Research Award Details

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Training Clinical Examination Skills for Diagnosing Infants with Developmental Dysplasia of the Hip

Grant Recipient: Meredith Lazar-Antman, MD

New York Winthrop University Hospital
Presentations & Publications:
Further Funding:
Additional Information:
Developmental dysplasia of the hip (DDH) is a spectrum of structural hip joint abnormalities including dysplasia, subluxation, and dislocation as a result of abnormal hip development. Early diagnosis and treatment of DDH with bracing can lead to excellent outcomes with a low risk of complications. In contrast, a delayed diagnosis of DDH can result in inferior outcomes resulting in permanent gait abnormalities, early degenerative arthritis, and need for multiple surgical interventions. While the use of hip ultrasound has improved the detection of DDH, universal infant screening with ultrasound has not consistently been shown to be more cost-effective than selective screening and the American Academy of Orthopaedic Surgeons (AAOS) recommends against it. In addition, missing DDH on exam has been reported as much as 50% of successful malpractice suits against pediatricians.  Such findings along with the progressive nature of untreated DDH underscore the need for reliable infant hip exams.  It is therefore necessary for providers to perform a proper infant hip exam at every routine well baby visit throughout their first year of life. An unstable hip can be extremely difficult to determine on clinical exam, but with time and experience can become more readily appreciable. Simulation centers have become invaluable for resident training and to date there has not been a study documenting the efficacy of using a model to educate trainees and providers on how to assess an unstable hip in order to enhance knowledge, confidence, and proficiency in performing a clinical assessment on an infant to evaluate for DDH. 
The primary aim was to evaluate if a dedicated educational curriculum built around the “Hippy Baby” as a model can improve the confidence and aptitude for learners across multiple disciplines in performing physical examination on an infant hip to evaluate for hip instability.
All study participants were identified from the NYU Winthrop community including the NYU Long Island School of Medicine. Medical students, residents, and faculty from pediatrics and orthopedics were invited to participate. The lecture and study demonstrations were scheduled during a 1-hour time slots that is part of the dedicated teaching sessions for their respective departments and a class was set up for the medical students. Participants were asked to voluntarily complete a pre-intervention survey, attend a lecture on DDH which included a demonstration of a hip exam using the “hippy baby” model, then a clinical assessment was done for each learner with using the model, and a post-assessment survey. The pre-clinical survey assessed level of experience and baseline knowledge about DDH. The lecture and exam demonstration was performed by a single board-certified fellowship trained pediatric orthopedic surgeon (senior author), who provided a comprehensive review of DDH and how to perform a proper newborn hip exam.  The lecture also included a short video demonstrations recorded with the hippy model. Study participants were assessed at using the model by study coordinators and then completed a post assessment survey which was used to assess the efficacy of the curriculum and skills training with the model.
A total of 50 participants attended the 3 educational workshops we set up and provided online consent to participate in the study. Of these, only 6 of 50 had received formal education on the subject. Also, 40 % and 44% incorrectly identified Barlow and Ortolani maneuver, respectively on the pre-survey.  
Twenty-four participants’ pre- and post- surveys and clinical assessments were linked and used for analysis. This included faculty, pediatric residents, and medical students.  After concluding the lecture and exam demonstration, of the 24 participants, 92% were able to correctly position their hands for exam; All participants were able to correctly perform Barlow and Ortolani maneuvers. Additionally, 92% were able to correctly identify the side with the positive Barlow and positive Ortolani. 
Following completion of the clinical examination, 91% felt more confident at identifying an unstable hip; 97% had a better understanding on how to perform a newborn/infant hip exam and all (100%) felt the “hippy baby” model was a useful tool to help learn how to feel and diagnose an unstable infant hip and they would recommend for other learners to use as part of their training.
A dedicated educational curriculum that included a lecture and clinical skills portion using a hippy baby model was found to be beneficial in improving the confidence and ability to diagnose DDH.  In our sample population, there was an identified knowledge gap which suggests need for additional training in this area.  Providers and trainees with varying levels of experience including medical students, residents, and faculty found the “baby hippy” model to be helpful and would recommend its use as a mode for teaching the infant hip exam. Empowering providers and trainees with effective educational simulation tools will help them in their medical careers.
Success of the Project:
Identified knowledge gaps in our sample population
Learners who took the course all agreed that the model was useful to gain an appreciation for how to perform an infant hip exam.
This served as a good pilot project to demonstrate the utility in having these models available to our learners.
Limitations of the Project:
Biggest limitation was on the small numbers of people who received the education module.  This is due to scheduling issues and low numbers of orthopedic residents. Also due to scheduling, we were unable to get our whole orthopedic faculty to use the model. The percentages of pediatric faculty attending also is low given the attendances at their grand rounds.
We used a QR code in the power point presentation before and after the lectures for learner to put into the phones.  We found many people did the pre-assessment survey.  A lot of people then did the exam on the model and we had study coordinators confirm it. They would then forget to fill out the post-assessment surveys – so it was difficult to link which limited our data analysis. 
We also had difficulty in timing how fast someone was able to learn the maneuvers which would have been a nice objective measure of learned success with the model.
We didn’t have a hip model built with a normal hip which would have served as a helpful control, but the company couldn’t make one.  Perhaps building the “hippy” with one normal hip and one abnormal in stead of one side with an ortolni and one with a barlow would be helpful. We also felt in time, the rubber on the model would loosen and the model is delicate.
Our data measures are also all subjective.  The surveys we linked for pre and post assessment may just be on the quality of the lecture given, not necessarily on the success of the model.
Originally the study was designed to be performed in time increments.  So re-assessing the same learners 3 month after the module would be helpful.  Due to the need to de-identify the participants, this would be nearly impossible with our current study population to continue.
Future Plans/Presentations for the Project
This was used as an E-poster presentation for our in house Faculty Scholars 2020 session and we look forward to sharing the E poster for POSNA next year. The orthopedic resident who assisted will also submit for the NYU Winthrop resident research day and possibly at the Nassau County Surgical Society meeting.
Given the difficulty in standardization and no control, I don’t know that we will conduct any future sessions to increase the study population.