Pediatric Orthopaedic Society Of North America Research Articles

Management of Syndesmotic Ankle Injuries: Results of a Survey of Pediatric Orthopaedic Society of North America Members

BackgroundAlthough utilization of dynamic suture-button fixation for adult syndesmotic injuries has shown improved outcomes over static screw fixation, data in pediatric populations is limited. This study evaluated trends in management and identified factors influencing surgeon choice of implant for pediatric syndesmotic injuries. MethodsThe Pediatric Orthopaedic Society of North America (POSNA) members were surveyed regarding syndesmotic injury implant preferences between October 2021 and May 2022. Respondents that opted out, treated <1 syndesmotic ankle injury in the past year, or had conflicting financial obligations were excluded. Results were summarized and analyzed using logistic regression to assess for significance between years posttraining and technique preference. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for significance (P-values<.05). ResultsAmong 103 respondents to the survey (with 102 complete responses), 25% were <5 years posttraining, 24% between 5 and 10 years, 21% between 11 and 15 years, and 28% ​> ​15 years posttraining. Twenty-four percent (24/102) preferred screw versus 76% (78/102) preferring suture-button implants for syndesmotic injuries. Members >15 years posttraining were 4.7 times more likely to prefer screw implants compared to members <5 years posttraining (OR ​= ​4.7; 95% CI, 1.14–19.34; P ​= ​.03). Since starting their clinical practice, 62 respondents (60%) reported an implant preference change, with avoidance of secondary surgery (46/62; 74%) and extrapolation from adult outcomes (39/62; 63%) cited as primary motivating factors. Of the 40 members with no preference change, comfort with the procedure was the primary cited reason (33/40; 83%). Among those choosing operative intervention, radiograph-based cases showed preference for the suture-button in 70%–79% of respondents for skeletally mature patients versus 71%–81% for skeletally immature patients. ConclusionsOur data shows that the shift over time from screw to suture-button implant fixation for pediatric and adolescent syndesmotic ankle injuries is largely due to interest in avoiding implant removal and extrapolation from superior outcomes seen with suture-button use in adults. Larger comparative studies of pediatric and adolescent patients treated with suture-button versus screw fixation are needed to establish standards of care for these challenging injuries. Key Concepts(1)Literature for operative syndesmotic injury management in adults has shown improved outcomes of dynamic suture-button fixation over static screw fixation, but data in pediatric and adolescent populations is limited.(2)A survey of 102 POSNA members shows that 76% prefer suture-button, 24% prefer screw fixation with members >15 years posttraining 4.7 times more likely to prefer screw fixation to members <5 years posttraining.(3)Among 62 respondents who switched implant preference during their clinical practice, avoidance of secondary surgery and extrapolation from outcomes in adults were the two most cited reasons.(4)Among 40 respondents who did not switch implant preference, comfort with the procedure was the most cited reason.(5)Comparative studies of suture-button versus screw implants for treatment of pediatric and adolescent syndesmotic ankle injuries are needed to establish an evidence-based standard of care management. Level of EvidenceLevel V: Expert Opinion

Post-Surgical Dental Precautions/Prophylaxis in Pediatric Patients: Results of a 2023 Survey of the Membership of the Pediatric Orthopaedic Society of North America (POSNA)

IntroductionGuidelines regarding post-surgical dental care have been common in adult total joint arthroplasty patients, despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in post-operative pediatric orthopaedic patients without any published evidence to guide clinicians. Material and MethodsA survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of post-surgical guidelines regarding dental care (procedures and prohylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. ResultsOne hundred and seventy-three POSNA members opened the link to the survey. 163 respondents self-identified as Active, for a response rate of 19.8%. One hundred and fifty-seven (96.3%) reported direct involvement in surgical and post-surgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a post-operative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. ConclusionsThese results demonstrate that many of the active members of POSNA utilize post-surgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients, and no literature regarding use of such guidelines in pediatric orthopaedic patients. Level of EvidenceLevel V

Do ChatGPT and Gemini Provide Appropriate Recommendations for Pediatric Orthopaedic Conditions?

Artificial intelligence (AI), and in particular large language models (LLMs) such as Chat Generative Pre-Trained Transformer (ChatGPT) and Gemini have provided additional resources for patients to research the management of healthcare conditions, for their own edification and the advocacy in the care of their children. The accuracy of these models, however, and the sources from which they draw conclusions, have been largely unstudied in pediatric orthopaedics. This research aimed to assess the reliability of machine learning tools in providing appropriate recommendations for the care of common pediatric orthopaedic conditions. ChatGPT and Gemini were queried using plain language generated from the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) listed on the Pediatric Orthopedic Society of North America (POSNA) web page. Two independent reviewers assessed the accuracy of the responses, and chi-square analyses were used to compare the 2 LLMs. Inter-rater reliability was calculated via Cohen's Kappa coefficient. If research studies were cited, attempts were made to assess their legitimacy by searching the PubMed and Google Scholar databases. ChatGPT and Gemini performed similarly, agreeing with the AAOS CPGs at a rate of 67% and 69%. No significant differences were observed in the performance between the 2 LLMs. ChatGPT did not reference specific studies in any response, whereas Gemini referenced a total of 16 research papers in 6 of 24 responses. 12 of the 16 studies referenced contained errors and either were unable to be identified (7) or contained discrepancies (5) regarding publication year, journal, or proper accreditation of authorship. The LLMs investigated were frequently aligned with the AAOS CPGs; however, the rate of neutral statements or disagreement with consensus recommendations was substantial and frequently contained errors with citations of sources. These findings suggest there remains room for growth and transparency in the development of the models which power AI, and they may not yet represent the best source of up-to-date healthcare information for patients or providers.

Knowledge and Utilization of Sex-Specific Lead Aprons Among Pediatric Orthopaedic Surgeons.

Orthopaedic surgeons routinely face exposure to ionizing radiation during intraoperative use of fluoroscopy. Lead personal protective equipment reduces occupational radiation exposure. Female-specific lead aprons are designed with expanded lateral coverage to improve protection of breast tissue against radiation beams. The purpose of this study was to identify current trends in knowledge and utilization of female-specific lead aprons as well as any barriers to utilization. An anonymous electronic survey including 20 multiple choice and multiple selection responses was distributed to all members of the Pediatric Orthopaedic Society of North America (POSNA). Respondents who reported the use of intraoperative fluoroscopy in their practice were included in the study. Most respondents were attending surgeons (91%) and practiced in an academic setting (85%) in an urban environment (75%). Most respondents reported using a lead apron for every case (76%) and a thyroid shield for every case (75%), while most respondents reported they do not wear lead glasses (73%). Fifty-one percent of respondents were aware of female-specific lead aprons. The majority of respondents reported female-specific lead is unavailable (45%) or available in insufficient quantities (5.5%) at their institution. Ninety percent of females reported they do not wear female-specific lead with the common reasons being lack of availability and discomfort. Knowledge of female-specific lead is low with lack of availability as a common barrier to utilization. As female presence in the field of orthopaedic surgery expands, efforts should be made to improve education and availability of sex-specific lead aprons.

Estimated Incidence of Pediatric Distal Radius Buckle Fractures in the United States

BackgroundDistal radius buckle fracture care has been extensively studied, yet the incidence in the United States is unknown. This study aims to determine the incidence of pediatric buckle fractures using geospatial analysis. MethodsPediatric distal radius buckle fractures (patients aged <18) from 2018 to 2022 were identified via a retrospective chart review from a single health care organization. The catchment area was defined as all of the home ZIP codes of verified buckle fracture patients. Corrections were made for buckle fractures treated at institutions with overlaying catchment areas. Adjusted incidence was then used to calculate annual buckle fractures nationally. Pediatric Orthopaedic Society of North America member rolls were used to identify and locate pediatric orthopaedic surgeons. It was assumed that each pediatric orthopaedic surgeon would treat up to 20 buckle fractures annually from a 25-mile radius of the primary office. Based on this, the percentage of buckle fractures nationally that are able to be treated by pediatric Orthopaedic surgeons was estimated. ResultsA total of 594 distal radius buckle fractures over 5 years were confirmed in an estimated catchment area of 866,238 population. With adjustments for overlapping institutions, the estimated annual incidence was 17.3 per 100,000 people (95% CI [14.5, 20.1]). In the United States, there are an estimated 66,513 buckle fractures annually, with 1,182 pediatric orthopaedic surgeons potentially able to treat 26.5% of these cases. ConclusionsThis investigation estimates the incidence of pediatric buckle fractures in the United States, allowing for estimates of expected volumes and implications for care. Based on the geographic distribution of pediatric orthopaedic surgeons and estimated incidence, it is impractical for buckle fracture care to be delivered exclusively by pediatric orthopaedic surgeons. Key Concepts(1)The estimated annual incidence of distal radius buckle fracture is 17.3 per 100,000 people.(2)Pediatric orthopaedic surgeons are able to treat up to 26.5% of these cases.(3)Buckle fractures cannot be the exclusive domain of pediatric orthopaedic surgeons, as the number of pediatric Orthopaedic surgeons is too small for them to be the sole providers of care. Level of EvidenceIII

Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members

BackgroundParalytic agents are occasionally used during the surgical treatment of type III (OTA 13A2) supracondylar humerus fractures (SCHFx) in children depending on surgeon preference. Paralytic agents create a neuromuscular blockade and therefore may potentially help with ease of fracture reduction. Controversy regarding the use of a paralytic agent as an adjunct to anesthesia exists due to potential associated adverse drug reactions, including prolonged paralysis, cardiovascular effects, or electrolyte abnormalities.The purpose of this study was to investigate intraoperative paralytic use in pediatric type III SCHFx and to report survey responses of members of the Pediatric Orthopaedic Society of North America (POSNA) on paralytic use in SCHFx management. MethodsA retrospective chart review identified 319 type III SCHFx treated at our institution (January 2016-May 2019). Patients were assigned to three groups: Group 1, surgical treatment without a paralytic agent (n=240); Group 2, treatment with rocuronium (n=43); Group 3, treatment with succinylcholine (n=36). POSNA members were surveyed regarding paralytic use intraoperatively for type III SCHFx (November–December 2021) on paralytic use frequency, request for paralytics, reversal agent use, average time to surgery after injury and/or presentation, effect of time to surgery after injury and/or presentation on when to use a paralytic, annual number of SCHFx surgeries performed, awareness of paralytic complications, and years of surgeon experience. Statistical analysis was performed. ResultsAverage patient age was 5.2±2.2 years. Group 2 had significant increases in anesthesia duration, surgical duration, fluoroscopic time, and radiation exposure compared to Group 1. Group 2 had a higher conversion rate to open reduction than other groups. No statistically significant difference was found among groups in terms of sex, body mass index (BMI), laterality, radiographic measurements, or rates of open procedures or complications. Survey results indicated 32% (24/76) routinely use paralytics during closed reduction maneuvers; 71% (17/24) request administering paralytics at the beginning/before the case; and 33% (8/24) use paralytics in all type III SCHFx. ConclusionsSurgeons at our center reported paralytic use for closed reduction in 25% of patients; similarly, one-third of POSNA survey respondents reported paralytic use during operative management. Although paralytic agents are used during the treatment of supracondylar humerus fractures in children this study was unable to demonstrate an association of advantageous outcomes, such as shorter surgical times. Routine paralytic use to facilitate closed reduction of supracondylar humerus fractures in children warrants further study. Level of EvidenceLevel III, Retrospective chart review; Therapeutic study

The carbon footprint of American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America national meetings

BackgroundThe health care sector contributes substantially to carbon emissions. Estimating the carbon emissions of an event can help determine its climate impact. This study calculates the carbon footprints of the 2019 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting and the 2019 Pediatric Orthopaedic Society of North America (POSNA) Annual Meeting. MethodsData regarding attendance volume, geographic origin of attendees and vendors, hotel room nights, event space, and duration of meetings were obtained from AAOS and POSNA. Data were entered into an online calculator designed to measure the carbon footprint of large events (www.terrapass.com). ResultsThe AAOS 2019 annual meeting was attended by 29 448 people, requiring 66 000 hotel room nights and 2 308 800 ft2 of convention center space for 5 days. We estimated 7179 short, 8374 medium, and 13 421 long-haul round-trip flights. The POSNA 2019 annual meeting was attended by 1103 people, requiring 1932 hotel room nights and 52 100 ft2 of convention center space for 4 days. We estimated 501 short, 280 medium, and 280 long-haul round-trip flights. The AAOS 2019 meeting emitted 26 075 metric tonnes of carbon dioxide equivalents (CO2e), while the POSNA 2019 meeting emitted 544 metric tonnes. Eighty-one percent of the carbon emissions from AAOS and 80% from POSNA came from flight travel alone. Carbon neutralization of in-person AAOS and POSNA annual meetings would require carbon-offset purchases of approximately $273 700 and $5700, respectively. ConclusionsAnnual orthopaedic meetings contribute to climate change through their large carbon footprint. Leaders in the field of orthopaedics should consider strategies to mitigate the impact of such meetings, examples of which include transitioning to hybrid formats when appropriate and by purchasing carbon offsets for essential in-person participation. Key Concepts1)Calculating the carbon footprint of an event estimates its total carbon dioxide emissions to help determine how to reduce its climate impact.2)The AAOS 2019 meeting emitted 26 075 metric tonnes (MT) of carbon dioxide equivalents (CO2e), while the POSNA 2019 meeting emitted 544MT, with ∼80% coming from air travel alone.3)Carbon neutralization of in-person AAOS and POSNA annual meetings would require carbon-offset purchases of approximately $273 700 and $5700, respectively. Level of EvidenceIV

Study Characteristics and Impact of Pediatric Orthopaedic Society of North America Annual Meeting's "Best Papers" From 2009 to 2019.

Award-winning abstracts are selected every year at the Pediatric Orthopaedic Society of North America (POSNA) annual meeting as "best paper" or poster. It is unknown how many achieve publication in peer-reviewed journals and the impact they have. We sought to determine the characteristics, including the level of evidence (LoE), publication rates, and the impact of award-winning abstracts on pediatric orthopaedic surgery practice from 2009 to 2019. Award-winning abstracts or "best papers" from 2009 to 2019 were retrospectively reviewed from the POSNA website from abstract publication to manuscript publication. A search across Pubmed was used to match abstracts to their publications by comparing author names, titles, study design and methodology, results, and conclusions. Area of focus, abstract authors, institutions, publication status, LoE, time to publication, authors of publication, journals of publication, and the journal's latest Hirsch Index and impact factor were recorded. There have been 54 "best papers" at the POSNA annual meeting from 2009 to 2019. Of those, 39 have been published across 17 different journals for a publication rate of 72%. The average time from abstract presentation to publication was 21.2 months with a range of 0 to 121 months. Of the published award-winning abstracts, 64% (25) were published within 2 years, 87% (34) within 3 years, and 95% (37) within 4 years. Out of the published abstracts, 26% (10) were in the Journal of Pediatric Orthopaedics , 23% (9) were in the Journal of Bone and Joint Surgery , and 10% (4) were in the Journal of Child Orthopaedics . The median number of abstract authors was 4 and increased to a median of 6 authors once published. Most award-winning abstracts had a LoE of 3. The average journal impact factor for all publications was 4; the average Hirsch Index for the corresponding author was 29.9, and the average number of citations for a publication was 41 with a range of 0 to 270. The majority of the "best papers" presented at POSNA annual meetings from 2009 to 2019 were published in peer-reviewed journals within 2 years of presentation, with approximately half being published in the Journal of Pediatric Orthopaedics or Journal of Bone and Joint Surgery . The publication rate of "best papers" at the POSNA annual meeting was found to be higher than rates reported for abstracts presented at the annual meetings of POSNA, American Society for Surgery of the Hand and European Pediatric Orthopaedic Society, but similar to the rates observed for American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, and Orthopaedic Trauma Association. Most of the selected "best papers" at the POSNA annual meeting are published and have a substantial impact on pediatric orthopaedic surgery practice. Level IV.

Opioid Prescription Trends for Isolated Diaphyseal Femur Fractures in Pediatric Patients

Purpose: Despite the ongoing opioid epidemic, there is a lack of research on narcotic prescribing in the pediatric orthopaedic population. The Pediatric Orthopaedic Society of North America (POSNA) therefore published a survey on pain management to provide recommendations for opioid dosing. The goal of this study was to characterize opioid prescribing patterns for pediatric femur fractures in the context of the opioid epidemic and emerging national studies/guidelines.Methods: A retrospective review of 128 pediatric patients (age < 16) with isolated diaphyseal femur fractures was conducted between 2003-2019 at a level I pediatric trauma center. Comparison groups included before distribution of the POSNA survey (pre-POSNA = 01/01/2016 or earlier, N = 85) and after the survey (post-POSNA, N = 43).Results: Median total hospital postoperative opioids prescribed was 27.2 morphine milligram equivalents (MME). The two groups differed in age (pre-POSNA = 9.0 years, post-POSNA = 3.7 years, P = 0.0381), hospital length of stay (LOS) (pre-POSNA = 2 days, post-POSNA = 1 day, P < 0.0001), and procedural incision required for fracture reduction (pre-POSNA = 28.3%, post-POSNA = 58.1%, P = 0.0019). Adjusted postoperative opioid dosing was significantly lower post-POSNA (median reduction of 18.351 MME per year, P = 0.0408).Conclusions: The period following the POSNA survey was associated with a significant decline in postoperative narcotic prescriptions for pediatric femur fractures. The timing of the survey likely represents an increased concern for pediatric opioid use and a shift in clinical practice. Further work is needed to optimize injury and patient-specific narcotic prescribing.Level of Evidence: Therapeutic Level III Key Concepts•The 2016 POSNA survey identified a lack of consensus on opioid prescribing practices for common orthopaedic procedures in the United States.•The 2016 POSNA survey and subsequent 2019 published narcotic prescription recommendations represent a shift in the specialty of orthopaedic surgery regarding opioid usage in the pediatric population.•Postoperative morphine milligram equivalents significantly decreased for the treatment of pediatric diaphyseal femur fractures at a single-level I pediatric trauma center following administration of the 2016 POSNA survey.

Current Clubfoot Practices: POSNA Membership Survey

Clubfoot management has advanced in the 21st century with increases in formal training, practitioner experience, and improved casting/bracing constructs. The Ponseti method is the gold standard, yet variations in application persist. This survey aims to identify current treatment practices among clubfoot practitioners within the Pediatric Orthopaedic Society of North America (POSNA). A 23-question online survey of members was conducted between June and August 2021. Eighty-nine respondents self-identified as clubfoot providers. Of these, 93.1% had an MD degree, 23.6% possessed >30 years' experience, and the majority (65.6%) worked in a teaching hospital associated with a medical school. Most responders (92.0%) were pediatric fellowship trained. A total of 51.7% had participated in a clubfoot training course. More than half (57.5%) noted changes to clubfoot management practices throughout their training. A majority used between four and seven (88.7%) long leg casts (98.4%), changed at seven-day intervals (93.4%). Plaster (69.4%) was most commonly used. The most common bracing device was Mitchell-Ponseti (72.9%). A mean 84.8% of clubfeet required tenotomy. The most common anesthetic agent was numbing gel (43.0%). Tenotomies mostly occurred in patients aged <6 months (63.1%). Tenotomy locations were operating room (46.5%), clinic (45.4%) and procedure room (8.1%). Cast removal was primarily performed with saws (54.7%). The mean incidence of observed cast burns was 5.5%. Most providers did not use a device to prevent cast burns (76.6%). Reported cast complications included slippage (85.9%), skin irritation (75.8%), and saw-related injuries (35.9%). Clubfoot management variations exist in orthotics, tenotomy indications and practices, and cast material. Casting complications continue to be a problem. Further studies are warranted to determine if certain practices predispose patients to specific complications.

What's New in Hand and Wrist Surgery.

What's New in Hand and Wrist Surgery.

Gender Representation in Major Orthopaedic Surgery Meetings: A Quantitative Analysis.

Orthopaedic surgery suffers from gender disparity, and annual conferences are visible opportunities to quantify gender representation within a field. Therefore, the purpose of this manuscript was to investigate the prevalence of female speakers and moderators, and male-only panel sessions, at 10 major Orthopaedic Surgery meetings. Conference programs and details of faculty moderating or presenting in 10 Orthopaedic Surgery annual meetings in 2021 were retrieved. Conferences were selected with the aim of size and diversity in subspecialty topics and included American Association of Hip and Knee Surgeons, American Association for Hand Surgery, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Canadian Orthopaedic Association (COA), European Federation of National Associations of Orthopaedics and Traumatology, North American Spine Society, Orthopaedic Research Society (ORS), Orthopaedic Trauma Association, and Pediatric Orthopaedic Society of North America (POSNA). Primary outcomes included percentage of female chairs and speakers and percentage of male-only panels, while secondary outcomes included number of publications, number of citations, and H-indexes of faculty. Further subgroup comparisons were performed between male-only panels and non-male-only panels and female members and male members. Of 207 included sessions, 121 (58.5%) were male-only panels and 150 (12.6%) of 1,188 faculty members were women. Conferences organized by the COA, ORS, and POSNA had higher percentages of female representation, while spine surgery and adult hip/knee reconstruction sessions had more than 70% male-only panels and fewer than 10% female members. There were no significant differences between male members and female members regarding years of practice; however, male members were more likely to hold the title of professor (p < 0.001). Male members and female members stratified by quartiles of publications, citations, and H-indexes, moderated or participated in similar numbers of sessions, indicating an absence of selection bias. There is a high prevalence of male-only panels (58.5%) and an overall lack of female representation (12.6%) in 10 major Orthopaedic Surgery meetings. Male members and female members from these conferences were found to have similar qualifications academically. Specific strategies such as the elimination of male-only panels, selecting diverse conference organizers, and forming conference equity, diversity, and inclusion committees can help achieve cultural change. Level V.

Pediatric Orthopaedic Surgery Research Quality: A Decade of Change at POSNA Annual Meetings from 2011-2020

Background: The Pediatric Orthopaedic Society of North America (POSNA) is a leading organization focused on disseminating research and promoting high-quality pediatric orthopaedic care. The purpose of our study was to understand how research quality in pediatric orthopaedic surgery has evolved over time by evaluating trends in clinical evidence and study design in podium presentations given at POSNA annual meetings from 2011-2020.Methods: Podium presentation abstracts for all POSNA meetings from 2011-2020 were independently reviewed for number of study patients, single center versus multicenter, randomized vs. non-randomized design, and abstract focus/topic. The level of evidence (LOE) assigned in the abstract program was also recorded. Chi-squared and Mann-Whitney U tests were used to compare differences in abstract characteristics between 2011-2015 and 2016-2020. Linear regressions were performed to analyze changes in level of evidence and the proportion of multicenter studies over time.Results: A total of 1589 podium presentations were reviewed including 679 from 2011-2015 and 910 from 2016-2020, representing a 34% increase in the total number of presentations. The median number of patients per abstract was higher in 2016-2020 compared to 2011-2015 (81.5 vs. 49, p<0.001). An increased proportion of presentations from 2016-2020 were multicenter (14.1% vs. 9.7%, p=0.009), with spine abstracts having the highest proportion of multicenter collaboration (23.9%, p=0.002). The subspecialty focus of podium presentations has remained consistent over time with the exception of spine-related abstracts (19.5% vs. 14.9%, p=0.018). Overall, 4.9% of the presentations were categorized as level 1 evidence, 18.5% level 2, 41.8% level 3, and 34.8% level 4. Between 2011-2020, the proportion of LOE 3 studies increased significantly (p=0.039). The proportion of LOE 4 studies decreased, but not significantly (p=0.060). There was no change in the proportion of level 1 and 2 studies (p=0.416).Conclusions: POSNA podium presentations have increased in number over the past decade, in large part due to the development of subspecialty day programs. This appears to have resulted in greater diversity in the academic program, with a lower proportion of spine abstracts over time. The LOE of POSNA presentations has improved with a higher proportion of level 3 studies compared to earlier years. More recent abstracts have evaluated higher numbers of patients and there has been a significant increase in multicenter study designs, suggesting improved collaboration.Level of Evidence: IVKey Concepts•POSNA podium presentations have increased in number over the past decade due to subspecialty day programming.•A decrease in the proportion of studies focused on spine-related topics has been observed.•Improved level of evidence has been observed with a higher proportion of level 3 evidence.•More recent podium presentations have evaluated higher numbers of patients and more commonly utilized multicenter study designs, suggesting improved collaboration.•Further work focusing on fostering and promoting multicenter collaboration across all pediatric subspecialties should be promoted.

A 10-Year Review of Designated Leadership Positions of the American Orthopaedic Foot & Ankle Society (AOFAS).

In 2019 the majority of US medical students were women (50.5%). However, despite this representation, female representation within orthopaedic surgery remains low when compared to male counterparts. Previously, the American Society for Surgery of the Hand (ASSH) and Pediatric Orthopaedic Society of North America (POSNA) published their gender diversity data. No such study has been conducted in the American Orthopaedic Foot & Ankle Society (AOFAS), which is the largest membership organization for foot and ankle-trained orthopaedic surgeons. This study sought to investigate whether increased female representation in the AOFAS membership roster is reflected in different levels within the organization. The 2012-2022 membership rosters were obtained from the AOFAS and compared by gender. Volunteer, elected, and appointed leadership positions as well as rates of engagement were compared for each of the activities. Leadership positions were defined as committee chair, vice chair, or board of directors (BOD). When available, time for advancement through leadership positions to the presidential role was analyzed by gender. Comparative data were available for 2 other respective subspecialty groups, ASSH and POSNA, from previously published studies. Between 2012 and 2022, the percentage of female membership in the AOFAS has continued to increase from 7.5% (n=76) to 13% (n=163). Engagement in committee membership positions during this time has more than doubled from 11 of 26 (14.4%) to 57 of 163 (34.9%). When participation trends were evaluated by gender, women showed higher rates of committee involvement than their male counterparts. In 2021 compared to 2012, the percentage of female committee members more than doubled compared with their male counterparts (female 34.9% to male 23.2% vs female 14.4% to male 16.8%). This increase in female gender committee composition trend has been seen in the ASSH and POSNA, but it is more pronounced in the AOFAS. Representation of women in committee chair positions and elected positions has not seen this same parallel increase. The female membership of the AOFAS has a similar gender composition to other orthopaedic subspecialities. Female membership within the society has increased over the past 10 years. The rates of female involvement within committee membership positions have seen a parallel increase. It will take time to mature into leadership roles as we continue to increase diversity within our respective subspecialty organizations. Inception of the AOFAS Diversity Equity and Inclusion and Women's Subcommittee demonstrate a continued emphasis on this core value within the society. Level IV, cohort study.

A 10 Year Review of Designated Leadership Positions of the American Orthopaedic Foot &amp; Ankle Society (AOFAS)

Category: Other Introduction/Purpose: In 2019 the majority of U.S medical students were women (50.5%). Despite this, in 2019 Orthopaedic surgery had the lowest representation of female surgeons (5.8%). Previously, the American Society for Surgery of the hand (ASSH) and Pediatric Orthopaedic Society of North America (POSNA) published their gender diversity data. However, no such study has been conducted in the largest membership organization for foot and ankle trained orthopaedic surgeons. This study sought to investigate whether increased female representation in the American Orthoapedic Foot &amp; Ankle Society (AOFAS) membership roster is reflected in different levels within the organization. Methods: The 2012-2022 membership rosters were obtained from the American Orthopaedic Foot &amp; Ankle Society (AOFAS) and compared by gender. Volunteer, elected and appointed leadership positions and rates of engagement were compared for each of the activities. Leadership positions were defined as appointment as committee chair, vice chair of board of directors. When available, time for advancement through leadership positions was analyzed by gender. Comparative data was available for comparison to two other respective subspecialty groups (ASSH and POSNA) from previously published studies. Results: Between 2012-2022, the percentage of female membership in the AOFAS has continued to increase from 7.5 (n=76) to 13% (n=163) (Table 1). Engagement in committee membership positions in this time has more than doubled from 11/26 (14.4%) to 57/163 (34.9%) (Table 1-3). When participation trends were evaluated by gender, women showed higher rates of committee involvement than their male counterparts (Table 4). In 2021 the percentage of female committee involvement more than doubled their male counterparts (female 57% vs male 23.2 %) (Figure 1). This committee gender composition trend has been seen in the ASSHA and POSNA however is more pronounced in the AOFAS. Representation of women in committee chair positions and elected positions has not seen this same parallel increase (Figure 2). Conclusion: The AOFAS is on trend with the respective Orthopaedic subspecialities. Female membership within the society has increased over the past ten years. The rates of female involvement within committee membership positions have seen a parallel increase. It will take time to mature into leadership roles as we continue to increase diversity within our respective subspecialty organizations. Inception of the Diversity Equity and Inclusion and Women's Subcommittee demonstrate a continued emphasis on this core value within the society.

An Analysis of Academic Background and Research Activity Among Pediatric Orthopaedic Surgery Division Chiefs and Fellowship Program Directors

Background: Pediatric orthopedics has seen a large increase in the number of practicing surgeons. As a field that is concentrated at tertiary referral centers, research productivity can be a critical component of academic advancement for pediatric orthopedics. Little has been published on the academic profiles of pediatric orthopedic leaders, and therefore, this study sought to highlight the demographics of these individuals. Methods: Pediatric orthopedic division chiefs and fellowship program directors (PD) were identified for all Pediatric Orthopedic Society of North America (POSNA) accredited fellowship programs in the 2020-21 application cycle. A combination of organizational and public websites was used to compile the academic profiles of these leaders, including demographic variables and research productivity. Division chiefs and PDs were then compared, as were leaders when stratified by fellowship size. Results: A total of 46 POSNA-accredited fellowships were identified. As 12 surgeons held dual roles as division chief and PD, 46 division leaders and 34 PDs formed the groups for comparison. Division chiefs had greater median years-in-practice (24.0 vs 13.0, p&lt;0.001), PubMed publications (56.0 vs 27.0, p=0.037), and more frequently were appointed as “Professor” (54.3% vs 23.5%, p=0.013) compared to fellowship PDs. Leaders working at programs with &gt;1 spot/year were more likely to have completed fellowship at their home program (40.0% vs 8.0%, p=0.001) and had higher research productivity across all metrics (all p&lt;0.002) than leaders at programs with 1 position/year. Female representation among division chiefs and fellowship PDs was 10.9% and 14.7%, respectively. Conclusions: When compared to fellowship PDs, pediatric division chiefs had higher research productivity and academic appointments. Division leaders at larger programs additionally had higher research output and more commonly trained at their current institution. Female representation among pediatric orthopedic leaders was higher than the field of orthopedics at large, but lagged behind reported POSNA membership.

Increased Incidence of Early Mortality in POSNA Members: A Canary in the Coal Mine?

Background: In light of increasing productivity demands and modern changes to work/life balance, physician wellness has become a more pertinent topic among physicians. We investigated whether modern pediatric orthopaedic surgeons are at higher risk for early mortality than their historic cohorts. Methods: Data was collected from the Pediatric Orthopaedic Society of North America (POSNA), which records the passing of its members. The members were sorted into the decennial nearest their birth year. Using publicly available data from the US Social Security Administration, we determined life expectancy from age 45 for all deceased members (LE45), and compared this to their actual age at death. Results: There was a total of 45 deceased POSNA members included. POSNA members born nearest the deciles of 1930 and 1940 had only one instance of a member dying more than 15 years prior to their expected age at death, compared to eight instances from the 1950 and 1960 deciles. There was one member each from the 1950 and 1960 deciles dying more than 30 years prior to their expected age at death, compared to three from the 1970 decile. Conclusions: Although this data is difficult to analyze due to limitations in the denominator, the results are concerning and highlight the importance of more understanding of how to improve physician wellness. Additional study is necessary to further investigate if younger surgeons are at risk for early mortality.

Poster 121: Inter- and Intra-Observer Agreement are Unsatisfactory when Determining Study Design and Level of Evidence

Objectives:Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate inter- and intra-observer reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments.Methods:Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Inter- and intra-observer reliability were calculated using Fleiss’ kappa statistic (k). Chi-square analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews.Results:Inter-observer reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Inter-observer reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger study design. The most common disagreements were between retrospective cohort, retrospective case-control, and case series. Intra-observer reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (p<0.001). Six of the 13 respondents improved in round 2, and 3 were 100% correct both times.Conclusions:Inter-observer reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. Professional societies and journals may consider requiring more specific information on SD from authors, while authors and reviewers may benefit from improved instruments to guide SD and LOE designation.

Virtual Pediatric Orthopaedic Fellowship Interviews During the Pandemic: What Did the Applicants and Programs Think?

The COVID-19 pandemic precluded in-person interviews for the 2020-2021 fellowship application cycle and may impact future interview cycles. No information is available detailing the implications of a virtual format on either the interviewee or the fellowship program. Two surveys regarding the 2020-2021 virtual interview season were developed and distributed by the Pediatric Orthopaedic Society of North America (POSNA) Fellowship Training and Practice Qualifications Committee: one survey for fellowship applicants and one survey for fellowship program directors. Surveys were completed by 45 pediatric orthopaedic fellowship applicants and 34 fellowship program directors. Nineteen (42.2%) applicants applied to more programs because of the virtual format and 30 (66.7%) applicants accepted more interviews because of the virtual format. Thirty-one (67%) applicants did not feel the virtual interview format negatively affected their match process. Thirty-eight (84.4%) applicants indicated that they saved >$2000 with the virtual format. Approximately half (22/45, 48.5%) of the applicants would keep the fellowship-interview process virtual-even if in-person interviews were possible-whereas 8 (17.8%) applicants would transition back toward in-person interviews.Most program directors utilized online interviews for the first time (n=28, 82.3%) during the 2020-2021 application cycle. Programs interviewed more applicants for the 2020-2021 cycle than in the prior 5 years (19.3 vs. 15.7 applicants, P <0.01), with programs interviewing 10.1 applicants per fellowship position. The majority (n=22, 64.7%) of programs utilized Zoom for the interview platform. Program directors indicated that the applicants were either more accomplished (n=14, 41.2%) or similar in accomplishment (n=20, 58.8%) when compared with the applicants from prior years. Half of the program directors (n=17, 50%) surveyed would utilize virtual interviews next year, even if in-person interviews are possible. During the 2020-2021 fellowship application process, interviewees applied to and were interviewed at more programs because of the virtual format, while saving >$2000. In a similar manner, fellowship programs were able to interview a greater number of applicants without adversely impacting the applicant quality. Approximately half of the interviewees and program directors would continue to perform virtual interviews, even if in-person interviews are possible. Level V.

Variability Exists in Pain Management Practices for Pediatric ACL Reconstruction

Background:Effective pain management for anterior cruciate ligament (ACL) reconstruction may improve both patient satisfaction and function. However, there is limited data supporting clear guidelines regarding pain management for ACL reconstruction in the pediatric population.Hypothesis/Purpose:The purpose of this study is to survey current pain management practices for ACL reconstruction 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 ACL reconstruction. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America (POSNA). Inclusion criteria were performs ACL repair or reconstruction on patients under age eighteen and willing to participate in the survey. Responses were anonymous and consisted of demographics, training, current practice, and pain management strategies. Survey data were assessed using descriptive statistics, Pearson’s chi-squared test and Fisher’s exact test for categorical variables, and two-sample t-test for continuous variables.Results:There were 77 responses, of which 64 fit the inclusion criteria. The average age of respondents was 48.9 years, 84.4% were male, and 31.3% practiced in the southern region of the US (Table 1). 39.1% of respondents utilized preemptive analgesia, 90.6% utilized perioperative blocks, 82.8% routinely advocated for scheduled non-narcotic medications post-operatively, and 93.8% recommended cryotherapy post-operatively (Table 2). Respondents that reported not using a peri-operative block and not advocating for scheduled non-narcotic pain management post-operatively were older on average than those that did (57.6 vs. 47.7 years, p=0.04; 56.7 vs. 47.0 years, p<0.01; respectively).Acetaminophen was the most commonly used pre-operative medication (31.3%), the most common perioperative block was an adductor canal block (73.4%), and the most typically prescribed post-operative analgesic medication was ibuprofen (60.9%). Most respondents reported prescribing 10-20 opioid pills (46.9%), 20.3% prescribed >20 opioid pills, and 10.9% did not prescribe opioid pain medication at all. In total, 89.1% of respondents reported prescribing opioid pain medication post-operatively, however, only 59.4% reported counseling patients on appropriate disposal of extra pills. Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.Conclusion:Significant variability exists in pain management practices in pediatric ACL reconstruction. There is a need for more evidence-based practice guidelines regarding pain management.Table 1.Demographics (N=64)Table 2.Pain Management Practices