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Despite recent policy efforts to increase price transparency, obtaining estimated prices for surgery remains difficult for most patients and families.Assess availability and variability of cost and self-pay discounts for pediatric anterior cruciate ligament (ACL) reconstruction in the United States.This was a prospective study using scripted telephone calls to obtain price estimates and self-pay discounts for pediatric ACL reconstruction. From July to August 2020, investigators called 102 hospitals, 51 "top-ranked" pediatric orthopaedic hospitals and 51 "non-top ranked" hospitals randomly selected, to impersonate the parent of an uninsured child with a torn ACL. Hospital, surgeon, and anesthesia price estimates, availability of a self-pay discount, and number of calls and days required to obtain price estimates were recorded for each hospital. Hospitals were compared on the basis of ranking, teaching status, and region.Only 31/102 (30.3%) hospitals provided a complete price estimate. Overall, 52.9% of top-ranked hospitals were unable to provide any price information versus 31.4% of non-top-ranked hospitals ( P =0.027). There was a 6.1-fold difference between the lowest and highest complete price estimates (mean estimate $29,590, SD $14,975). The mean complete price estimate for top-ranked hospitals was higher than for non-top-ranked hospitals ($34,901 vs. $25,207; P =0.07). The mean complete price estimate varied significantly across US region ( P =0.014), with the greatest mean complete price in the Northeast ($41,812). Altogether, 38.2% hospitals specified a self-pay discount, but only a fraction disclosed exact dollar or percentage discounts. The mean self-pay discount from top-ranked hospitals was larger than that of non-top-ranked hospitals ($18,305 vs. $9902; P =0.011). An average of 3.1 calls (range 1.0 to 12.0) over 5 days (range 1 to 23) were needed to obtain price estimates.Price estimates for pediatric sports medicine procedures can be challenging to obtain, even for the educated consumer. Top-ranked hospitals and hospitals in the Northeast region may charge more than their counterparts. In all areas, self-pay discounts can be substantial if they can be identified but they potentially create an information disadvantage for unaware patients needing to pay out-of-pocket.Economic; Level of Evidence II.Previous studies have highlighted the importance of value-based health care decisions and deficits of price transparency in various fields including pediatric and orthopaedics procedures.This study is the first to examine availability and variability of health care cost in pediatric sports medicine and the first to assess availability and magnitude of self-pay discounts, setting expectations for the uninsured patient incurring large out-of-pocket expenses.

The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone.We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision.For patients followed2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at2 years of follow-up.This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation.Therapeutic IV.

Animal studies have shown evidence of neurotoxicity from inhalational anesthesia, yet clinical studies have been less conclusive. While ongoing studies investigate the clinical significance of anesthesia-associated neurodevelopmental changes in young children, reducing anesthetic exposure in pediatric orthopaedic surgery is prudent. The primary objective of this study is to determine if local anesthetic injection before surgical incision versus after surgical release decreased inhalational anesthetic exposure in children undergoing unilateral trigger thumb release. The secondary objectives were to determine if the timing of local anesthetic injection affected postoperative pain or length of stay.This was a single-center randomized controlled trial of pediatric patients (4 y and below) undergoing unilateral trigger thumb release. Subjects were randomized into preincision or postrelease local anesthesia injection groups. The surgeon was aware of the treatment group, while the anesthesiologist was blinded. Patient demographics, operative times, cumulative sevoflurane dose, and postoperative anesthesia care unit recovery characteristics were collected. The χ2, Fisher exact, and Mann-Whitney U tests were conducted.A total of 24 subjects were enrolled, with 13 randomized to the preincision injection group and 11 to the postprocedure injection group. There was no significant difference in age, sex, operative time, or tourniquet time between groups. There was a significant difference in the cumulative sevoflurane dose between the preincision injection group (23.2 vol%; interquartile range: 21.7 to 27.6) and the postprocedure injection group (28.1 vol%; interquartile range: 27 to 30) (P=0.03), with a 21% reduction in cumulative dose. There were no significant differences in postoperative pain scores, use of rescue pain medications, the incidence of nausea, or time to discharge between groups.Administering local anesthesia before incision versus at the end of the procedure significantly decreased cumulative sevoflurane dose for unilateral trigger thumb release. The results of this study suggest that local anesthetic injection before the incision is a low risk, easy method to reduce general anesthesia requirements during trigger thumb release and could decrease sevoflurane exposure more substantially in longer procedures and mitigate risks of neurotoxicity. Preincision injection with local anesthetic should be incorporated into routine clinical practice.Level I.

BACKGROUND Study groups are multicenter collaborations aimed at improving orthopaedic decision-making through higher-powered, more generalizable studies. New research is disseminated through peer-reviewed literature and academic meetings, including the Pediatric Orthopaedic Society of North America (POSNA) annual meeting, which brings together academic and medical professionals in pediatric orthopaedics. The goal of this study was to identify patterns in podium presentations (PP) at the POSNA annual meeting resulting from multicenter study groups during a 15-year period. METHODS A total of 2065 PP from the 2006 to 2020 POSNA annual meetings were identified. The abstracts of each PP were reviewed to determine if they resulted from a multicenter study group and for characteristics including subspecialty focus. PP from 2006 to 2018 were further reviewed for publication in academic journals. Pearson correlation was used to assess change in the number of PP resulting from study groups overtime. Univariate analysis was used to compare characteristics of PP based on study group involvement (significance P

Women are underrepresented across the field of orthopedic surgery and may face barriers to academic advancement. Research presentation at national meetings and publication record are important drivers of advancement in academic orthopedic surgery. However, little is known regarding potential gender differences in publication after orthopedic conference research presentation. This investigation analyzed research presentations at the Annual Meeting of the American Academy of Orthopaedic Surgeons in 2016 and 2017. Author gender was determined through a search of institutional and professional networking websites for gender-specific pronouns. Resulting publications were identified using a systematic search of PubMed and Google Scholar databases. A total of 1696 of 1803 (94.1%) abstracts from 2016 to 2017 had identifiable gender for both the first and last authors, with 1213 (71.5%) abstracts ultimately being published. There were no differences in average sample size or level of evidence between genders. Abstracts authored by women were significantly less likely to lead to publication compared with those by men (67.1% vs 72.1%, P =.023), with articles authored by women having a longer median time to publication (median, 20 months [interquartile range, 19] vs 17 months [interquartile range, 15]; P =.003). This discrepancy was most apparent in adult reconstruction, with women having a 15.5% lower rate of publication (55.1% [27/49] vs 70.6% [307/435]; P =.026) and lower publication journal impact factor (2.7±1.4 vs 3.4±3.4, P =.040) than men. Potential reasons for these discrepancies, including disproportionate domestic obligations, inadequate mentorship, and bias against female researchers, should be addressed. [ Orthopedics . 2023;46(2):e118–e124.]

More than 1 in 4 pediatric fractures involves the distal radius. Most prior epidemiologic studies are limited to retrospective, single center investigations, and often include adults. This study aims to describe the contemporary epidemiology of pediatric distal radius fractures using prospectively collected data from a multicenter Pediatric Distal Radius Fracture Registry.Patients aged 4 to 18 years diagnosed with a distal radius fracture from June 2018 through December 2019 at 4 tertiary care pediatric centers were screened and enrolled in this prospective longitudinal cohort study. Patients were excluded if they presented with bilateral distal radius fractures, polytrauma, or re-fracture. Demographic information, mechanism of injury, fracture characteristics, associated injuries, and procedural information were recorded. All radiographs were reviewed and measured. Descriptive statistics and bivariate analyses were performed.A total of 1951 patients were included. The mean age was 9.9±3.3 years, and 61.3% of patients were male ( P0.001). Most injuries occurred during a high-energy fall (33.5%) or sports participation (28.4%). The greatest proportion of fractures occurred during the spring months (38.5%). Torus fractures (44.0%) were more common than bicortical (31.3%) or physeal (21.0%) fractures. Of the physeal fractures, 84.3% were Salter-Harris type II. Associated ulnar fractures were observed in 51.2% of patients. The mean age at injury was higher for patients with physeal fractures (11.6±2.9 y) than patients with torus or bicortical fractures (9.4±3.1 and 9.6±3.1 y, respectively; P0.001). Thirty-six percent of distal radius fractures underwent closed reduction and 3.3% underwent surgical fixation. Patients treated with closed reduction were more likely to be male (68.7% vs. 57.2%; P0.001), obese (25.3% vs. 17.2%; P0.001), and have bicortical fractures (62.2% vs. 14.5%; P0.001).Distal radius fractures in children have a male preponderance and are most likely to occur in the spring months and during high-energy falls and sports. Physeal fractures tend to occur in older children while torus and bicortical fractures tend to occur in younger children.Level I-prognostic.

Multiple enchondromas in the pediatric hand is a relatively rare occurrence and the literature regarding its incidence and treatment is sparse. Within this rare subset of patients, we identified a unique cohort in which lesions are confined to multiple bones in a single ray or adjacent rays within a single nerve distribution. We review the clinical and pathologic characteristics and describe the indications for and outcomes of treatment in this unique subset of patients as well as offer conjectures about its occurrence.Institutional review board (IRB)-approved retrospective multicenter study between 2010 and 2018 identified subjects with isolated multiple enchondromas and minimum 2-year follow-up. Data analyzed included demographics, lesion quantification and localization, symptoms and/or fracture(s), treatment of lesion(s), complications, recurrence, and presence of malignant transformation.Ten patients were evaluated with average age at presentation of 9 years (range: 4 to 16) and mean clinical follow-up of 6 years (range: 2.8 to 8.6). Five subjects had multiple ray involvement in a single nerve distribution and 5 had single ray involvement with an average of 4 lesions noted per subject (range: 2 to 8). All children in the study had histopathologic-proven enchondromas and underwent operative curettage±bone grafting. Indications for surgical intervention included persistent pain, multiple prior pathologic fractures, impending fracture and deformity. During the study period three subjects experienced pathologic fracture treated successfully with immobilization. Recurrence was noted in 40% at an average of 105 weeks postoperatively (range: 24 to 260) and appears higher than that reported in the literature. No case of malignant transformation was observed during the study period.A rare subset of pediatric patients with multiple enchondromas of the hand is described with lesions limited to a single ray or single nerve distribution. Further awareness of this unique subset of patients may increase our understanding of the disease and improve patient outcomes.Level IV-therapeutic (case series).

Racial and ethnic minority patients continue to experience disparities in health care. It is important to understand provider-level factors that may contribute to these inequities. This study aims to evaluate the presence of implicit racial bias among pediatric orthopaedic surgeons and determine the relationship between bias and clinical decision making.A web-based survey was distributed to 415 pediatric orthopaedic surgeons. One section measured for potential implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared with US physicians and the US general population using publicly available data. Another section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, White or Black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (ie, surgeon with pro-White score assigned White vignette version) were compared with those that were discordant.IAT results were obtained from 119 surveyed surgeons (29% response rate). Overall, respondents showed a minor pro-White implicit bias ( P0.001). Implicit bias of any strength toward either race was present among 103/119 (87%) surgeons. The proportion of pediatric orthopaedic surgeons with a strong pro-White implicit bias (29%) was greater than that of US physicians overall (21%, P =0.032) and the US general population (19%, P =0.004). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups.Most of the pediatric orthopaedic surgeons surveyed demonstrated implicit racial bias on IAT testing, with a large proportion demonstrating strong pro-White bias. Despite an association between implicit bias and clinical decision making in the literature, this study observed no evidence that implicit racial bias affected the management of pediatric fractures.Level IV.

A 7-year-old girl sustained a radiographic appearance seemed harmless (TRASH) elbow lesion after falling from play equipment. Initial radiographs demonstrated a transolecranon fracture-dislocation. Additional injury was suspected, given valgus instability after reduction. Subsequent magnetic resonance imaging (MRI) revealed a large osteochondral coronoid fragment only partially visible on initial radiographs and computed tomography (CT). Successful outcomes were achieved by ulnar nerve decompression, open reduction, and fixation.TRASH lesions, including this osteochondral coronoid injury, may be overlooked in younger children because of an abundance of unossified cartilage. A high index of suspicion and early MRI can lead to successful diagnosis and treatment.

Price transparency purports to help patients make high-value health care decisions, however, there is little data to support this. The pediatric distal radius buckle fracture (DRBF) has 2 equally efficacious but not equally priced treatment options (cast and splint), serving as an excellent potential model for studying price transparency. This study uses the DRBF model to assess the impact of up-front cost information on a family's treatment decisions when presented with clinically equivalent treatment options for a low-risk injury.Participants age 4 to 14 presenting with an acute DRBF to a hospital-based pediatric orthopaedic clinic were recruited for this randomized controlled trial. Participants were randomized into cost-informed or cost-blind cohorts. All families received standardized information about the injury and treatment options. Cost-informed families received additional cost information. Both groups were allowed to freely choose a treatment. Families were surveyed regarding their decision factors. Cost-blinded families were subsequently presented with the cost information and could change their decision. Independent samples t tests and χ2 tests were utilized to evaluate differences.A total of 127 patients were enrolled (53% cost-informed, 47% cost-blind). The 2 groups did not significantly differ in demographics. Immobilization selection did not differ between groups, with 48% of the cost-informed families selecting the more expensive option (casting), compared with 47% of the cost-blind families. Cost was the least influential factor in the decision-making process according to participant survey, influencing only 9% of families. Only one family changed their decision after receiving cost information, from a splint to a cast.Families appear to be cost-insensitive when making medical treatment decisions for low-risk injuries for their child. Price transparency alone may not help families arrive at a decision to pursue high-value treatment in low-risk orthopaedic injuries.Level I.

Risk factors for congenital upper limb differences (CoULDs) are often studied at the general population level. The CoULD registry provides a unique opportunity to study prenatal risk factors within a large patient sample.All patients enrolled between June 2014 and March 2020 in the prospective CoULD registry, a national multicenter database of patients diagnosed with a CoULD, were included in the analysis. We analyzed self-reported, prenatal risk factors, including maternal smoking, alcohol use, recreational drug use, prescription drug use, gestational diabetes mellitus (GDM), and gestational hypertension. The outcome measures included comorbid medical conditions, proximal involvement of limb difference, bilateral involvement, and additional orthopedic conditions. Multivariable logistic regression was used to analyze the effect of the risk factors, controlling for sex and the presence of a named syndrome.In total, 2,410 patients were analyzed, of whom 72% (1,734) did not have a self-reported risk factor. Among the 29% (676) who did have at least 1 risk factor, prenatal maternal prescription drug use was the most frequent (376/2,410; 16%). Maternal prescription drug use was associated with increased odds of patient medical comorbidities (odds ratio [OR] = 1.43,Most caregivers (72%) did not report a risk factor during enrollment. However, reporting a risk factor was associated with patient medical and orthopedic comorbidities. Of note, GDM alone significantly increased the odds of both these outcome measures along with proximal limb differences. These findings highlight the ill-defined etiology of CoULDs but suggest that prenatal risk factors, especially GDM, are associated with a higher degree of morbidity.Prognostic III.

Purpose Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort. Methods A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores. Results A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores. Conclusions Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function. Type of study/level of evidence Diagnostic II.