Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. Study design Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. Results 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI.

Introduction: Acute musculoskeletal infections (MSKi) affect >1:6000 children in the United States annually, which could lead to arthritis, chronic infection, limb deformity, and even death. MRI is the gold standard for MSKi diagnosis but traditionally requires contrast and anesthesia, delaying results and slowing treatment decision-making. A rapid MRI protocol is an unsedated MRI with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to help identify abscesses. The objective of this study was to compare MRI access, timing, treatment, length of stay, and charges between the traditional and rapid MRI protocols among pediatric patients undergoing MSKi evaluation. Methods: A single-center retrospective study was conducted among 128 patients undergoing MSKi evaluation before (“Traditional cohort” [TC] of 60 patients admitted in Jan-Dec 2019) and after implementation of the Rapid MRI protocol (“Rapid cohort” [RC] of 68 patients admitted in Jun 2021-Jul 2022). Demographic, clinical, and charge data were extracted from electronic health records. Mann-Whitney U tests were performed to compare the two groups. Results: Demographics and diagnoses were similar, while rates of sedation and contrast administration were significantly different (53% and 88% in TC versus 4% and 0% in RC). The median time to MRI after ordering was 6.5 hours (IQR=3.2-12.2) in TC and 2.2 hours (IQR=1.1-4.5) in RC (P<0.01). The median duration of MRI was 63.2 minutes (IQR=52.4-85.3) in TC and 24.0 minutes (IQR=18.5-41.1) in RC (P<0.01). The median time between ordering and receiving the MRI final interpretation was 13.5 hours (IQR=2.35-66.3) in TC and 7.0 hours (IQR=1.25- 41.7) in RC (P<0.01). The median hospital length of stay was 5.3 days (IQR=2.7-7.9) in TC and 3.7 days (IQR=1.0-5.8) in RC (P<0.01). The median charges for the entire hospital stay were $48,015 (IQR=$28,086-$88,496) in TC and $33,532 (IQR=$13,622, $54,710) in RC (P<0.01). While 10/68 of Rapid MRIs were canceled or aborted due to patient motion or pain, only 6/68 required repeat MRI with sedation. No infection diagnoses were missed on Rapid imaging. Conclusion: In patients being evaluated for MSKi, the Rapid MRI protocol eliminated contrast and nearly eliminated sedation while leading to improved MRI access, scan and interpretation times, and significant decreases in hospital length of stay and charges. Future steps include continuing quality control, studying interobserver reliability between protocols, and multicenter program expansion. Significance: Pediatric MSKi carry a large treatment burden, and this Rapid MRI protocol improves imaging access while eliminating contrast, decreasing sedation, scan time, length of stay, and hospital charges, with a <10% rescan rate and without missing actionable diagnoses.

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