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Introduction: The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak., Methods: The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes., Results: A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year., Discussion: A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients., Methods: An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification., Results: A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission., Conclusions: Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H249 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Opioids constitute the fastest-growing drug problem among children and adolescents in the United States. Recent heavy media coverage on the opioid prescription epidemic has garnered increased attention from prescribers and policymakers. The purpose of this study was to analyze trends in opioid prescribing for nonoperatively managed pediatric fractures and dislocations in order to examine changes in opioid-prescribing patterns across various U.S. regions., Methods: A retrospective review of the national Pediatric Health Information System (PHIS) database comprising 42 pediatric hospitals was performed to identify pediatric fractures and dislocations presenting to the emergency department (ED) or outpatient clinics from 2004 to 2017. We included patients with the 10 most frequently encountered diagnoses who were nonoperatively managed and were discharged home the same day. To account for hospital variation, we utilized a mixed-effects logistic regression model., Results: The final cohort included 134,931 patients, with a mean age (and standard deviation) of 12.57 ± 2.00 years (range, 10 to 18 years); 69.23% of patients were male. Overall, 51.69% of patients were prescribed at least 1 opioid dose during their ED or clinic visits. Of the patients receiving opioids, 72.04% were male and 54.10% were insured through a private insurance plan. When prescription trends were compared according to regions, children were more likely to be prescribed opioids in the South (71.37% more likely) and the Midwest (26.17% more likely) than in the Northeast., Conclusions: Although the opioid prescription rates in all 4 regions have decreased dramatically over the years, some regions were quicker than others in responding to the opioid epidemic. A significant interregional variability in opioid-prescribing practices still exists, but an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis., Clinical Relevance: Opioid-related misuse is a national epidemic and reducing the use of opioids in pediatric orthopaedic procedures is critical. Although regional variability in opioid-prescribing practices still exists, an overall downward trend in opioid prescription rates for acute pain management in conservatively treated pediatric fractures and dislocations is evidence of progress in tackling the opioid crisis., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G978)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice., Methods: We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age., Results: There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics., Conclusions: This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields., Clinical Relevance: The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this investigation was to assess the utilization of telehealth capabilities by pediatric orthopaedic departments across the United States in response to the COVID-19 pandemic., Methods: One hundred four pediatric orthopaedic departments were investigated regarding each institution's current telehealth utilization as a direct response to the COVID-19 pandemic., Results: Of the 104 hospitals contacted across the United States, 100 pediatric orthopaedic departments in 39 states responded for an overall response rate of 96%. Of the 95 institutions offering telehealth services, 83 (87.4%) cited the COVID-19 pandemic as the impetus for the implementation of telehealth services. Of these, 29 institutions (31%) began offering services from March 16 to March 31 and 34 (36%) began offering services from April 1 to April 15. Regional analysis demonstrated an 800% increase in telehealth services in the state of New York, a 600% increase in Florida, a 500% increase in Texas, a 400% increase in Michigan, a 200% increase in Pennsylvania, and a 1,100% increase in California., Discussion: This study demonstrates the rapid response measures instituted by pediatric orthopaedic institutions to meet the fundamental needs of the pediatric population during this unprecedented pandemic., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Objective: As orthopedic surgery residency programs are becoming more competitive, medical students interested in orthopedics are increasingly completing "year-out" programs. This study sought to evaluate student and faculty perceptions of these programs., Design: A survey evaluating baseline characteristics was disseminated to directors of year-out programs identified through postings on the orthopedics forum, Orthogate.org. A second survey was sent to all program directors (PDs) of accredited US orthopedic residencies, while a final survey was distributed to participants identified by year-out PDs., Setting: Ninety-six orthopedic year-out programs at 56 institutions were contacted., Participants: Twenty-six year-out programs, 72 PDs of ACGME-accredited orthopedic residencies, and 34 year-out participants from 6 programs completed our questionnaires., Results: 73.1% (19) year-out program provided funding to participants, averaging $30,368. 84.6% (22) reported >75% match rates into orthopedics for participants. 65.4% (17) of programs selected students between their MS3/MS4 school years. 4.2% (3) of residency PDs agreed or strongly agreed that year-out programs were important factors for consideration in residency programs, compared with 82.4% (28) of year-out participants and 69.2% (18) of year-out PDs (p < 0.001). 58.8% (2) of year-out participants cited completion of a year-out for improving the chance of matching into any orthopedic residency, while 85.3% (29) wanted to be more competitive for top programs. The average Step 1 score was 248, which was insignificantly different from the national average for matched orthopedic applicants., Conclusions: Orthopedic year-out programs have dramatically increased in number over the last 20 years. Most of these programs are funded, 1-year clinical research fellowships with relative match success for participants pursuing orthopedic residencies. While year-out PDs and students consider participation in such programs to be an important factor for residency applications, and often participate in them in order to improve their competitiveness for matching at desired programs, residency PDs overall hold different views., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children., Methods: Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade., Results: ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004)., Conclusions: Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons., Level of Evidence: Level III.

Background: Pediatric orthopaedic surgery has become increasingly subspecialized over the past decade. The purpose of this study was to analyze the volume of pediatric sports medicine cases performed by surgeons applying for the American Board of Orthopaedic Surgeons (ABOS) Part II certification exam over the past decade, comparing caseloads according to the type(s) of fellowship completed., Methods: The ABOS database was reviewed for all surgeons applying for the ABOS Part II certification exam from 2004 to 2014. Fellowship training of the candidates was recorded as Pediatrics, Sports, and Dual-Fellowship (fellowship in both Pediatrics and Sports). All other candidates were categorized as "Other". A total of 102,424 pediatric cases (patients below 18 years) were reviewed to identify sports medicine cases performed by CPT code. Multiple linear regression and Mann-Whitney U tests were used to determine trends in case volume overall and according to fellowship training for all patients, patients ≥13 and patients <13. One-way ANOVA testing was used to compare multiple means followed by multiple post hoc comparisons using a Tukey all pairwise approach using SPSS., Results: A total of 14,636 pediatric sports medicine cases were performed. There was an increase in the number of sports medicine cases performed in patients <13 (117.5±31.8 from 2004-2009 to 212.4±70.1 from 2010-2014, P=0.035; r=0.743, P=0.0007). The number of Pediatrics (r=0.601, P=0.005), Sports (r=0.741, P=0.0007) and Dual-Fellowship candidates increased (r=0.600, P=0.005) from 2004-2014. Dual-Fellowship surgeons performed 21.4% of pediatric sports medicine cases in 2014 when compared to 2.1% in 2004 (919% increase). As a group, the number of pediatric sports cases performed by Dual-Fellowship (r=0.630, P=0.004) and Sports (r=0.567, P=0.007) candidates has increased, while the number performed by "Other" candidates has decreased (r=0.758, P=0.0005). Per surgeon, Dual-Fellowship candidates performed a greater number of pediatric sports cases per collection period (36.5±9.18) than Pediatrics (6.71±0.94), Sports (5.99±0.46), and "Other" (1.21±0.15, P<0.0001 for each) candidates from 2004 to 2014., Conclusions: Over the past decade operative sports injuries have increased in children with a similar increase in the number of orthopedic surgeons specializing in pediatric sports medicine. On a per surgeon basis, these dual fellowship-trained candidates have performed on average five times the number of pediatric sports medicine cases compared to all other ABOS Part II candidates. These trends may point towards the development of a new subspecialty of pediatric sports medicine among orthopedic surgeons., Level of Evidence: Level IV-Retrospective Database Review.

Background: There has been an increase in the number of the graduates of pediatric orthopaedic fellowship programs over the past decade creating the potential for increased competition in the field. The purpose of this study was to analyze the effect of increased number of pediatric orthopaedic fellowship graduates on case volume as well as the type of procedures performed by recent graduates of pediatric orthopaedic fellowship programs from 2004 to 2014., Methods: Case logs submitted for the American Board of Orthopaedic Surgery Part II examination by applicants with the self-declared subspecialty of pediatric orthopaedics from 2004 to 2014 were analyzed. Cases were categorized as trauma (upper and lower extremity), spine, sports medicine, hip, deformity correction, foot and ankle, hardware removal, soft tissue procedures, and other. The period was divided into 3 sections: 2004-2007, 2008-2011, 2012-2014. Descriptive analysis was used to report the change in the volume and pattern of practices over the study period., Results: Although the number of pediatric orthopaedic subspecialty applicants increased from 15 to 44 from 2004 to 2014, the average cases per year increased from 2142 in 2004-2007 to 2960 in 2007-2011, and to 4160 in 2012-2014. The number of cases performed per applicant remained stable over the study period. Upper extremity trauma cases were the largest category of cases reported and increased in case volume by 141% from 2004 to 2014. Sports medicine cases increased in volume by 175%., Conclusions: Despite a large increase in the number of pediatric orthopaedic surgeons over the past decade, there is a concomitant increased in case volume across almost all subspecialties within pediatric orthopaedics. As such, pediatric orthopaedic surgeons who start a new practice can expect to develop a robust practice with a diverse group of pathologies., Level of Evidence: Level III.

Background: Although the number of women in surgical specialties has increased dramatically over the past two decades, little research exists regarding how a surgeon's gender impacts job selection and practice models. Because the number of women specializing in pediatric orthopaedics continues to increase, it is important to understand how one's gender affects practice choices and how this may affect the future workforce., Questions/purposes: (1) Among pediatric orthopaedic surgeons, is gender associated with choice of practice type (academic, private practice, hospital-based, solo)? (2) For men and women, what are the most common reasons for choosing a job? (3) For new graduates, do men and women have equal starting salaries? (4) Do men have a higher chance of getting job offers? (5) Is there a difference in workload (call frequency and surgical case volume) for men and women? (6) Finally, is there a difference in imminent retirement plans for men and women?, Methods: The 2015 Pediatric Orthopaedic Society of North American (POSNA) Needs Assessment Survey was sent to POSNA members and a special 36-question survey was sent to recent pediatric orthopaedic fellowship graduates. Both surveys included questions about self-reported gender, practice type, reasons for job selection, and call frequency. In addition, the new graduates' survey also included questions about starting salary, job offers, and number of additional fellowships completed. Responses were analyzed by gender. Chi-square and Fisher's exact tests assessed for statistical significance., Results: Among the new graduates, women are more likely to choose academic practice (women: 13 of 18 [72%], men: 21 of 44 [48%], odds ratio [OR], 3.10 [confidence interval {CI}, 0.86-11.10], p < 0.001), whereas men are more likely to choose private practice (men: 14 of 44 [32‰], women: one of 18 [6%], OR, 0.12 [CI, 0.015-1.001], p < 0.001). The primary reasons for choosing a job were not different between men and women. Among the new graduates, geography/family considerations were reported as being highly important when selecting a job (men: 33 of 44 [75%], women: 16 of 18 [89%]) followed by academic opportunities (men: 24 of 44 [55%], women: 14 of 18 [78%]). Interestingly, a higher percentage of males reported finances as being important when selecting a job (men: 23 of 44 [52%], women: five of 18 [28%]). For the current POSNA members, the most important reasons when choosing a job for both men and women were quality of partners (men: 168 of 408 [41%], women: 66 of 122 [54%]) and an interesting practice (men: 155 of 408 [38%], women 54 of 122 [44%]. As a result of our small sample size, there was no difference in starting salaries between men and women (< USD 350,000: men 22 of 44 [50%], women 12 of 18 [67%]; USD 350,000-450,000: men 11 of 44 [25%], women six of 18 [33%]; > USD 450,000: men eight of 44 [18%], women zero of 18 [0%], p = 0.131). When stratified by practice type, for private practice starting salaries, over half of men (seven of 13 [54%]) placed in the highest category of > USD 400,000, whereas the single woman respondent placed in the lowest category of < USD 300,000. Men were more likely to report having job offers before starting their fellowship (men: 24 of 44 [54%], women: eight of 18 [44%], OR, 0.67 [CI, 0.22-2.0], p = 0.042). Finally, among POSNA members, women reported a lower weekly surgical case volume compared with men. Of the men, 108 of 408 (26%) reported performing more than seven surgeries per week compared with 12 of 122 women (10%; OR, 3.4 [CI, 1.8-6.44], p < 0.001)., Conclusions: Although the numbers are small given the specialized nature of pediatric orthopaedic surgery, this study has uncovered some initial gender differences regarding practice characteristics and job opportunities among pediatric orthopaedic surgeons. As more men plan to reduce their workload or retire in the next 5 years, there may be further increases in the percentage of women surgeons in the workforce, so it is important that we begin to understand what effect, if any, gender has on practice patterns, job selection, and opportunities. Also, the finding that among the new graduates more women than men are choosing careers in academic practice over private practice suggests an extraordinary opportunity to develop more female leaders and role models at major pediatric orthopaedic centers.

Enhancing patient safety and the quality of care continues to be a focus of considerable public and professional interest. We have made dramatic strides in our technical ability to care for children with pediatric orthopaedic problems, but it has become increasingly obvious that there are also significant opportunities to improve the quality, safety, and value of the care we deliver. The purpose of this article is to introduce pediatric orthopaedic surgeons to the rationale for and principles of quality improvement and to provide an update on quality, safety, and value projects within Pediatric Orthopaedic Society of North America.

Objective: The purpose of this study is to determine the seroprevalence of blood borne transmissible diseases of the orthopaedic trauma surgical patients who deny or did not have knowledge of having disease or risk factors, but are positive for either human immunodeficiency virus, hepatitis B virus, and hepatitis C virus., Background: Orthopaedic surgeons practicing in areas with a high prevalence of HIV infection may expect that up to 7% of their patients who undergo emergency procedures and 1% to 3% of those who undergo elective surgery will be HIV-positive., Method: All conscious adult patients consecutively admitted for surgical management by the orthopaedic service were evaluated. A detailed questionnaire was completed asking the patient of knowledge of having a transmissible disease and documenting certain risk factors. Blood samples were taken to test for HIV, HBV and HCV and all positive patients were sent to a follow up clinic., Results: Out of 100 patients the following results were found: 7% were positive for HIV, 12% positive for HBV, 12% positive for HCV, 19% were positive to at least one test, and 9% were positive in more than one test. Of the one hundred patients, 6% had a positive test in spite of denying having a disease or any risk factors. None of the patients with HBV and/or HCV knew they were positive and three (43%) of the seven with HIV were also unaware of their condition., Conclusions: This study suggests that a worrisome number of patients are seropositive for a blood borne transmissible disease, even though they had no knowledge of such disease and claimed they had no risk factors. In order to protect orthopaedic surgeons from the unreliability of some patients' histories, all trauma orthopaedic surgical patients should be managed with universal precautions.

Data regarding orthopaedic work-force is presented. Data is based on information obtained from the Puerto Rico Board of Medical Examiners, the Puerto Rico Department of Health and orthopaedic surgeon's practice. The purpose of this study is to compare the local orthopaedic manpower with the American Academy of Orthopaedic Surgeons most recent national manpower survey and to provide a database of the local orthopaedic work-force.

This study reviews the medical records of 29 patients that were submitted to 29 spinal fusion procedures with the purpose to evaluates the efficacy of using predeposited autologous blood transfusions to replace operative blood loss. The patients age ranged from 8 to 25 years. Each patient was started on oral iron supplement as soon as surgery was scheduled. The phlebotomies were performed at the American Red Cross Blood Services Puerto Rico Chapter. Blood was drawn 1 unit every 6 days if the hematocrit was above 34%. The last phlebotomy was performed at least 7 days before surgery. The average amount of blood donated was 3.17 units (1,427 ml). The whole blood was stored using the adenine saline solution (ADSOL) as preservative for as long as 35 days. The average preoperative hematocrit value was 35%. In 89% of the cases only autologous blood was transfused. In the rest of the cases family donated homologous blood was required. The use of pre deposited autologous blood for replacement of operative blood loss has proven to be a safe, easy and well accepted method for the pediatric age patients. It also reduced the need for homologous blood and helps to increase the blood reserve at banks.