Purpose To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations. Methods A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parametersif there was greater than 10°difference in side-to-side abduction or symmetric abduction of less than 60°. Results Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months. Conclusions Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.Keywords Developmental dysplasia of the hip Á Ultrasound Á Breech presentation Study conducted at Rady Children's Hospital,

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Maximizing Lenke 1 curve correction to achieve greater lumbar correction and improved clinical appearance can be done without compromising coronal balance but may occur at the expense of sagittal alignment. However, surgeons who are learning to apply powerful new corrective methods should be cautious in trying to obtain full correction. Proper preoperative evaluation, fusion level selection, and surgical technique are needed to attain this outcome.

Objectives: In many health systems, the costs of surgical implants are one of the largest components for surgical budgets, and economies of scale in purchasing agreements do not always provide increased value due to lack of data transparency and administrative complexity. The purpose of the study was to determine if clinician-informed, well-defined negotiation strategies informed by market-based pricing and volume data from supply chain experts within the health system could achieve lower pricing levels for spinal implants and reduce the number of vendors.Methods: Market data based upon pricing levels for implants were reviewed from an industry implant price database and utilized by surgeon clinicians and supply chain management (SCM) to select benchmark pricing levels for common spine implants used at our institution.Results: Benchmark modeling to the 25 th percentile among comparable institutions was used in the request for proposal (RFP) sent to all vendors. After three rounds of structured negotiation involving SCM and surgeon leaders, 20% savings over the previous year's total spend was achieved, with a total savings upward of one million dollars; 8 of 22 vendors were excluded from the system. Conclusion:Negotiation tactics included utilizing benchmark pricing data, "economies of scale" principles, game theory principles, and strong internal communication strategies between supply chain, physician leadership, and actively practicing surgeons. These findings demonstrate that there is significant opportunity for healthcare SCM to further negotiate contracts and achieve favorable pricing on items such as spinal implants with surgeon collaboration and utilization of benchmark data.