Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics

OBJECTIVES

This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation.

METHODS

A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture).

RESULTS

In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001).

CONCLUSION

Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis

BACKGROUND

Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified.

PURPOSE

To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data.

RESULTS

A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture).

CONCLUSION

Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Higher complication rates following primary total shoulder arthroplasty in patients presenting from areas of higher social deprivation

Aims

The aim of this study was to characterize the influence of social deprivation on the rate of complications, readmissions, and revisions following primary total shoulder arthroplasty (TSA), using the Social Deprivation Index (SDI). The SDI is a composite measurement, in percentages, of seven demographic characteristics: living in poverty, with < 12 years of education, single-parent households, living in rented or overcrowded housing, households without a car, and unemployed adults aged < 65 years.

Methods

Patients aged ≥ 40 years, who underwent primary TSA between 2011 and 2017, were identified using International Classification of Diseases (ICD)-9 Clinical Modification and ICD-10 procedure codes for TSA in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperation, and other complications were analyzed using multivariable Cox proportional hazards regression controlling for SDI, age, ethnicity, insurance status, and Charlson Comorbidity Index.

Results

A total of 17,698 patients with a mean age of 69 years (SD 9.6), of whom 57.7% were female, underwent TSA during this time and 4,020 (22.7%) had at least one complication. A total of 8,113 patients (45.8%) had at least one comorbidity, and the median SDI in those who developed complications 12 months postoperatively was significantly greater than in those without a complication (33 vs 38; p < 0.001). Patients from areas with higher deprivation had increased one-, three-, and 12-month rates of readmission, dislocation, humeral fracture, urinary tract infection, deep vein thrombosis, and wound complications, as well as a higher three-month rate of pulmonary embolism (all p < 0.05).

Conclusion

Beyond medical complications, we found that patients with increased social deprivation had higher rates of humeral fracture and dislocation following primary TSA. The large sample size of this study, and the outcomes that were measured, add to the literature greatly in comparison with other large database studies involving TSA. These findings allow orthopaedic surgeons practising in under-served or low-volume areas to identify patients who may be at greater risk of developing complications.

Update on Pediatric Medial Epicondyle Fractures

The ideal evaluation and treatment of pediatric patients with medial epicondyle fractures remain controversial. It is important to examine the most recent literature and provide an update on the current clinical practices, imaging modalities, treatment techniques, outcomes, and complications associated with displaced pediatric medial epicondyle fractures. There remains substantial variability across recommended treatment options and the outcomes between surgical versus nonsurgical management of these injuries. Despite the lack of consensus regarding management of pediatric medial epicondyle fractures, both nonsurgical and surgical approaches have demonstrated equivocal results.

Management Principles and Current Debates Surrounding Common Pediatric Elbow Fractures

Elbow fractures are among the most common fractures sustained in pediatric patients. A specific set of pediatric elbow fractures (olecranon, radial neck, and lateral condyle fractures) comprises the ones that occur most often. It is important to review commonly accepted principles in the evaluation and treatment of these injuries as well as highlight some debates that exist within the literature regarding the optimal management of these injuries. Although management of pediatric olecranon, radial neck, and lateral condyle fractures has been well described, controversy persists among orthopaedic surgeons regarding the surgical indications and preferred fixation techniques for these injuries.

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients

INTRODUCTION

Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution.

METHODS

We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships.

RESULTS

Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10.

CONCLUSIONS

We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases

BACKGROUND

Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

METHODS

Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant.

RESULTS

Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

CONCLUSIONS

There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury

Background

Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability.

Hypothesis

Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables.

Results

While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049).

Conclusion

In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.

Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter?

Background

Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament.

Purpose

To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed.

Results

Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories.

Conclusion

Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.

Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture

Purpose

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities.

Methods

A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression.

Results

Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P = .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance.

Conclusions

In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance.

Level of Evidence

Level III, retrospective comparative study.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures

OBJECTIVES

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation.

METHODS

Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities.

RESULTS

Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism.

CONCLUSION

There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons.

METHODS

A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics.

RESULTS

Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.

CONCLUSIONS

Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management.

LEVEL OF EVIDENCE

Level V.

Do Patient Demographic and Socioeconomic Factors Influence Surgical Treatment Rates After ACL Injury?

INTRODUCTION

Anterior cruciate ligament (ACL) injuries may be managed nonoperatively in certain patients and injury patterns; however, complete ACL ruptures are commonly reconstructed to restore anterior and lateral rotatory stability of the knee. While ACL reconstruction is well-studied, the literature is sparse with regard to which socioeconomic patient factors are associated with patients undergoing ACL reconstruction rather than nonoperative management after diagnosis of an ACL injury. The current study seeks to evaluate this relationship between patient demographics as well as socioeconomic factors and the rate of surgery following ACL injuries.

METHODS

Patients ≤65 years of age with a primary ACL injury between 2011 and 2018 were retrospectively identified in the New York Statewide Planning and Research Cooperative System database. International Classification of Disease 9/10 and Current Procedural Terminology codes were used to identify these patients and their subsequent ACL reconstructions. Logistic regression was performed to determine the effect of patient factors on the likelihood of having surgery after the diagnosis of an ACL injury.

RESULTS

Compared to White patients, African American patients were significantly less likely to undergo ACL reconstruction following an ACL injury (OR=0.65, 95% CI, 0.573-0.726). Patients older than 35 had decreased odds of undergoing ACL reconstruction compared to younger patients, with patients 55-64 having the lowest odds (OR=0.166, 95% CI, 0.136-0.203). Patients with Medicaid (OR=0.84, 95% CI, 0.757-0.933) or self-pay insurance (OR=0.67, 95% CI, 0.565-0.793), and those with worker's compensation (OR=0.715, 95% CI, 0.621-0.823) had decreased odds of undergoing ACL reconstruction relative to patients with private insurance. Patients with higher Social Deprivation Index (SDI) were significantly more likely to be treated nonoperatively after ACL injuries compared to those with lower SDI (mean nonoperative SDI score, 61, operative SDI, 56, P<0.0001).

DISCUSSION

In patients with ACL injuries, there are socioeconomic and patient-related factors that are associated with increased odds of undergoing ACL reconstruction. These factors are important to recognize as they represent a source of potential inequality in access to care and an area with potential for improvement.

A Comparison of the Rates of Postoperative Infection Following Distal Radius Fixation Between Pediatric and Young Adult Populations: An Analysis of 32 368 Patients

BACKGROUND

Infection following surgical fixation of a distal radius fracture can markedly compromise a patient's functional outcome. This study aimed to compare infection rates in pediatric (5-14 years) and adolescent (15-17 years) patients undergoing fixation of a distal radius fracture to a cohort of young adult (18-30 years) patients.

METHODS

A matched retrospective study was performed using PearlDiver to determine the rates of postoperative infection following distal radius fixation. χ2 and logistic regression were used to assess differences in rates, while linear regression was used to analyze rates of infection over time.

RESULTS

In 32 368 patients, young adults experienced postoperative infection at a significantly increased rate (odds ratio [OR] = 1.81; 95% confidence interval [CI], 1.45-2.27). This trend was consistent among the male (OR = 1.96; 1.49-2.57) and female (OR = 2.11, 1.37-3.27) cohorts. In the multivariate model, the adult cohort remained at increased risk (OR = 1.40; 95% CI, 1.04-1.89), with open fracture (OR = 4.99; 3.55-6.87), smoking (OR = 1.76; 1.22-2.48), hypertension (OR = 1.69; 1.20-2.33), and obesity (OR = 1.37; 1.02, 1.80) identified as other significant risk factors. There was no significant change in the rate of postoperative infections over the 11-year study period.

CONCLUSION

This study demonstrated that although surgical site infections following distal radius fixation are low in patients aged 30 years or younger (0.97%), young adults develop infections at a significantly increased rate. This is important for surgeons to recognize when counseling patients on the risks of surgical fixation.

Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type

BACKGROUND

This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes.

RESULTS

A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs.

CONCLUSIONS

Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care.

LEVEL OF EVIDENCE

Level III.

Visual Joint Angle Assessment: Does Accuracy Improve with a Higher Level of Orthopaedic Surgery Training?

INTRODUCTION

The purpose of this study was to evaluate the accuracy of visual joint angle assessments by orthopaedic surgery trainees amongst various levels of training.

METHODS

Sagittal plane photographs of several joints at various angles were distributed to trainees within an orthopaedic residency program. Joint angles were estimated and compared to those obtained with a goniometer. Inter-and intra-rater reliability and ANOVA were conducted to assess differences between groups.

RESULTS

Twenty trainees were studied. The percent error for knee measurements differed at 23.1%, 26.2% and 11.1% for the PGY 2-3, PGY 4-5 and PGY 6 groups, respectively (P=0.024). Percentage error for ankles showed the greatest variability at 69.7-96.3%. Intra-rater reliabilities for all visual joint angle assessment were similar amongst groups.

CONCLUSIONS

Visual joint angle assessments vary amongst trainees, with PGY 6s most accurately identifying knee joint angles. Visual assessment is inaccurate compared to goniometric measurements, thus limiting visual measurements during patient encounters.

Atraumatic Displaced Femoral Neck Insufficiency Fracture Because of Severe Hypocalcemia in a Pediatric Patient: A Case Report

CASE

This is a case of a 14-year-old autistic boy who presented with an atraumatic transcervical femoral neck fracture in the setting of significant hypocalcemia and vitamin D deficiency. We discuss his surgical and medical management and metabolic derangements associated with atraumatic femoral neck fractures.

CONCLUSION

Pediatric femoral neck fractures in the absence of trauma are uncommon and often have underlying metabolic abnormalities. In addition, autism poses unique challenges in caring for these patients who are at an increased risk of complications. Interdisciplinary care is integral to achieving successful outcomes.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

METHODS

We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

RESULTS

A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

CONCLUSIONS

Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

LEVEL OF EVIDENCE

Level IV-narrative review.

Orthopedic manifestations of child abuse

Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.

Risk of reoperation after primary anterior cruciate ligament reconstruction in children and adolescents

OBJECTIVE

To examine the incidence and risk factors of any-cause reoperation after primary ACLR in children and adolescents.

DESIGN

Retrospective Cohort.

SETTING

Electronic medical records from a large tertiary care, single institution integrated healthcare delivery system.

PATIENTS

Patients were under the age of 18 years and had anterior cruciate ligament reconstruction. They were excluded if they had a multi-ligamentous knee injury or <1 year follow-up.

INTERVENTIONS

Patients were further identified to have undergone a subsequent knee operation ipsilaterally or contralateral ACLR.

MAIN OUTCOME MEASURES

The rate of any-cause reoperation was our primary outcome measure.

RESULTS

The median age was 16. There were 208 females (53.9%) and 178 males (46.1%) included. The median follow-up was 25 months with a minimum of 12 months (interquartile range: 16.0, 46.0). The rate of any-cause reoperation was 34.7%. There was no statistically significant difference between those who underwent reoperation versus those who did not undergo reoperation relative to age, sex, BMI, graft type, or the presence of concomitant meniscal injury. The rates of ipsilateral ACLR and contralateral ACLR at any time during the study period was 8.0% and 10.9% respectively. There was no statistically significant difference for rate of reoperation between graft types, between various concomitant injuries, between those who underwent meniscus repair or no repair.

CONCLUSIONS

This study reflects a 34.7% rate of a subsequent knee operation after ACLR in patients younger than 18 years. These findings can be used to inform pediatric patients undergoing primary ACLR on their risk of returning to the operating room.

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty

INTRODUCTION

This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care.

METHODS

Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty.

RESULTS

Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.

DISCUSSION

Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

Purpose

To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.

Methods

Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.

Results

In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.

Conclusions

Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.

Clinical Relevance

Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty

BACKGROUND

The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA).

METHODS

Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research.

RESULTS

In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities.

CONCLUSION

Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Trends and Reported Complications in Ankle Arthroplasty and Ankle Arthrodesis in the State of New York, 2009-2018

Background:

Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications.

Methods:

Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10), Clinical Modification (CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression.

Results:

A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis.

Conclusion:

Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis.

Level of Evidence:

Level III, retrospective cohort.

Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group

Background:

Type 1 tibial spine fractures are nondisplaced or ≤2 mm–displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization.

Hypothesis:

Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently.

Results:

A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1).

Conclusion:

The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

Treatment of Osteochondral Fractures After Acute Patellofemoral Instability: A Critical Analysis Review

»

An osteochondral fracture (OCF) of the patella or the femur is a frequent sequela after an episode of acute patellofemoral instability.

»

Patients commonly present with anterior knee pain after direct trauma to the patella or a noncontact twisting injury.

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Radiographs and magnetic resonance imaging (MRI) are the most common imaging modalities that are used to diagnose OCFs.

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Arthroscopy may be indicated in cases of displaced OCFs, and the decision regarding osteochondral fragment fixation or loose body removal depends on fragment size, location, and extent of injury.

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Most of the current literature suggests worse outcomes for patients with OCFs who undergo nonoperative treatment, no significant differences in outcomes for patients sustaining an acute patellar dislocation with or without an OCF, and inconclusive results concerning outcomes for patients treated with loose body removal compared with fixation.

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Current outcome data are limited by studies with low levels of evidence; therefore, well-designed randomized controlled trials are needed.

A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures

BACKGROUND

When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction.

METHODS

We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups.

RESULTS

There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training.

CONCLUSION

This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification.

LEVEL OF EVIDENCE

Level III.

Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State

BACKGROUND

There are limited epidemiologic data examining the incidence of pediatric anterior cruciate ligament reconstruction (ACLR) over the past decade.

PURPOSE

To examine statewide population trends in the incidence of ACLR in a pediatric population.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Inpatient and outpatient claims for pediatric patients who underwent ACLR between 2009 and 2017 were identified in the New York Statewide Planning and Research Cooperative System database via International Classification of Diseases (ICD), Revision 9, Clinical Modification; ICD, Revision 10, Clinical Modification and Procedural Classification System; or Current Procedural Terminology codes. New York population data for each year between 2009 and 2017 were used from the New York State Department of Health to calculate the rates of ACLR per 100,000 people aged 3 to 19 years and determine the 95% confidence limits. The rates were then stratified by age, sex, and insurance. Two-year rates of revision and contralateral ACLR were also analyzed by sex.

RESULTS

Between 2009 and 2017, 20,170 pediatric ACLRs were identified. The rates of pediatric ACLR increased steadily from 49.3 per 100,000 in 2009 (95% CI, 47.2-51.4) to a peak of 61.0 (95% CI, 58.6-63.4) in 2014 and decreased to 51.8 (95% CI, 49.6-54.1) by 2017. The age group 15 to 17 years had the highest rates of ACLR of all age groups, peaking at 198.5 (95% CI, 188.3-208.7) per 100,000. Analysis by sex showed that ACLR rates between males and females were not different. Males had a 2-year ipsilateral revision rate of 4.3%, while females had a rate of 3.3% (P = .0001). Females had a contralateral ACLR rate of 4.0%, while males had a rate of 2.6% (P = .0002).

CONCLUSION

Pediatric ACLR rates continued to rise until 2014, but there was a demonstrable decrease in rates after 2014. This decline in pediatric ACLR may point to the efficacy of injury prevention programs or changes in practice management. The high revision rate in males and high contralateral surgery rate in females can help guide patient counseling for return to play and complication risk.

CLINICAL RELEVANCE

This study showed that ACLR in pediatric patients may be decreasing in recent years. There were differences in revision and contralateral ACLR by sex.

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

Background:

The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown.

Purpose:

To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders.

Results:

A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03).

Conclusion:

Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty

BACKGROUND

There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA.

RESULTS

Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001).

CONCLUSION

THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.

Surgeon and Facility Volume are Associated With Postoperative Complications After Total Knee Arthroplasty

Background

Surgeon and hospital volumes may affect outcomes of various orthopedic procedures. The purpose of this study is to characterize the volume dependence of both facilities and surgeons on morbidity and mortality after total knee arthroplasty.

Methods

Adults who underwent total knee arthroplasty for osteoarthritis from 2011 to 2015 were identified using International Classification of Diseases-9 Clinical Modification diagnostic and procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, while controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.

Results

Of 113,784 identified patients, 71,827 were treated at a high- or low-volume facility or by low- or high-volume surgeon. Low-volume facilities had higher 1-month, 3-month, and 12-month rates of readmission, urinary tract infection, cardiorespiratory arrest, surgical site infection, and wound complications; higher 3- and 12-month rates of pneumonia, cellulitis, and in-facility mortality; and higher 12-month rates of acute renal failure and revision. Low-volume surgeons had higher 1-, 3-, and 12-month rates of readmission, urinary tract infection, acute renal failure, pneumonia, surgical site infection, deep vein thrombosis, pulmonary embolism, cellulitis, and wound complications; higher 3- and 12-month rates of cardiorespiratory arrest; and higher 12-month rate of in-facility mortality.

Conclusions

These results suggest volume shifting toward higher volume facilities and/or surgeons could improve patient outcomes and have potential cost savings. Furthermore, these results can inform healthcare policy, for example, designating institutions as centers of excellence.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018

BACKGROUND

In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care.

METHODS

Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery.

RESULTS

A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.

CONCLUSIONS

This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND

Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown.

PURPOSE

To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.

RESULTS

Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001).

CONCLUSION

Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

Effect of Skeletal Maturity on Fixation Techniques for Tibial Eminence Fractures

Background:

Several fixation methods have been reported for the operative treatment of tibial eminence fractures. Previous biomechanical studies have demonstrated that suture fixation may be a stronger construct; however, the maturity status of these specimens was not scrutinized.

Purpose:

To examine if suture fixation remains a biomechanically superior fixation method to screw fixation in both skeletally mature and immature specimens.

Study Design:

Controlled laboratory study.

Methods:

Sixteen total matched porcine (Yorkshire) knees (8 skeletally immature knees and 8 skeletally mature knees) were procured, and a standardized tibial eminence fracture was created. In each age-matched group of knees, 4 knees underwent randomization to fixation with 2 screws while 4 knees were randomized to fixation using a dual-suture technique. Once fixation was complete, the specimens underwent cyclic loading (200 cycles) in the anteroposterior plane of the tibia and load-to-failure testing, both with the knee positioned at 30° of flexion. Relevant measurements were recorded, and data were analyzed.

Results:

Among mature specimens, load to failure was 1.9 times higher in the suture fixation group compared with the screw fixation group (1318.84 ± 305.55 vs 711.66 ± 279.95 N, respectively; P = .03). The load to failure was not significantly different between the groups in immature specimens (suture: 470.00 ± 161.91 N vs screw: 348.79 ± 102.46; P = .08).

Conclusion:

These findings suggest that suture fixation may represent a better construct choice for fixation of tibial eminence fractures in the skeletally mature population. However, in the skeletally immature population, fixation with screws or suture may be equivalent. Displacement after cyclic loading did not appear to differ by fixation method, nor did stiffness.

Clinical Relevance:

A stronger fixation construct may be beneficial and allow for earlier range of motion to help potentially decrease postoperative stiffness. Clinical studies are warranted to see if these results may be replicated in humans.

Predictors of Surgery and Cost of Care Associated with Patellar Instability in the Pediatric and Young Adult Population

Purpose

To determine how patient demographics, socioeconomic status, history of recurrence, and initial point of presentation for health care influenced the decision for surgical treatment following a patellar instability episode.

Methods

The New York SPARCS database from 2016 to 2018 was queried for patients aged 21 and younger who were diagnosed with a patellar instability episode. These were linked to later surgeries with Current Procedural Terminology (CPT) codes 27405 (MPFL repair), 27418 (tibial tubercle osteotomy), 27420 (dislocating patella reconstruction), 27422 (Campbell/Roux-Goldthwait procedure), and 27427 (extra-articular knee ligamentous reconstruction). χ²-analysis and binary logistic regression were used to assess demographic and injury-specific variables for association with operative management. A generalized linear model was used to estimate charges associated with patellar instability.

Results

There were 2,557 patients with patellar instability, 134 (5.2%) of whom underwent surgery. Patients with recurrent instability had 1.875 times higher odds of undergoing surgery (P = .017). Compared to white patients, black patients had 0.428 times the odds of surgery (P = .004). None of the patients without insurance had surgery. In the cost model, an initial visit to an outpatient office was associated with $1,994 lower charges compared to an emergency department (ED) visit (P < .001). Black patients had $566 more in charges than White patients (P = .009). Compared with nonoperative treatment, surgeries with CPT 27405 added $13,124, CPT 27418 added $10,749, CPT 27422 added $18,981, CPT 27420 added $23,700, and CPT 27427 added $25,032 (all P < .001).

Conclusions

Patients with recurrent instability had higher odds of surgery, while Black and uninsured patients had lower odds of surgery. ED visits were associated with significantly higher charges compared to office visits, and Black patients had higher charges than white patients. Minority and uninsured patients may face barriers in access to orthopedic care.

Level of Evidence

Level III, retrospective cohort study.

Trends in Operative Treatment of Pediatric and Adolescent Forearm Fractures Among American Board of Orthopaedic Surgery Part II Candidates

BACKGROUND

Pediatric and adolescent forearm fractures are among the most common injuries treated by orthopaedic surgeons. Recent literature shows that there has been an increased interest in operative management for these injuries. The purpose of the current study was to examine the trends in case volume, patient age, surgeon fellowship training, and postoperative complications of surgically treated pediatric forearm fractures over >15-year period of American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination candidates.

METHODS

ABOS Part II candidates' Oral Examination Case List data from 2003 to 2019 was queried for all pediatric and adolescent (19 y of age and below) forearm fractures treated operatively. Patient demographics, fracture type, complications, and candidate fellowship type were identified for each case. Linear regression was used to delineate annual trends in patient age, complication rates, and case volume by fellowship type. Analysis of variance was performed to evaluate complication rates by fellowship type. Statistical significance for all comparative analyses was set at P-value <0.05.

RESULTS

A total of 4178 pediatric and adolescent forearm fractures (mean age: 12.6 y; SD: 3.7 y) were treated surgically among ABOS Part II Oral Examination candidates during their 6-month collection periods from 2003 to 2019. The mean patient age decreased significantly (P<0.001) over the study timeframe, while complication rates increased (P<0.001). Pediatric fellowship-trained orthopaedic surgeons performed significantly more cases than general orthopaedic surgeons over recent years (P<0.001). No significant trends were identified between fellowship type and complication rates. The overall surgical complication rate was 17%. The complication rate of open fractures was 24%, which was significantly >15% complication rate of closed fractures (P<0.001).

CONCLUSIONS

Fellowship-trained pediatric orthopaedic surgeons are performing an increasing number of pediatric and adolescent forearm fracture fixation when compared with other orthopaedic surgeons. The mean age of surgically managed pediatric forearm fracture patients has decreased from 2003 to 2019. There has been an increase in the rate of overall reported complications following pediatric forearm fracture surgery over recent years, without any significant association to any particular subspecialty. Future studies should evaluate the comparative effectiveness of surgical treatment of pediatric forearm fractures compared with closed management.

Risk Factors for Failure After Anterior Cruciate Ligament Reconstruction in a Pediatric Population: A Prediction Algorithm

Background:

Anterior cruciate ligament reconstruction (ACLR) in pediatric patients is becoming increasingly common. There is growing yet limited literature on the risk factors for revision in this demographic.

Purpose:

To (1) determine the rate of pediatric revision ACLR in a nationally representative sample, (2) ascertain the associated patient- and injury-specific risk factors for revision ACLR, and (3) examine the differences in the rate and risks of revision ACLR between pediatric and adult patients.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The PearlDiver patient record database was used to identify adult patients (age ≥20 years) and pediatric patients (age <20 years) who underwent primary ACLR between 2010 and 2015. At 5 years postoperatively, the risk of revision ACLR was compared between the adult and pediatric groups. ACLR to the contralateral side was also compared. Multivariate logistic regression was used to determine the significant risk factors for revision ACLR and the overall reoperation rates in pediatric and adult patients; from these risk factors, an algorithm was developed to predict the risk of revision ACLR in pediatric patients.

Results:

Included were 2055 pediatric patients, 1778 adult patients aged 20 to 29 years, and 1646 adult patients aged 30 to 39 years who underwent ACLR. At 5 years postoperatively, pediatric patients faced a higher risk of revision surgery when compared with adults (18.0 % vs 9.2% [adults 20-29 years] and 7.1% [adults 30-39 years]; P < .0001), with significantly decreased survivorship of the index ACLR (P < .0001; log-rank test). Pediatric patients were also at higher risk of undergoing contralateral ACLR as compared with adults (5.8% vs 1.6% [adults 20-29 years] and 1.9% [adults 30-39 years]; P < .0001). Among the pediatric cohort, boys (odds ratio [OR], 0.78; 95% CI, 0.63-0.96; P = .0204) and patients >14 years old (OR, 0.62; 95% CI, 0.45-0.86; P = .0035) had a decreased risk of overall reoperation; patients undergoing concurrent meniscal repair (OR, 1.84; 95% CI, 1.43-2.38; P < .0001) or meniscectomy (OR, 2.20; 95% CI, 1.72-2.82; P < .0001) had an increased risk of revision surgery. According to the risk algorithm, the highest probability for revision ACLR was in girls <15 years old with concomitant meniscal and medial collateral ligament injury (36% risk of revision).

Conclusion:

As compared with adults, pediatric patients had an increased likelihood of revision ACLR, contralateral ACLR, and meniscal reoperation within 5 years of an index ACLR. Families of pediatric patients—especially female patients, younger patients, and those with concomitant medial collateral ligament and meniscal injuries—should be counseled on such risks.

Orthopedic Manifestations of Abuse

Intimate partner violence and elder abuse are common in the United States but often remain undetected. The incidence of these forms of abuse is difficult to quantify, but those with a history of abuse are at risk of chronic health conditions. Physicians are in a unique position of triaging trauma patients and differentiating unintentional from abusive trauma in patients. Certain orthopedic injuries, in particular, may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through physician education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. Therefore, this review evaluates current literature regarding the orthopedic manifestations of abuse in hopes of increasing physician awareness.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures

Background:

Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively.

Purpose:

To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations.

Results:

At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%).

Conclusion:

Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Symptomatic Posterior Cruciate Ligament Ganglion Cyst in a Child with Hemophilia: A Case Report

CASE

We report the case of an active 8-year-old boy with a history of hemophilia and with a 1-year history of knee pain and limited range of motion. Magnetic resonance imaging of the knee demonstrated a ganglion cyst arising from the posterior cruciate ligament (PCL). Arthroscopic decompression of the cyst was performed, and he was asymptomatic at the 1-year follow-up.

CONCLUSION

This case demonstrates a rare finding of a pediatric PCL ganglion cyst. We suggest that clinicians should be aware of this as a cause of knee pain in the pediatric population and that arthroscopic management can be successful.

Fitness habits and barriers to exercise during residency training

While physicians advise patients on healthy lifestyle habits, physicians may struggle to abide by their own recommendations. We sought to characterize resident physician participation in exercise, their barriers to exercise, and the effect of exercise on their overall wellness. We hypothesized that residents who exercised would have less depression and greater wellbeing. Trainees at a university-based institution were surveyed. Data regarding exercise habits, hours worked, barriers to exercise, and mental health were acquired. Mental health was assessed via the Patient Health Questionnaire-2. Inter-group differences were analyzed using chi-squared testing; statistical significance was set at PÃ0.05. 129 trainees responded to the survey. 84 trainees reported exercising while 45 denied. 63 exercisers reported “living a healthy lifestyle” compared to 18 nonexercisers (PÃ0.001). Exercisers were more likely to report “Time” as their greatest barrier to exercise (PÃ0.001). Fifty-five exercisers answered “Not at all” when asked about how often they experience anhedonia compared to 23 non-exercisers. Trainees who exercise are more likely to report living a healthy lifestyle and less likely to experience anhedonia than non-exercisers, demonstrating the importance of exercise during residency.

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study

BACKGROUND

There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI).

PURPOSE

To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI.

STUDY DESIGN

Cross-sectional study; level of evidence, 3.

METHODS

We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups.

RESULTS

There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P < .001). There was a higher rate of lateral meniscal tears (P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment.

CONCLUSION

Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study

BACKGROUND

Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.

PURPOSE

To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.

RESULTS

A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA.

CONCLUSION

Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis

BACKGROUND

Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population.

METHODS

PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration).

RESULTS

The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69).

CONCLUSIONS

Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Affecting Patient Decision-Making Regarding Midshaft Clavicle Fracture Treatment

Introduction Midshaft clavicle fractures are a common problem encountered by orthopedic surgeons. There remains debate between non-surgical and surgical treatment options for certain midshaft clavicle fractures. Due to the lack of a clear treatment strategy, this presents an opportunity for shared decision-making, which has been shown to be important to patients. Methods A 19-question survey was created encompassing basic demographic information, then taking respondents through a simulation of a midshaft clavicle fracture patient encounter. Subjects were subsequently asked their preferred treatment choice as well as shared decision-making preferences for the simulated encounter. A pilot study was performed with medical students from our home institution to assess study sample size. The survey was then distributed through an online software platform (Amazon Mechanical Turk). Statistical analysis was performed using STATA, Microsoft Excel, and Qualtrics. Results 253 subjects responded to the online survey. Over 70% of respondents had no to minimal knowledge of clavicle fractures and potential medical interventions/treatments. 67.6% of respondents preferred shared decision-making, over autonomous or paternalistic models. 45.5% of respondents wanted additional time outside the physician-patient consultation before making a treatment decision. A majority of the respondents who selected surgery (44.3%; 43/97) and no surgery (69.9%; 109/156), based their decisions on outcomes data provided in the simulation alone. There was no statistically significant relationship between income, race/ethnicity, education level, work status, sex, or type of visual fracture representation (i.e., radiograph vs. cartoon image) and treatment decision (p>0.05). Younger age (p=0.007) and being married (p=0.001) were associated with increased likelihood to select surgery as the treatment decision.  Conclusion Most respondents had no-to-minimal knowledge about clavicle fractures, placed a high value in shared decision-making for midshaft clavicle fractures, and prioritized outcomes data in making treatment decisions. Younger age and marital status may increase the likelihood of a patient selecting to proceed with surgery over non-operative treatment.

Shoulder and Elbow Injuries in the Adolescent Throwing Athlete

Shoulder and elbow injuries in the adolescent population can be generally divided into skeletally immature and skeletally mature. Skeletally immature injuries refer to damage to the open growth plate (physis) in the young athlete, which have distinct differences in long-term risks if not managed correctly due to the potential for growth disturbance. Skeletally mature injuries occur in athletes with closed growth plates and are less likely to limit growth potential. It is important to recognize these different types of injuries, as well as the patients most at risk for each type because treatment may vary significantly between the two groups. The main skeletally immature injuries covered by this review will include: medial epicondyle apophysitis ("Little Leaguer's elbow), medial epicondyle fractures, olecranon stress fractures, capitellar osteochondritis dissecans (OCD), and proximal humeral apophysitis ("Little Leaguer's shoulder"). The skeletally mature injuries discussed will include: valgus extension overload syndrome (VEOS), ulnar collateral ligament (UCL) tear, shoulder instability, and superior labral anterior-posterior (SLAP) tears. We will review the history and presentation of the injuries as well as different treatment strategies and return to play guidelines for both primary care sports physicians as well as orthopedic surgeons.

Sudden Cardiac Death in the Adolescent Athlete: History, Diagnosis, and Prevention

Sudden cardiac death in young athletes is a devastating condition that occurs without warning. While most middle and high school athletes require preparticipation screening, many predisposing conditions go undiagnosed until they occur. The frequency of sudden cardiac death is often under-reported because there is no mandatory system for reporting sports-related death in high school sports. Additionally, there is debate about the cost-effectiveness of more advanced screening tests, such as electrocardiogram, due to high false-positive rates. It is, however, accepted that participants with a family history of sudden cardiac death should undergo more in-depth screening. If sudden cardiac arrest occurs, it is important for the patient to undergo immediate defibrillation. Community outreach to ensure that automated external defibrillators are present at athletic events, as well as cardiopulmonary resuscitation training for coaches, could potentially save lives. Ultimately, prevention of sudden cardiac death depends on physician awareness of how to properly screen and identify those at risk, and how to best be prepared if sudden cardiac arrest occurs.

Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this study was to systematically review and quantitatively analyze outcomes in operative versus nonoperative management of displaced midshaft clavicle fractures in pediatric and adolescent patients.

DATA SOURCES

Using the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic searches of PubMed and EMBASE were conducted to identify English-language studies reporting outcomes in displaced pediatric midshaft clavicle fractures from 1997 to 2018.

STUDY SELECTION

Studies that reported on outcomes of operative and/or nonoperative treatment of displaced midshaft clavicle fractures in patients younger than 19 years were included.

DATA EXTRACTION

Patient and treatment characteristics, union rates, time to union, time to return to activity, patient-reported outcome measures, and complications were extracted.

DATA SYNTHESIS

All extracted data were recorded and qualitatively compared. QuickDASH (Quick Disabilities of the Arm, Shoulder, and Hand) scores and Constant scores were pooled using random-effects modeling and compared among studies, which adequately reported data for hypothesis testing.

CONCLUSIONS

Three thousand eight hundred ten articles were identified, and 12 met inclusion criteria. These studies encompassed 497 patients with an average age of 14.1 years (8-18 years, range). Both operative and nonoperative management of displaced midshaft clavicle fractures in this population provide excellent rates of union and patient-reported outcome measures. Compared with nonoperative management, operative management yielded faster return to activity, superior Constant scores, and equal QuickDASH scores. Operative management had higher complication rates and complications that required secondary operative treatment (mostly related to implant prominence).

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.