An Early Evaluation of Remote Site Visits for ACGME Program Applications.

Background: Prior to the COVID-19 pandemic, accreditation site visit interviews occurred in-person. In response to the pandemic, the Accreditation Council for Graduate Medical Education (ACGME) developed a remote site visit protocol. Objective: To perform an early assessment of the remote accreditation site visits for programs applying for initial ACGME accreditation. Methods: A cohort of residency and fellowship programs that had remote site visits was evaluated from June to August 2020. Surveys were sent to program personnel, ACGME accreditation field representatives, and executive directors following the site visits. Comparison of accreditation decisions (Initial Accreditation or Accreditation Withheld) was completed for matched residency or fellowship programs having in-person site visits in 2019. Results: Surveys were sent to all program personnel from the 58 residency and fellowship programs that had remote site visits for new program applications, as well as the accreditation field representatives who performed the remote visits. The survey response rate was 58% (352 of 607). Ninety-one percent of all respondents were extremely or very confident that remote site visits provided a thorough assessment of proposed residency or fellowship programs. Fifty-four programs having remote site visits were matched by specialty to programs having had in-person program application site visits in 2019. Forty-six programs that had remote site visits received Initial Accreditation, and 52 programs that had in-person site visits in 2019 received Initial Accreditation (P=.093, 95% CI 0.91-22.38). Conclusions: Most program personnel and accreditation field representatives were confident that remote site visits conducted for program applications provided fair and thorough assessments of the program.

An Analysis of Relative Gait Impairment in Commonly Diagnosed Pediatric Conditions.

BACKGROUND: Gait indices were developed to represent the magnitude of impairment extracted from a gait analysis with a single value. The Gillette Gait Index (GGI), and the Gait Deviation Index (GDI) are 2 widely used indices that represent gait impairment differently based on their statistical properties. Our purpose was to (1) report on the results of gait analysis for a broad spectrum of pediatric conditions using the GGI and GDI, and (2) identify the parameters that dominate impairment. METHODS: A total of 1439 children with 13 different diagnoses with a complete, baseline gait analysis were identified. The GGI and its 16 parameters were calculated in all cases, and the GDI was calculated from a smaller subset. T tests, and z-scores were used to compare each of these values to typically developing children for each diagnosis. A separate linear regression controlling for age, sex, and use of an orthosis, or assistive device was performed for the GGI. RESULTS: In our series, there were 71 typically developing children with a GGI of 31. We qualify relative gait impairment as severe, mild, or moderate as based on the GGI, and propose that values <100 represent mild, 100 to 200 represent moderate, and >200 represents severe impairment. On the basis of strong correlation between the GGI and GDI, we suggest that GDI values >80 represent mild, and values <70 represent severe impairment. T tests and z-scores demonstrated that both the number and magnitude of abnormal parameters increase the GGI. These tests also identified the most clinically relevant parameters contributing to functional impairment for each diagnosis. Multivariate linear regression showed that all diagnoses except flatfoot and scoliosis demonstrated statistically significant differences in GGI scores. CONCLUSIONS: This is the first study to apply these gait indices to a large population of diverse pediatric conditions. We propose GGI and GDI values to qualify gait impairment among these conditions as severe, moderate, or mild. Furthermore, impairment in gait reflects both the number and magnitude of abnormal parameters within each condition. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Adult outcomes following amputation or lengthening for fibular deficiency.

BACKGROUND: Fibular deficiency results in a small, unstable foot and ankle as well as a limb-length discrepancy. The purpose of this study was to assess outcomes in adults who, as children, had had amputation or limb-lengthening, commonly used treatments for fibular deficiency. METHODS: Retrospective review of existing data collected since 1950 at six pediatric orthopaedic centers identified 248 patients with fibular deficiency who were twenty-one years of age or older at the time of the review. Excluding patients with other anomalies and other treatments (with the excluded group including six who had had lengthening and then amputation), we identified ninety-eight patients who had had amputation or limb-lengthening for the treatment of isolated unilateral fibular deficiency. Sixty-two patients (with thirty-six amputations and twenty-six lengthening procedures) completed several questionnaires, including one asking general demographic questions, the Beck Depression Inventory-II, the Quality of Life Questionnaire, and the American Academy of Orthopaedic Surgeons Lower Limb Questionnaire including the Short Form-36. A group of twenty-eight control subjects completed the Beck Depression Inventory-II and the Quality of Life Questionnaire. RESULTS: There were forty men and twenty-two women. The average age at the time of the interview was thirty-three years. There were more amputations in those with fewer rays and less fibular preservation. Lengthening resulted in more surgical procedures (6.3 compared with 2.4 in patients treated with amputation) and more days in the hospital (184 compared with sixty-three) (both p<0.0001). However, when we compared treatment outcomes we did not find differences between groups with regard to education, employment, income, public assistance or disability payments, pain or use of pain medicine, sports participation, activity restriction, comfort wearing shorts, dislike of limb appearance, or satisfaction with treatment. No patient who had been treated for fibular deficiency reported signs of depression. The only significant difference between treatment groups shown by the Quality of Life Questionnaire was in the scores on the Job Satisfiers content scale, with the amputees scoring better than the patients treated with lengthening (p=0.015). The American Academy of Orthopaedic Surgeons Lower Limb Module did not demonstrate differences in health-related quality of life or physical function. CONCLUSIONS: The patients who were treated with lengthening had started out with more residual foot rays and more fibular preservation than the amputees. They also required more surgical intervention than did those with an amputation. While patients with an amputation spent less of their childhood undergoing treatment, they were found to have a better outcome in terms of only one of seventeen quality-of-life parameters. Both groups of patients who had had treatment of fibular deficiency were functioning at high levels, with an average to above-average quality of life compared with that of the normal adult population.

Reliability of the metaphyseal-diaphyseal angle in tibia vara as measured on digital images by pediatric orthopaedic surgeons.

BACKGROUND: Levine and Drennan described the tibial metaphyseal-diaphyseal angle (MDA) in an attempt to identify patients with infantile Blount's disease. Pediatric orthopaedic surgeons have debated not only the use, but also the reliability of this measure. Two techniques have been described to measure the MDA. These techniques involved using both the lateral border of the tibial cortex and the center of the tibial shaft as the longitudinal axis for radiographic measurements. The use of digital images poses another variable in the reliability of the MDA as digital images are used more commonly. METHODS: The radiographs of 21 children (42 limbs) were retrospectively reviewed by 27 staff pediatric orthopaedic surgeons. Interobserver reliability was determined using the intraclass correlation coefficients (ICCs). Nine duplicate radiographs (18 duplicate limbs) that appeared in the data set were used to calculate ICCs representing the intraobserver reliability. A scatter plot was created comparing the mean MDA determined by the 2 methods. The strength of a linear relationship between the 2 methods was measured with the Pearson correlation coefficient. Finally, we tested for a difference in variability between the 2 measures at angles of 11 degrees or less and greater than 11 degrees by comparing the variance ratios using the F test. RESULTS: The interobserver reliability was calculated using the ICC as 0.821 for the single-measure method and 0.992 for the average-measure method. The intraobserver reliability was similarly calculated using the ICC as 0.886 for the single-measure method and 0.940 for the average-measure method. Pearson correlation coefficient (0.9848) revealed a highly linear relationship between the 2 methods (P = 0.00001). We also found that there was no statistically significant variability between the 2 methods of calculating the MDA at angles of 11 degrees or less compared with angles greater than 11 degrees (P = 0.596688). CONCLUSIONS: There was excellent interobserver reliability and intraobserver reliability among reviewers. Using either the lateral diaphyseal line or center diaphyseal line produces reasonable reliability with no significant variability at angles of 11 degrees or less or greater than 11 degrees. LEVEL OF EVIDENCE: Level IV.

Management of open fractures in pediatric patients: current teaching in Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs.

The purpose of this study was to determine the method of treatment for open fractures in pediatric patients that is used and taught at academic orthopedic residency programs. A web-based survey was constructed and emailed to program directors of orthopedic residencies. Seventy programs out of a total of 140 surveyed programs responded. Data were tabulated and charts created in an Excel spreadsheet. Type I fractures were treated by most with a cephalosporin alone (97%) for less than 48 h (87%). Type II were treated by most programs with a cephalosporin alone with no aminoglycoside (84%) for less than 48 h (80%). Type IIIa were treated by most programs with a cephalosporin and an aminoglycoside (50%) for less than 48 h (60%). Type IIIb were treated by most programs with a cephalosporin and aminoglycoside (54%) for less than 48 h (53%). Type IIIc were also treated by most with a cephalosporin and an aminoglycoside (53%) for less than 48 h (51%). Wounds were closed by most responders for type I (90%), type II (86%) and type IIIa (50%) but not type IIIb (10%), and type IIIc (16%). For the programs responding to the pediatric section of the survey over half (53%) reported using a trauma room and 58% reported allowing residents to irrigate and debride wounds in the emergency room. In conclusion, for pediatric patients most orthopedic residencies use a cephalosporin alone for type I and type II open fractures with an aminoglycoside added for type III fractures. Treatment is typically for 48 h or less. Delay of 6 h seems to be accepted for type I and type II fractures but not type III fractures.

Management of open fractures in adult patients: current teaching in ACGME accredited residency programs.

The purpose of this study is to determine the methods of treatment for open fractures that are currently used by academic orthopaedic residency programs. A Web-based survey was constructed and e-mailed to program directors of orthopaedic residencies. Seventy-four programs out of a total of 140 (53%) surveyed programs responded. Data were tabulated and charts were created in an Excel spreadsheet. Type I fractures were treated by most with a cephalosporin alone (99%) for less than 48 hours (86%). Type II fractures were treated by most programs with a cephalosporin alone with no aminoglycoside (85%) for less than 48 hours (81%). Type IIIa fractures were treated by most programs with a cephalosporin and an aminoglycoside (55%) for less than 48 hours (54%). Type IIIb fractures were treated by most with a cephalosporin and aminoglycoside (55%) for less than 48 hours (54%). Type IIIc fractures were also treated by most with a cephalosporin and an aminoglycoside (57%) for less than 48 hours (49%). Wounds were closed by most responders for type I (88%), type II (86%), and type IIIa (57%), but not type IIIb (5%) and type IIIc (11%) fractures. Fifty-four percent of programs reported having trauma rooms and 58% of programs allow residents to irrigate and débride wounds in the emergency room. The study concluded that most orthopaedic residencies utilize a cephalosporin alone for types I and II open fractures with an aminoglycoside added for type III fractures. Antibiotic treatment is typically given for 48 hours or less. A delay of 6 hours is accepted for types I and II fractures but not type III fractures.

Lack of seasonal variation in idiopathic talipes equinovarus.

BACKGROUND: One proposed etiology of idiopathic talipes equinovarus is an in utero enterovirus infection. Enterovirus infections demonstrate seasonal variation in temperate climates. METHODS: We collected data on 1202 children with idiopathic talipes equinovarus born in the Northeastern United States, Midwestern United States, and the United Kingdom to investigate a seasonal variation in this congenital deformity. Birth date, gestational age at the time of delivery, gender, race, and laterality were tabulated and subjected to univariate and bivariate analyses. RESULTS: There were 774 boys and 428 girls with idiopathic talipes equinovarus. The birth location was the United Kingdom (458 children), the Midwestern United States (426 children), and the Northeastern United States (318 children). No significant differences were detected among the geographic groups with respect to gender, race, or laterality, and no variation in month of birth or month of conception was noted. CONCLUSIONS: This study does not support an in utero enterovirus infection as an etiology of idiopathic talipes equinovarus in industrialized populations.

Cheilectomy of the hip in children.

Cheilectomy of the hip is a salvage operation for patients with pain and limitation of motion caused by a mechanical blockage of an abnormally shaped femoral head. Eight patients ranging in age from 8 to 15 years were retrospectively reviewed in order to evaluate the intermediate-term results of cheilectomy to address the separate problems of pain, range of motion, and function. A mean follow-up of 5 years is reported. Clinical records and radiographs were analyzed. All patients were found to have short-term relief of pain and an increase in hip motion. Six of the eight patients regressed in terms of increased pain and loss of range of motion 2-4 years after cheilectomy. Children with an abnormally shaped femoral head causing pain and limitation of motion can benefit for a short time from cheilectomy, even if the physes are closed.

Leg length inequality and epiphysiodesis: review of 96 cases.

A retrospective analysis of 96 patients who underwent an epiphysiodesis procedure for leg length discrepancy was performed. Forty patients were identified who had an open Phemister-type epiphysiodesis. Fifty-six patients underwent a percutaneous epiphysiodesis procedure. All patients' medical records and radiographs were reviewed for complications. No angular deformities or epiphysiodesis failures occurred in the open group; however, one deep infection requiring intravenous antibiotics and serial surgical debridement was successfully treated. Five complications occurred in the percutaneous group. The complications included two superficial infections, two failures of physeal arrest, and one postoperative angular deformity. The occurrence of complications in the two groups was not statistically significant. Regular follow-up and radiographic evaluation of patients who have undergone a percutaneous epiphysiodesis is essential. Failure of physeal arrest and angular deformities are rare in this patient population, but they can occur.