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Background: Social determinants of health (SDOH) are conditions in the environments where people are born, live, learn, work, play, and worship that affect a wide range of health and quality of life outcomes. While SDOH have been shown to have a significant effect on outcomes and access to care for many orthopaedic conditions, their effect on pediatric orthopaedic care is less well established. The purpose of this study was to evaluate the effects of race, income, parental employment status and education level, and type of insurance, on time to initial evaluation of pediatric fracture patients in an orthopaedic clinic. Methods: A retrospective chart review was performed for fracture patients who presented to a children’s emergency department (ED) and were followed up at an outpatient pediatric orthopaedic clinic. Socioeconomic and demographic data were collected including patient age at presentation of fracture, type of insurance, patient race and ethnicity, patient ZIP code, primary guardian’s employment status and education level, and household annual income. Multivariable negative binomial regression analysis was used to determine the effect of SDOH on time from ED visit to initial orthopaedic follow up. Results: A total of 516 patients were included in the study (mean follow-up time = 8.54 days; SD = 4.53 days) between the ED visit and initial orthopaedic follow up. After adjusting for all other collected variables, there was a correlation between time to follow up and patient race (White patients had 0.76 days shorter time compared with that of non-White patients, P = .0455), insurance status (self-pay patients had 1.73 days longer time compared with that of insured patients), and mean household income in the patient’s ZIP code (decrease of 0.92 days per $10,000 increase in mean household income, P = .0431). Patient age also correlated with increased time to follow up (1.03-day increase per year of age, P = .0051). Conclusions: The time from ED visit to initial evaluation in an orthopaedic clinic for pediatric fracture patients was correlated with certain SDOH including race, insurance status, mean income in patients’ respective ZIP code, and age of the patient. Key Concepts: (1) Social determinants of health may impact access to care and outcomes in pediatric orthopaedics, and this relationship is confounded by multiple factors. (2) Time to follow up for pediatric fracture patients is affected by race, income, and insurance status. (3) Pediatric orthopaedic surgeons must be aware of this disparity and use specific strategies to address potential barriers to care. Level of Evidence: III, Prognostic Study

Study Design Retrospective study. Purpose To identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective. Overview of Literature Spine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking. Methods A retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed. Results For patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33–23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment. Conclusions Spine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Background Estimates pertaining to the timing of the adolescent growth spurt (e.g. peak height velocity; PHV), including age at peak height velocity (aPHV), play a critical role in the diagnosis, treatment, and management of skeletal growth and/or developmental disorders. Yet, distinct statistical methodologies often result in large estimate discrepancies. Aim The aim of the present study was to assess the advantages and disadvantages of three modelling methodologies for height as well as to determine how estimates derived from these methodologies may differ, particularly those that may be useful in paediatric clinical practice. Subjects and methods Height data from 686 individuals of the Fels Longitudinal Study were modelled using 5th order polynomials, natural cubic splines, and SuperImposition by Translation and Rotation (SITAR) to determine aPHV and PHV for all individuals together (i.e. population average) by sex and separately for each individual. Estimates within and between methodologies were calculated and compared. Results In general, mean aPHV was earlier, and PHV was greater for individuals when compared to estimates from population average models. Significant differences between mean aPHV and PHV for individuals were observed in all three methodologies, with SITAR exhibiting the latest aPHV and largest PHV estimates. Conclusion Each statistical methodology has a number of advantages when used for specific purposes. For modelling growth in individuals, as one would in paediatric clinical practice, we recommend the use of the 5th order polynomial methodology due to its parameter flexibility.