Panel discusses the future of pediatric orthopedics, part 2

Issue: October 2015

In the second part of this Orthopedics Today Round Table, I asked leaders in the field of pediatric orthopedics about what they perceive to be better patient care, how they envision clinical care changing in the future and the potential impact of subspecialization. Click here, to read part 1 of this discussion.

Shital N. Parikh, MD
Moderator

Parikh: What innovations will drive the field forward in the coming years?

Roundtable Participants

Moderator
Shital N. Parikh, MD
Cincinnati

Alvin H. Crawford, MD
Cincinnati

John M. Flynn, MD
Philadelphia

James J. McCarthy, MD
Cincinnati

Michael G. Vitale, MD, MPH
New York City

McCarthy: When I started my career, everyone felt bioabsorbable plates would be routinely used by this time; that stem cells would completely change how we treat many of disorders and intrauterine surgery would eliminate myelodysplasia and clubfoot. Clearly, that has not occurred. What we did not predict was the Ponseti form of treatment for clubfoot — simple, but highly effective — which has nearly eliminated standard clubfoot surgery, or the use of steroids for children with Duchenne’s muscular dystrophy, which has nearly eliminated the need for scoliosis surgery in teenagers. In short, predictions have a high risk of being wrong.

Genomics will improve our ability to diagnose and predict disorders. Navigation techniques will eventually become routine and more practical. Growing implants are, and have already, changed how we treat limb and spine deformities, and biologics will have a growing (no pun intended) role in our treatment.

Vitale: We need to get better at understanding who we should be treating, and what treatments may not add value. Technology is an opportunity for progress and also is a prime cause of inefficiency in medicine. We need to first better understand what constitutes best practice, seek to dispel variability, and finally execute these best practices for our patients.

Flynn: Advances in biologics and genomics will change pediatric orthopedics as it changes other fields. It is easy to imagine medical solutions for osteogenesis imperfecta, storage disorders and perhaps other disorders that affect the developing skeleton. Early diagnosis will inspire some parents to prevent the birth of children with some diseases, and other diseases (like spina bifida) will decline as we better understand prevention. There are likely numerous technical advances for implants and instrumentation that will lead to new techniques in the areas of limb deformity, spine and sports.

Crawford: Tissue engineering and scaffolding with 3-D reconstruction is amazing, and I look to see this use in children with acquired and congenital deficiencies. These technologies have tremendous potential to help children. While gene identification for many of our diseases, especially the syndromic ones, are exciting, most to date have enhanced classifications more so than therapeutic applications. It remains a work in progress. Growing implants in extremities work well, especially those with intrinsic lengthening capabilities and, in some cases, are state-of-the art. These spine-growing implants are undergoing scrutiny. The ability to mechanically achieve length without interval, open surgical procedures will enhance their value.

Intrauterine recognition of orthopedic anomalies is a wonderful diagnostic tool and gives enough detailed information for functional parent/family/child planning. Direct surgical correction of these conditions has yet to be fully realized and is undergoing limited investigation.

Parikh: Going forward, how would you define better patient care in our field?

McCarthy: Clearly, numerous stakeholders are looking to define quality of care. Unfortunately, most of these are done in a substandard fashion. This includes most of the online methods of measuring. Ultimately, I strongly feel that, as surgeons, we need to define quality care. We need to measure it and try to improve it. This is a difficult task. Care needs to be defined as some combination of quality and value. Although I am a strong supporter of pushing the quality agenda forward, this needs to be done with prudence and reason. Many of the rankings have little to no statistical validity. Orthopedics can learn a great deal from how the transplant and the thoracic surgeons have created appropriate registries and measures to ensure high quality of care among all their institutions and have done so with a great deal of surgeon acceptance.

Vitale: Easy. For the most part, clinical variability reflects chaos of processes and holes in our evidence base. We need to fix these things.

Flynn: In the past 5 years, the momentum for improvement in quality, safety and value is palpable in orthopedics — especially in pediatric orthopedics. Our national meetings are now dominated by research to reduce the rate of complications and improve the value of our work. Ultimately, safety and quality will increase as we assemble expert teams to treat certain conditions. These expert teams will get the reps necessary to have better results than surgeons who occasionally perform complex procedures or work with teams that are always varying. Clearly, there are some conditions we are over-treating (especially certain mild injuries) and wasting resources.

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Parikh: Are there any potential drawbacks to subspecialization in pediatric orthopedics?

McCarthy: On one hand, the benefits of subspecialization are for specific, high technical procedures. Having someone who focuses just on a few specific procedures can provide a high level of care, as well as incorporate research protocols. On the other hand, there are a number of environments where a well-trained pediatric orthopedic surgeon can cover a wide variety of disorders and do so at a high level, and on the rare occasion when the surgeon does not feel comfortable doing a procedure or more complicated version thereof, that surgeon can seek advice and treatment from a large pediatric center.

Vitale: The biggest risk to our field is fragmentation. Are we spine doctors, sports doctors, deformity doctors or specialists in clubfeet? But then again, we do not practice to defend the status quo of our field. We do so to provide the best care to patients, and I think the move to subspecialization fosters that. The trick will be for our national societies to maintain value to an increasingly subspecialized membership, and I am proud of what Pediatric Orthopaedic Society of North America (POSNA) is doing in this regard.

Flynn: The only drawbacks to subspecialization are for the surgeon: it is fun to treat everyone with every condition and feel omnipotent. The truth is, subspecialization is great for patients, it is great for safety and it is great for value.

Indeed, there are too many medical meetings, but I am confident the free-market forces will right-size the meeting calendar effectively. Surgeons will attend meetings where they can gain information and skills to improve patient care, and where they can enjoy the company of their colleagues. Ultimately, meetings are supported by industry grants, and if industry will not fund a particular meeting, eventually it will die out because registration fees generally cannot cover the costs.

There are too many journals and there is too much information, but the next generation of pediatric orthopedic surgeons will be extremely skilled in managing information overload. They will patronize sources of information that best deliver the content clearly and efficiently.

Crawford: Subspecialization in pediatric orthopedics is becoming the rule, as opposed to the exception. We are learning more about less, so to speak. There is a need for this level of training at major academic medical centers for specific conditions. However, the most common musculoskeletal problems in growing children have been and will continue to be managed well by community orthopedists and single fellowship-trained providers.

Parikh: How would clinical care change in future?

McCarthy: Clinical care in the future will be dependent on the market and clinical forces of the next few years. There is a dynamic in the United States between large government-controlled health care that is typified in the Affordable Care Act and market-driven health care. Ultimately, as clinicians, our goal is to deliver the highest quality of care. If we do that, we will always derive great satisfaction from our job and always be in high demand. Many trends will come and go, but what it means to be a great physician has changed little over time. Personally, I am thankful to be able to do a job in which I can care for patients, feel I have made a positive difference in the world and do not have to sit behind a desk.

Flynn: The Internet has put patients and families in charge. Even moderately sophisticated families arrive in your office with Internet information (true and untrue) that must be addressed. Increasingly they will demand the most specialized provider, the most excellent results and maybe the most affordable good outcome.

Crawford: Parental demand for immediate radiographic perfection of all fractures is driving the operative fracture engine. As a result, more fractures are operated and instrumented. In addition, we may be undertraining our residents in ambulatory fracture care including cast wedging and re-manipulation, etc. Although the desire to completely eliminate a “painful experience fracture” has affected training outpatient manipulation with hematoma-blocked anesthesia, there are metabolic risks of operative intervention. Every fracture clinic should have a file of radiographic examples of less than perfect reduction of limb fractures with perfect results following remodeling to show patients and their families. This visual has, on occasion, been able to calm the family of children whose parents have used their smartphones to photograph X-rays and solicited opinions from social media on how the injury should be treated. These long-term follow-up examples are a must have. Social media has already begun to affect how treatment is rendered and appears to be commanding a more extensive role. These are indeed interesting times.

For more information:
Alvin H. Crawford, MD, can be reached at 222 Piedmont Ave. #2200, Cincinnati, OH 45219 email: alvin.crawford@uc.edu.
John M. Flynn, MD, can be reached at Children’s Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104; email: flynnj@email.chop.edu.
James J. McCarthy, MD, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., ML 2017, Cincinnati, OH 45229; email: james.mccarthy@cchmc.org.
Shital N. Parikh, MD, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., ML 2017, Cincinnati, OH 45229 email: shital.parikh@cchmc.org.
Michael G. Vitale, MD, MPH, can be reached at Columbia University Medical Center, 622 West 168th St., PH11— Center, New York, NY 10032; email: mgv1@columbia.edu.

Disclosures: Crawford, Flynn, Parikh and Vitale report no relevant financial disclosures. McCarthy reports he does consulting work with Orthopedics and Philips Healthcare, gives talks for Synthes, has received royalties from Lippincott Williams & Wilkins and is on the board of POSNA.