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Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroup's task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroup's conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests. [ABSTRACT FROM AUTHOR]

Background: Understanding national trends in the treatment of pediatric supracondylar humeral fractures will provide important insight into variations in regional treatment and identify areas for improving value and quality in care delivery in the U.S.Methods: U.S. national trends in the treatment of supracondylar humeral fractures were evaluated through query of the Humana (2007 to 2014) and ING (2007 to 2011) administrative claims databases. Geographic variation and changes in surgical and transfer rates over time were further explored through the Nationwide Emergency Department Sample (NEDS) database (2006 to 2011). Hospital characteristics impacting treatment decisions were identified.Results: A total of 29,642 pediatric patients with supracondylar humeral fractures were identified in the administrative claims databases and a projected 63,348 encounters for supracondylar humeral fracture were identified in the NEDS database. The majority of the patients (76.1%; 22,563 of 29,642) were treated definitively with cast immobilization. Operative treatment was performed in 23.9% of the patients (7,079 of 29,642), with no change observed in the operative rate over time (p = 0.055). Of patients undergoing operative treatment, closed reduction and percutaneous pinning (CRPP) was performed in 87.3%, with a significant increase noted in the rate of CRPP over time (p = 0.0001); open reduction was performed in 12.7%, with a significant decrease noted in the rate of open reduction over time (p < 0.0001). Regional surgical rates generally showed significant variation from 2006 to 2010, followed by a convergence in the surgical rate among all geographic regions in 2011. These trends occurred simultaneous to a significant increase in transfer rates nationwide, from 5.6% in 2006 to 9.1% in 2011 (p = 0.0011). Transfer rates were significantly higher (p < 0.0001) for nontrauma, nonteaching, and nonmetropolitan centers while surgical rates were significantly higher (p < 0.0001) for trauma, teaching, and metropolitan centers when rates were analyzed by hospital designation.Conclusions: Operative treatment was performed in 24% of pediatric patients with supracondylar humeral fractures from 2007 to 2014. There was a convergence of surgical rates across geographic regions, suggesting that a "standard of care" in the treatment of supracondylar humeral fractures is being established nationally.Clinical Relevance: Cases of pediatric supracondylar humeral fracture are increasingly being transferred to and, when managed surgically, receiving care at metropolitan facilities designated as trauma centers or teaching hospitals, with a corresponding decrease observed in the rate of open reduction. The optimization of nationwide referral and treatment patterns may improve value in care delivery. [ABSTRACT FROM AUTHOR]

The article presents a summary of issues discussed at a pediatric orthopedics symposium at the Annual Meeting of the American Orthopaedic Association held on June 11, 2009, in Bonita Springs, Florida. Topics include training and staffing for urgent and trauma care in pediatric orthopedics, legal advocacy for pediatric orthopedic surgeons in the U.S., and practice management and insurance reimbursement issues.

Summarizes a symposium presented at the 2001 Annual Meeting of the American Orthopaedic Association. Importance of maintenance of certification from a public perspective; Recertification and professionalism.

Introduction: Multiple national studies suggest that among physicians, physiatrists are at increased risk for occupational burnout. Objective: The aim of the study is to identify characteristics of the work environment associated with professional fulfillment and burnout among US physiatrists. Design: Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists. Setting: Online interviews, focus groups, and survey were conducted. Participants: The participants are physiatrists in the American Academy of Physical Medicine and Rehabilitation Membership Masterfile. Main Outcome Measures: Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index. Results: Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items, Cronbach α = 0.86); integration of physiatry into patient care (3 items, Cronbach α = 0.71); personal-organizational values alignment (3 items, Cronbach α = 0.90); meaningfulness of physiatrist clinical work (6 items, Cronbach α = 0.90); teamwork and collaboration (3 items, Cronbach α = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age, 52 yrs; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio = 1.96; 95% confidence interval = 1.45–2.69), integration of physiatry into patient care (odds ratio = 1.77; 95% confidence interval = 1.32–2.38), personal-organizational values alignment (odds ratio = 1.92; 95% confidence interval = 1.48–2.52), meaningfulness of physiatrist clinical work (odds ratio = 2.79; 95% confidence interval = 1.71–4.71), and teamwork and collaboration score (odds ratio = 2.11; 95% confidence interval = 1.48–3.03) was independently associated with higher likelihood of professional fulfillment. Conclusions: Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in US physiatrists. Variation in these domains by practice setting and subspecialty suggests that tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists. [ABSTRACT FROM AUTHOR]

Background: Physiatry is a specialty with high rates of burnout. Although organizational strategies to combat burnout are key, it is also important to understand strategies that individual physiatrists can use to address burnout., Objective: To identify changes that resulted in improvement of occupational well-being of physiatrists over a 6- to 9-month period., Design: We employed two quantitative surveys spaced 6 to 9 months apart to identify physiatrists who experienced meaningful improvement in occupational burnout and/or professional fulfillment between the two survey timepoints. These physiatrists were subsequently recruited to participate in a qualitative study using semi-structured interviews to identify changes that respondents felt contributed to improvements in burnout and professional fulfillment., Setting: Online surveys and interviews., Participants: Physiatrists in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Membership Masterfile., Main Outcome Measure: Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index., Results: One hundred twelve physiatrists responded to the baseline and follow-up surveys. Of these, 35 were eligible for interviews based on improvements in the Stanford Professional Fulfillment Index, and 23 (64%) agreed to participate. Themes from the qualitative interviews highlighted the importance of personal lifestyle choices, approaches to improve professional satisfaction, and strategies to foster work-life harmony. Personal lifestyle strategies included investing in wellness and mental health. Efforts to improve professional satisfaction included decreasing work intensity, prioritizing meaningful aspects of work, and building relationships with colleagues. Fostering work-life harmony also included making trade-offs in both domains, setting boundaries at work, setting expectations at home, and overcoming personal challenges., Conclusion: Our findings illustrate that, in addition to organizational strategies demonstrated to be effective, there are actions that individual physiatrists can take to recover from burnout and foster professional fulfillment., (© 2024 American Academy of Physical Medicine and Rehabilitation and Wolters Kluwer Health, Inc.)

The concept of environmental sustainability, social responsibility, and good governance (ESG) is now well established in the corporate world and in for-profit organizations. However, it is not a concept that has reached medical and surgical association boardrooms in a meaningful way. It is important to define the concept of physician and corporate author expertise and objectives of ESG, provide a rationale for using ESG within orthopaedic organizations, and identify specific areas (primarily the "S" and the "G") where the American Academy of Orthopaedic Surgeons and other groups can align with this strategy.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Parents often access online resources to educate themselves when a child is diagnosed with clubfoot and/ or prior to treatment initiation. In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding clubfoot would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). Additionally, it was hypothesized that the outcomes measured would not correlate with the order of listed search results., Methods: Patient education materials were identified utilizing two independent online searches (Google.com) of the term "Clubfoot". From the top 50 search results, websites were included if directed at educating patients and their families regarding clubfoot. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to clubfoot were excluded. The readability of included resources was quantified using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG) Grade, Coleman-Liau Index (CLI), Gunning-Fog Index( GFI) and Automated Reading Index (ARI). The Patient Education Materials Assessment Tool (PEMAT) was used to assess actionability and understandability using a 0-100% scale for both measures of interest., Results: Of the 55 unique websites, 37 websites (65.2%) met inclusion criteria. The mean FKGL was 9.2 (+/- 2.1) with only three websites (7.32%) having a reading level ≤6. Mean understandability and actionability scores were 67.2±12.6 and 25.4±25.2, respectively. Thirteen (35%) websites met the understandability threshold of ≥70% but no websites met the actionability criteria. No readability statistics were statistically associated with Google™ search rank (p=0.07). There was no association between readability (p=0.94) nor actionability (p=0.18) scores and Google™ rank. However, understandability scores did correlate with Google™ rank (p=0.02)., Conclusion: Overall, online clubfoot educational materials scored poorly with respect to readability, understandability, and actionability. There is an association with Google™ search rank for understandability of clubfoot materials. However, readability and actionability are not significantly associated with search rank. In the era of shared decision-making, efforts should be made by medical professionals to improve the readability, understandability, and actionability of online resources in order to optimize parent understanding and facilitate effective outcomes. Level of Evidence ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: Adolescent idiopathic scoliosis (AIS) has been associated with unnecessary referrals, but the provider and patient costs associated with these referrals remain unknown. The purpose of this study was to determine the prevalence and associated costs of unnecessary referrals for AIS in a university hospital-based orthopaedic clinic. These data are required to estimate the cost-efficacy of scoliosis screening programs., Methods: We accessed the electronic medical records of all patients referred during 2013-2014 with suspected AIS. Spine radiographs were reviewed to determine whether the referral was "unnecessary," defined as a Cobb angle <20 degrees. Patient and provider costs were estimated. Patient costs included transportation expenses and parental lost wages. Provider costs included orthopaedic evaluation, diagnostic imaging, and overhead. Transportation costs were based on actual driving distances and the Internal Revenue Service standard mileage rate. Parental lost wages and the cost of evaluation by an orthopaedic surgeon were calculated with time-driven activity-based costing. Diagnostic imaging costs were calculated with a traditional activity-based costing methodology., Results: Three hundred thirty-seven patients were included. The prevalence of unnecessary referrals was 39% (n=131). 17% of patients had a Cobb angle <10 degrees and 22% had a Cobb angle between 10-20 degrees. Males were more likely to be referred unnecessarily than females, 49% to 35% (p=0.02) as were non-Caucasians (54% vs. 37%, p=0.04). No difference was noted related to source of insurance (private or public, p=0.18). The average total cost of an unnecessary referral was $782.13 USD, including $231.07 in patient costs and $551.06 in provider costs., Conclusions: Nearly 40% of all referrals for AIS were deemed unnecessary. The average cost of an unnecessary referral is approximately $780, imposing significant costs on both patients and the healthcare system. Level of Evidence: III., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study.

Healthcare costs in the United States continue to rise, and substantial variations in the type, quality, and location of that care persist. It is critically important for all healthcare stakeholders to address and define value in orthopaedic care delivery. Evidence-based orthopaedic care delivery, reliable quality and performance measurement, and the delivery of the best care at the lowest cost are the key strategies to improve the value of musculoskeletal care. A failure to implement these strategies could negatively affect the reimbursement of all healthcare providers--at both the private and government payer levels.

Study Design: Retrospective review of prospectively collected data., Objective: To determine a cutoff below which worsening renal function is associated with increased risk of morbidity and to determine the types and magnitude of morbidity associated with renal impairment., Summary of Background Data: Renal impairment is associated with an increased risk of morbidity after lumbar spine surgery. However, the degree to which increasing levels of renal dysfunction are associated with morbidity has not been well defined., Methods: A large, multicenter, clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012, and 13,576 cases were identified. An estimated glomerular filtration rate (eGFR) was calculated for each patient. Propensity scores were used to match patients on the basis of preoperative comorbidities and the procedure-type performed. The incidence of 30-day morbidity was then compared between patients with no or mild renal impairment (eGFR ≥60 mL/min/1.73 m) and those with moderate or severe disease (eGFR <60 mL/min/1.73 m). Separately, the morbidity risk associated with eGFR was analyzed as a continuous variable., Results: The risk of morbidity increased with worsening eGFR in an inverse-logarithmic fashion (R = 0.84), and the magnitude of risk increased substantially for eGFR below 60 mL/min/1.73 m (odds ratio of ≥1.8). There was a 26% relative increase in morbidity for patients with moderate to severe renal impairment, as compared with the propensity score-matched cohort of patients with no or mild disease (5% absolute increase, 24% vs. 19%, P = 0.004). Wound complications (3% vs. 2.1%), reoperation rates (4.6% vs. 3.3%), and need for blood transfusions (16.3% vs. 12.8%) trended higher in patients with moderate or severe disease, but only the need for blood transfusion reached significance. Patients with preoperative moderate or serve renal impairment were 10 times more likely to develop acute renal failure postoperatively (0.6% vs. 0.06%, P = 0.01)., Conclusion: Thirty-day morbidity risk after lumbar spine surgery is strongly associated with renal impairment. These data may be useful for preoperative patient counseling, and surgeons should consider the relative magnitude of risks and benefits before operating on a patient with severe renal disease, particularly in elective cases., Level of Evidence: 3.

Background: Few references are available describing the epidemiology of pediatric spine injuries. The purpose of this study is to examine the prevalence, risk factors and trends during the period from 1997 to 2009 of pediatric spine injuries in the United States using a large national database., Methods: Data was obtained from the Kid's Inpatient Database (KID) developed by the Healthcare Cost and Utilization Project (HCUP), for the years 1997-2009. This data includes >3 million discharges from 44 states and 4121 hospitals on children younger than 20 years. Weighted variables are provided which allow for the calculation of national prevalence rates. The Nationwide Emergency Department Sample (NEDS), HCUP. net, and National Highway Traffic Safety Administration (NHTSA) data were used for verification and comparison., Results: A prevalence of 107.96 pmp (per million population) spine injuries in children and adolescents was found in 2009, which is increased from the 77.07 pmp observed in 1997. The group 15 to 19 years old had the highest prevalence of all age groups in (345.44 pmp). Neurological injury was present in 14.6% of the cases, for a prevalence of 15.82 pmp. The majority (86.7%) of these injuries occurred in children >15 years. Motor vehicle collisions accounted for 52.9% of all spine injuries, particularly in children >15 years. Between 1997 and 2009 the hospital length of stay decreased, but hospital charges demonstrated a significant increase., Conclusions: Pediatric Spine Injuries continue to be a relevant problem, with rates exceeding those of other industrialized nations. Teenagers >15 years of age were at greatest risk, and motor vehicle collisions accounted for the most common mechanism. An increase in prevalence was observed between 1997 and 2009, and this was matched by a similar increase in hospital charges., Level of Evidence: III.

Health care reform is upon us, including changes in models of care delivery and physician and institution compensation. The resulting tsunami of uncertainty offers physiatrists the opportunity to relocate to higher ground and help the specialty thrive as well as to identify the possible quagmires into which practices could sink. For this reason, it is prudent for physiatrists to more carefully consider how their professional lives may be altered in the aftermath of reform. We believe that understanding and preparation will facilitate opportunities and mitigate challenges. In this essay, we will discuss various alternative scenarios that represent population health and health care delivery in the year 2032, the real-world opportunities and challenges for the physiatrist in the present and in the next 2 decades, along with ideas as to how physiatry can thrive in the post-health care reform world., (Copyright © 2014. Published by Elsevier Inc.)

Study Design: Retrospective review of prospectively collected data., Objective: To determine the incidence and risk factors for 30-day wound complication after spinal arthrodesis in pediatric patients., Summary of Background Data: Although multiple prior studies have reported on wound complications in pediatric spine, the majority have been single-center retrospective series., Methods: The National Surgical Quality Improvement Program (NSQIP) employs on-site personnel to prospectively collect 30-day morbidity data from 50 pediatric centers. Year 2012 was the first year of enrollment, and 1915 cases with thoracic or lumbar spinal fusion were included. Patients were divided into cohorts of those with and without a wound complication, with univariate and multivariate analyses used to identify risk factors. A P value of less than 0.05 was considered significant., Results: Wound complications occurred in 67 patients (3.5%). The incidence was significantly higher in patients with congenital (4.35%) or neuromuscular (4.67%) diagnoses, as opposed to idiopathic (2.7%) or infantile (1.61%). Procedures with fusions extending to the pelvis (9.91%) or an osteotomy (4.99%) were associated with higher risk. Longer hospital lengths of stay, increased operative time, increased patient body mass index, and patients with cardiac, gastrointestinal, neurological, or pulmonary comorbidities were also associated with a higher risk. In the multivariate analysis, a body mass index of more than 30 kg/m2, patients with cardiac risk factors, and fusions extending to the pelvis were independent risk factors., Conclusions: Data from this large prospective multicenter study confirm that the incidence of early wound complications in pediatric spine surgery is low. Patients with a fusion extending to the pelvis, obese patients, and patients with significant cardiac conditions were independently associated with higher risk for this complication. These data should be useful for patients' counseling and for preoperative risk stratification. Interventions for minimizing wound complication risk may be most applicable to the high-risk groups identified here., Level of Evidence: 2.

Study Design: Retrospective review of a prospective cohort., Objective: To determine the incidence and risk factors for 30-day morbidity and mortality after pediatric deformity spinal surgery., Summary of Background Data: Pediatric deformity spinal surgery is generally considered a safe and effective treatment option. The rising costs associated with spinal surgery and related perioperative complications have received national attention. Few studies with standardized definitions and data collection methods exist., Methods: A large, multicenter clinical registry specifically designed to collect pediatric surgical outcomes was queried for all patients undergoing spinal deformity surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing anterior, posterior, and combined fusions. Detailed patient and case characteristics were analyzed. Thirty-day morbidity and mortality rates were calculated. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of complication., Results: In total, 2005 pediatric patients undergoing deformity spinal fusion were included. The rate of 30-day complications was 10.0%; with a mortality rate of 0.15% (3 patients), a morbidity rate of 8.4%, reoperation rate of 3.74%, and readmission rate of 3.94%. The morbidity rate was highest in the neuromuscular group (13.09%) and lowest in the idiopathic cohort (5.69%), P < 0.01). Compared with posterior fusions, anterior fusions and those extending to the pelvis were associated with higher complication rates (P < 0.01). Risk factors for complication included hepatobiliary disease (P = 0.03), cognitive impairment (P = 0.02), elevated American Society of Anesthesiologists class (P < 0.01), and prolonged operative time (P < 0.01)., Conclusion: The overall rate of 30-day morbidity after pediatric spinal deformity surgery was 10%. Multiple patient comorbidities and surgical duration and invasiveness were associated with an increased complication risk. These data may aid in the informed consent process, facilitate patient risk assessment, and allow quality comparisons between surgeons and institutions., Level of Evidence: 2.

The crisis of medical liability has resulted in drastic increases in insurance premiums and reduced access for patients to specialty care, particularly in areas such as obstetrics/gynecology, neurosurgery, and orthopaedic surgery. The current liability environment neither effectively compensates persons injured from medical negligence nor encourages addressing system errors to improve patient safety. The author reviews trends across the nation and reports on the efforts of an organization called "Doctors for Medical Liability Reform" to educate the public and lawmakers on the need for solutions to the chaotic process of adjudicating medical malpractice claims in the United States.