Efficacy of Self-Directed Learning in the Supracondylar Fracture Performance Improvement Module at an Academic Pediatric Orthopedic Institution

Maintenance of certification (MOC) within a medical society requires continuing medical education that demonstrates life-long learning, cognitive expertise, and practice-based self-assessment. This prospective study sought to evaluate whether a self-directed Practice Improvement Module (PIM) would improve pediatric orthopedic patient outcomes, thus demonstrating evidence of life-long learning (Part II MOC credit) in treating supracondylar humerus fractures. Six surgeons and 113 patients were included. There was no significant difference in actual fracture outcome before or after PIM at any level of surgeon experience regarding radiographic appearance or need for reoperation (p>0.10). Junior staff demonstrated a statistically significant improvement in the percentage of time that marking the operative site was documented in the chart by the surgeon before (38%) and after (65%) PIM (p=0.02). The self-directed education portion of the supracondylar fracture PIM led to modest improvement in documentation habits among junior staff, without impact on overall patient outcomes. Therefore, the PIM appears to be less useful in providing evidence for life-long learning as it relates to surgical outcomes (Part II MOC/CME), yet, it may directly benefit practice-based self-assessment (Part IV MOC), and the self-assessment and Personal Improvement Plan may be the most important portion of the PIM to improve outcomes

In situ screw fixation of slipped capital femoral epiphysis with a novel approach: a double-cohort controlled study

In situ fixation for mild to moderate slipped capital femoral epiphysis (SCFE) remains an acceptable treatment methodology in most centers. Satisfactory fixation results have been reported with the procedure using either the fracture table or radiolucent table, both of which allow the hip to be imaged during the procedure. The position of the pin within the center of the femoral head is important to secure adequate fixation of the capital femoral epiphysis and prevent further slippage with minimal risk for articular penetration and avascular necrosis (AVN) or chondrolysis. We describe a pre-operative planning technique to determine the pin-entry point for percutaneous pinning of SCFE on a radiolucent operating table. A retrospective review of patients who underwent in situ screw fixation with the usage of a cannulated screw on a radiolucent table or fracture table over a 6-year period was conducted. The pin-entry point with this technique was reliable in 92% of procedures and comparable in both accuracy and complications to in situ screw fixation on a fracture table. In situ screw fixation on a regular radiolucent table was straightforward and required significantly less surgical time than on the fracture table (P = 0.01). It was also more efficient during a bilateral procedure, as it required only a single preparation and draping of the patient. This pre-operative planning technique for deciding the starting point on the proximal femur is helpful in executing an accurate in situ screw fixation of hips with SCFE

Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types

SRS-7: A Valid, Responsive, Linear, and Unidimensional Functional Outcome Measure for Operatively Treated Patients With AIS

Comparison of the Scoliosis Research Society-22 (SRS-22) questionnaire with a 7-item Rasch-derived questionnaire (SRS-7)