can be used as a starting point to help design and direct multicenter studies with an ultimate goal of reducing infection after spinal deformity surgery. LEVEL OF EVIDENCE: Level V.