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Background: Treatment strategies for a symptomatic accessory navicular include both operative and nonoperative approaches. The primary aim of this study is to define health utility values for 7 health states experienced by those with a symptomatic accessory navicular who undergo operative and/or nonoperative treatment. Secondarily, the study incorporates the health utility values with treatment costs, probabilities of various outcomes, and duration of health states into a cost-effectiveness model comparing the nonoperative treatment protocol at our institution vs surgical excision. Methods: Institutional review board approval was obtained to call parents of patients 10-20 years old at the time of interview who were evaluated for a symptomatic accessory navicular from February 1, 2016, to March 2, 2023, at a single institution by one of 4 pediatric orthopaedic surgeons. Participants were asked to rate 7 health states from 0 to 100, with 0 representing death (if 18 years or older) or the worst health imaginable (if under 18 years) and 100 representing perfect health. Using published values for the probabilities of various treatment outcomes, time spent in various health states, and Medicare costs from the perspective of the payor and society, a decision analysis was constructed. Results: Health utility values for 7 health states were obtained. Operative treatment was preferred to nonoperative treatment in the base case model. Surgery was more expensive ($16 825) than nonoperative treatment ($7486). Using a willingness-to-pay threshold of <$50 000 per quality-adjusted life year (QALY), surgery was cost-effective compared to nonoperative treatment with an incremental cost-effectiveness ratio of $20 303/QALY. Sensitivity analysis revealed that the only variable that indicated a preference for nonoperative treatment is a 71% likelihood of nonoperative treatment resolving the condition. Conclusion: Unless a physician suspects at least a 71% chance of a symptomatic accessory navicular resolving without operative treatment, surgical excision is recommended from a cost-effectiveness perspective. [ABSTRACT FROM AUTHOR]

Background: Medial epicondyle fractures of the distal humerus are common pediatric fractures, which are increasing in frequency among pediatric and adolescent athletes. Residual elbow stiffness is a feared complication of both surgical and nonoperative treatment. The purpose of this study is to investigate the association of the relevant variables with the ability of patients to regain full elbow range of motion (ROM)., Methods: Patients 8-18 years old enrolled in the Medial Epicondyle Multicenter Outcomes prospective cohort with ≥3 mm of displacement, and >1 year of follow-up data were included. Bilateral elbow range of motion (ROM), complications, length of immobilization following definitive treatment (surgical vs. nonoperative), participation in formal physical or occupational therapy (PT/OT), and weeks from injury to treatment were recorded., Results: The study cohort consisted of 202 patients (aged 12.7 ± 2.3 years; 59% male). A greater proportion of surgically managed patients regained full ROM compared to nonoperatively managed patients (71% vs 56%, P = .05). Immobilization time was significantly shorter in surgical than in nonoperative patients (2.0 ± 1.1 weeks vs. 3.0 ± 1.2 weeks, P < .001). In multivariable logistic regression analysis, only immobilization time was an independent predictor of regaining full ROM (β = -0.353, P = .02), which remained statistically significant while controlling for PT/OT (β = 0.079, P = .829) and treatment strategy (β = -0.375, P = .35). While controlling for treatment strategy and whether a patient received PT/OT, each week of prolonged immobilization decreased the chance of regaining full ROM by 35%., Conclusions: This large multicenter cohort study found that of the variables studied, increased immobilization time was the only independent predictor of residual elbow stiffness following medial epicondyle fractures in children, independent of treatment strategy and receiving PT/OT. With surgical treatment often warranting shorter post-treatment immobilization times, surgery may provide an avenue for consistently regaining full ROM when treating these fractures, especially in the setting of concomitant dislocation. In cases of minimally displaced fractures, implementing protected early ROM in nonoperative cases could be considered. However, when nonoperatively-treated patients in this study were analyzed separately, earlier mobilization was not associated with a protective effect against residual stiffness. Further prospective study into the nuances of surgical indications as well as nonoperative and postoperative immobilization and early motion strategies is therefore warranted., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Recent evidence has identified a strong association between growth hormone therapy and physeal injuries in the lower extremity; however, few studies have investigated this association in the upper extremity., Questions/purposes: (1) Do pediatric patients with physeal tension injuries of the shoulder and elbow have higher odds of having exposure to recombinant growth hormone therapy than matched controls? (2) Are the odds of having exposure to recombinant growth hormone therapy in physeal tension injuries different when stratified by shoulder and elbow injuries?, Methods: Using a matched case-control study design, patients between 4 and 18 years of age treated at a large, urban, academic center from February 1, 2016, to November 6, 2023, were identified by ICD-10 codes using EPIC SlicerDicer, an electronic medical record-based data mining tool. Patients diagnosed with physeal tension injuries in the shoulder or elbow were included in the case group, and those with midshaft radius, metaphyseal radius, or both-bone forearm fractures were included in the control group. A total of 618 patients with physeal injuries and 1244 with non-physeal fractures were identified and screened for inclusion. After further chart review to confirm diagnoses, 46% (283) of patients with physeal injuries and 54% (670) of patients with non-physeal fractures were included. A further 6% (16) of patients with physeal injuries and 2% (15) of patients with non-physeal injuries were excluded due concomitant dislocations or missing data, resulting in 267 eligible patients with physeal injuries and 655 eligible patients with non-physeal fractures. Two patients with concurrent elbow and shoulder physeal injuries were additionally excluded from stratified analyses. Patients with physeal injuries and non-physeal fractures were 1:1 matched by age ± 0.5 years, sex, and BMI ± 2 kg/m2. In all, 522 patients were included in the analysis, including 261 patients with physeal injuries and 261 with non-physeal fractures. The mean ± SD ages for both patient groups was 13 ± 2 years (p = 0.44), 88% (229 of 261) of all participants were male, and the mean BMIs were 19.9 ± 3.0 kg/m2 and 19.4 ± 3.0 kg/m2 (p = 0.11), respectively. Growth hormone exposure was compared between patients with physeal injuries and non-physeal fractures using a conditional logistic regression model., Results: Overall, 4% (10 of 261) of patients with physeal injuries had exposure to growth hormone therapy as compared with 2% (4 of 261) of patients with non-physeal fractures (OR 2.5 [95% confidence interval 0.8 to 8.0]). Subgroup analyses of shoulder and elbow injuries demonstrated no difference in growth hormone exposure between patients with physeal injuries and non-physeal fractures (OR 2 [95% CI 0.4 to 10.2] and OR 3 [95% CI 0.6 to 14.9], respectively)., Conclusion: In light of these results, clinicians may not need to advise precaution against sports or other activities that put the upper extremity physes under stress when treating patients with growth hormone supplementation therapy. Future multicenter studies, however, are indicated to further investigate for the existence of any subtle association between growth hormone therapy and upper extremity physeal injuries relative to the large association previously noted in the lower extremity in pediatric and adolescent patients., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)