Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND: We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution. QUESTIONS/PURPOSES: Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment? METHODS: In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores. RESULTS: Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (ß 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (ß 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (ß -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment. CONCLUSION: Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics. LEVEL OF EVIDENCE: Level III, therapeutic study.

Minimal Clinically Important Difference for PROMIS Physical Function in Patients With Distal Radius Fractures.

PURPOSE: This study was conducted to determine the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Information System (PROMIS) Physical Function computer adaptive test (CAT) after distal radius fracture. METHODS: This study retrospectively analyzed data from 187 adults receiving nonsurgical care for a unilateral distal radius fracture at a single institution between February 2016 and November 2017. All patients completed the PROMIS Physical Function v1.2/2.0 CAT at each visit. At follow-up, patients also completed 2 multiple-choice clinical anchor questions querying their overall response to treatment. The MCID estimate was then calculated with an anchor-based method as the mean PROMIS Physical Function score change for the group reporting mild improvement and with a distribution-based method considering effect sizes of change and the minimum detectable change (MDC). The MCID estimate was examined for the influence of patient age, follow-up interval, and initial PROMIS score. RESULTS: Change in PROMIS Physical Function scores between visits was significantly different between patients reporting no change, mild improvement, and much improvement on the anchor questions. The anchor-based MCID estimate for PROMIS Physical Function was 3.6 points (SD, 8.4). Among patients reporting mild improvement, individual changes in PROMIS Physical Function were not correlated with patient age or time between visits but were moderately negatively correlated with the initial absolute PROMIS Physical Function score. Applying the effect size parameters to our data when patients indicated minimal change, the distribution-based MCID estimate was 4.6 (SD, 1.8). Both the anchor-based and the distribution-based MCID estimates were judged sufficient because they exceeded the MDC value of 2.3. CONCLUSIONS: The MCID value for PROMIS Physical Function is estimated between 3.6 and 4.6 in patients treated nonsurgically for distal radius fractures. Clinical improvement is associated with smaller magnitudes of change on PROMIS Physical Function when patients present with better reported function. CLINICAL RELEVANCE: The MCID estimations are needed to determine the clinical relevance of changes in PROMIS scores and to more accurately calculate sample sizes needed for research incorporating PROMIS.

The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture.

PURPOSE: Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures. METHODS: This cross-sectional evaluation analyzed data from 975 new pediatric patients (8-17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population. RESULTS: A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles. CONCLUSIONS: Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Obesity and Failure of Nonsurgical Management of Pediatric Both-Bone Forearm Fractures.

PURPOSE: In pediatric extremity fractures treated nonsurgically, maintaining reduction can be difficult in obese children owing to the larger soft tissue envelope. The purpose of this study was to investigate the relationship between obesity and failure of nonsurgical management of pediatric both-bone forearm fractures. METHODS: We conducted a retrospective review of 129 skeletally immature patients older than 2 years who received nonsurgical treatment for closed radius and ulna shaft fractures at a level I pediatric trauma center between 2011 and 2014. The patients were divided into 2 groups: (1) normal-weight children and (2) overweight and obese children. The primary outcome measure was failure of nonsurgical management, defined as the indication for repeat closed reduction under anesthesia or surgical intervention owing to unacceptable angulation after initial closed treatment. RESULTS: Of the 129 patients included in the study, 34 patients (26%) were female and 95 patients (74%) were male. Seventy-six patients (59%) were normal weight, 27 patients (22%) were obese, and 26 patients (20%) were overweight. Eighteen percent (14 of 76) of normal-weight children failed nonsurgical management compared with 34% (18 of 53) of overweight and obese children. Twenty-nine percent (4 of 14) of normal-weight children who failed nonsurgical management required surgery compared with 56% (10 of 18) of overweight and obese children. CONCLUSIONS: Overweight and obese children have a significantly higher rate of failure of nonsurgical management of both-bone forearm fractures compared with normal-weight children. These patients may benefit from closer clinical follow-up and a lower threshold for surgical intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis II.

Nonanatomic Tibial Tunnel Placement for Single-Bundle Posterior Cruciate Ligament Reconstruction Leads to Greater Posterior Tibial Translation in a Biomechanical Model.

PURPOSE: To determine the effect of varying proximal-distal tibial tunnel placement on posterior cruciate ligament (PCL) laxity. METHODS: Nine matched pairs (18 total) of cadaveric knees (mean age 79.3 years, range 60 to 89), were studied. The specimens from each pair were randomly divided into 2 groups based on tibial tunnel placement: (1) anatomic tunnel and (2) proximal nonanatomic tunnel. A 150-N cyclic posterior tibial load was applied using a Materials Testing System machine at 0°, 30°, 60°, and 90° of knee flexion. Each specimen completed 50 cycles at a rate of 0.2 Hz at each knee flexion angle. In 10 specimens, a static 250-N posterior tibial load was applied at 90° of knee flexion. Posterior tibial translation was recorded. Load to failure for all specimens was recorded. RESULTS: With application of a 150-N posteriorly directed cyclic force, the anatomic tunnel group had significantly less posterior tibial translation (millimeters, mean [standard deviation (SD)]) than the proximal nonanatomic tunnel group at 0°, 30°, 60°, and 90° of knee flexion: 1.1 (0.3) v 1.5 (0.4), P = .031; 1.1 (0.6) v 2.2 (0.9), P = .019; 0.9 (0.4) v 2.0 (0.6), P = .001; 0.9 (0.6) v 2.9 (0.7), P < .001, respectively. The anatomic tunnel group also demonstrated significantly less posterior tibial translation (millimeters, mean [SD]) than the nonanatomic tunnel group at 90° with a static 250-N posteriorly directed force applied (P <.05): 2.3 (1.3) v 6.1 (2.3), P = .016. Four pairs were excluded from the 250-N results because of prior load to failure testing. CONCLUSIONS: Anatomic tibial tunnel placement re-creating the tibial origin of the PCL results in significantly less posterior tibial translation than proximal nonanatomic tibial tunnel placement. Correct placement of the tibial tunnel during PCL reconstruction is essential for avoidance of posterior laxity. CLINICAL RELEVANCE: Anatomic tibial tunnel placement during PCL reconstruction may ensure a more stable reconstruction.

The impact of obesity on complications of elbow, forearm, and hand surgeries.

PURPOSE: To compare the rates of postoperative complications in obese and nonobese patients following elbow, forearm, and hand surgeries. METHODS: This case-control study examined 436 patients whose body mass index (BMI) was over 35 and who underwent hand, wrist, forearm, or elbow surgery between 2009 and 2013. Controls were patients (n = 433) with a BMI less than 30 who had similar surgeries over the same period, and who were frequency-matched by type of surgery (ie, bony, soft tissue, or nerve), age, and sex. Postoperative complications were defined as infection requiring antibiotic or reoperation, delayed incision healing, nerve dysfunction, wound dehiscence, hematoma, and other reoperation. Medical comorbidities (e.g., hypertension, diabetes, stroke, vascular disease, kidney disease, and liver disease) were recorded. Chi-square analyses were performed to explore the association between obesity and postoperative complications. Similar analyses were performed stratified by surgery type and BMI classification. Logisticregression modeling was performed to identify predictors of postoperative complications accounting for surgery type, BMI, the presence of comorbidities, patient age, and patient sex. This same model was also run separately for case and control patients. RESULTS: The overall complication rate was 8.7% with similar rates between obese and nonobese patients (8.5% vs. 9.0%). Bony procedures resulted in the greatest risk of complication in both groups (15% each group). Multivariate analysis confirmed surgery type as the only significant predictor of complications for nonobese patients. However, among obese patients, both bony surgery and increasing BMI were associated with greater complication rates. CONCLUSIONS: Not all obese patients appear to be at any higher risk for complications after elbow, forearm, and hand surgery compared with nonobese patients. However, there appears to be a dose-dependent effect of BMI among obese patients such that increasing obesity heightens the risk of complications, especially for those with a BMI greater than 45. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Performance of Pediatric PROMIS CATs in Children With Upper Extremity Fractures.

Background: This study was designed to quantify the performance of the pediatric Patient-Reported Outcome Measurement Information System (PROMIS) when delivered as part of routine care to children with upper extremity (UE) fractures. Methods: This cross-sectional study analyzed 964 new pediatric patients presenting with an UE fracture. All patients completed PROMIS computer adaptive tests for pain interference, peer relationships, UE function, and mobility domains at clinic registration. PROMIS was completed by parent-proxy (n = 418) for 5- to 7-year-olds and self-reported by 8- to 10-year-olds (n = 546). PROMIS score distributions were defined, and Pearson correlations assessed the interrelation between PROMIS domains. Student's t tests compared mean PROMIS scores between parent-proxy and self-completion groups. Results: UE scores indicated the greatest average impairment of all PROMIS domains. However, 13% of patients reached the UE score ceiling indicating maximal UE function. UE scores and mobility scores had a strong positive correlation while UE scores had a moderate negative correlation with pain interference. In all patients, peer relationships were, at most, very weakly correlated with any other PROMIS domain. After grouping by fracture type, parent-proxy completion estimated worse UE function, more pain interference, and worse peer relationship. Conclusions: Pediatric PROMIS UE function scores capture impairment from UE fractures but do have a strong positive correlation with pediatric PROMIS Mobility, which assesses lower extremity function. Among children with UE fractures, parent-proxy completion of pediatric PROMIS appears associated with worse scores on most PROMIS domains.

Clinical and Radiologic Outcomes of the Matti-Russe Technique for Scaphoid Nonunions in Pediatric Patients.

BACKGROUND: Scaphoid fractures are a common injury, and a known complication is nonunion. One option to treat this nonunion is with the Matti-Russe technique, which takes a corticocancellous graft and fits it into the defect without internal fixation. The advent of modern methods of fixation has led the classic Matti-Russe technique to fall out of favor. In this study, we describe the classic technique and evaluate the results of the Matti-Russe method for treatment of scaphoid nonunions specifically for the pediatric population. Our purpose was to evaluate the long-term clinical and radiologic outcomes after surgery for scaphoid nonunion using the Matti-Russe technique in the pediatric population. METHODS: A retrospective review was performed of patients less than 17 years of age, with a scaphoid nonunion that was treated with the Matti-Russe technique. This technique consisted of open reduction with intercalated bone graft and no internal fixation with hardware. Union was determined by radiographic evaluation. Computed tomography was obtained in 7 of 10 patients in this series and showed bony bridging in more than 50% of the scaphoid width in 3 different views. Intrascaphoid, scapholunate, and radiolunate angles were calculated. We reviewed wrist range of motion and complications. We obtained postoperative Mayo and Disabilities of the Arm, Shoulder and Hand (DASH) scores. RESULTS: There were 10 patients who underwent the Matti-Russe technique. The average age was 14.7 years old (±1.34, range: 13-17). All 10 of these patients had a scaphoid waist nonunion. There were 9 males and 1 female with an average follow-up of 13 months. The average amount of time to surgery from the date of injury was 12.3 months. All 10 patients went on to radiographic union at or before 6 months from surgery. Preoperative intrascaphoid, scapholunate, and radiolunate angles were 29° (±5.38), 62° (±18.28), and 20° (±9.22). Postoperative intrascaphoid, scapholunate, and radiolunate angles improved to 16° (±6.89), 38° (±8.50), and 10° (±4.69), which was significant. Seven out of 10 patients completed postoperative outcomes measures. The average postoperative Mayo wrist score was 87.9 (±14.10, range: 60-100). The average postoperative DASH score was 1.9 (±2.03, range: 0-4.5). There were no associated complications nor reoperations. CONCLUSION: The Matti-Russe technique is a safe and effective treatment for scaphoid nonunion in the pediatric population. It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware.

Activity Level Maintenance at Midterm Follow-up Among Active Patients Undergoing Periacetabular Osteotomy.

BACKGROUND: For active patients undergoing periacetabular osteotomy (PAO), returning to and maintaining a high level of activity postoperatively is a priority. PURPOSE: To evaluate the maintenance of activity levels at midterm follow-up in active patients treated with PAO for symptomatic acetabular dysplasia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent PAO for symptomatic acetabular dysplasia between June 2006 and August 2013 were identified by a retrospective review of our prospective longitudinal institutional Hip Preservation Database. All patients with a preoperative University of California, Los Angeles (UCLA) score of ≥7 and a potential minimum 5 years of follow-up were included in the study. Functional outcome measures were the UCLA score, modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The maintenance of high activity levels was defined as a UCLA score of ≥7 at final follow-up. Radiographic parameters were measured. Statistical significance was defined as a P value <.05. RESULTS: A total of 66 hips (58 patients) were included. The mean age was 25.3 years (range, 14-47 years), the mean body mass index was 23.9 kg/m2 (range, 19-32 kg/m2), and 72% were female. The mean follow-up was 6.8 years (range, 5-11 years). There were 67% of patients who maintained a UCLA score of ≥7. Patient-reported outcomes improved postoperatively from preoperatively for the mHHS (88 ± 14 vs 67 ± 17, respectively; P < .001) and WOMAC (89 ± 15 vs 73 ± 20, respectively; P < .001). The lateral center-edge angle, anterior center-edge angle, and acetabular inclination were significantly improved at final follow-up (P < .001). Only 4 patients (7%) cited postoperative activity limitations as being caused by hip pain. There were no conversions to total hip arthroplasty. CONCLUSION: The majority (67%) of active patients returned to preoperative or higher activity levels after PAO at midterm follow-up.

Do Orthopedic Trauma Surgeons Adhere to AAOS Guidelines when Treating Distal Radius Fractures?

Background: The American Academy of Orthopedic Surgeons (AAOS) has provided Clinical Practice Guidelines (CPG) and Appropriate Use Criteria (AUC) regarding management of distal radius fractures. The purpose of this study was to evaluate current practices in management of distal radius fractures among orthopedic trauma surgeons and to examine adherence to the AAOS criteria. Methods: An online survey was posted and distributed via the Orthopaedic Trauma Association (OTA) website. Information collected included demographics, injury management, and case based questions. For all cases, surgeons were asked to select their treatment of choice given the same fracture in a 25-year-old patient and a 65-year-old patient. Results were compared between surgeons with < 10 years of practice experience and those with > 10 years of experience. Results: There was a total of 51 survey respondents. 45% had <10 years in practice, while 55% had > 10 years in practice. All respondents reported routine use of preoperative radiographs, while 26% reported routine use of preoperative computed tomography (CT) scans. 73% of respondents reported that they perform operative adjunct fixation of associated ligamentous injuries at the time of distal radius fracture fixation. No one used wrist arthroscopy or fixed associated ulnar styloid fractures. 69% did not allow any range of motion in the immediate postoperative period, while the remainder allowed active and/ or passive ROM. 20% routinely used Vitamin C for Complex Regional Pain Syndrome (CRPS) prophylaxis postoperatively. 59% routinely used physical and/ or occupational therapy postoperatively. For case-based scenarios, respondents generally tended towards operative fixation in younger patients compared to older patients with the same fracture type. Surgeons with < 10 years in practice and those with > 10 years in practice varied significantly in terms of preoperative imaging and operative fixation of associated ligamentous injuries at the time of fracture fixation. Conclusions: When compared to the AAOS CPG and AUC, orthopedic trauma surgeons generally followed accepted treatment guidelines. Differing practices between surgeons with <10 years in practice compared to those with >10 years in practice may be reflective of what is taught in residency training programs.

A systematic review of opioid use after extremity trauma in orthopedic surgery.

BACKGROUND: The United States is in a prescription opioid crisis. Orthopedic surgeons prescribe more opioid narcotics than any other surgical specialty. The purpose of this study was to evaluate the state of opioid use after extremity trauma in orthopedic surgery. METHODS: A computerized literature search of PubMed/MEDLINE was conducted to evaluate the status of opioids after extremity fractures. Six articles were identified and included in the review. RESULTS: Patients who consume more opioids communicate greater pain intensity and less satisfaction with pain control. Intraoperative multimodal drug injection and nerve blockade are viable alternatives for postoperative pain control and can help decrease systemic opioid use. Orthopedic surgeons are overprescribing opioids. Compared to other countries, the United States consumes more opioids with no better satisfaction with pain control. CONCLUSION: Orthopedic trauma surgeons should tailor their postoperative opioid prescriptions to the individual patient and utilize alternative options in order to control postoperative pain. Patients should be counseled regarding narcotic addiction and dependence. Patients unable to manage pain postoperatively should be followed closely and receive the proper chronic pain management, mental and social health services referrals.

Evaluation of the Schöttle Technique in the Pediatric Knee.

BACKGROUND: The Schöttle point is commonly used for anatomic femoral tunnel placement during medial patellofemoral ligament (MPFL) reconstruction. This technique has not been previously validated in the skeletally immature patient, in whom femoral tunnel placement may put the distal femoral physis at risk of iatrogenic injury. HYPOTHESIS: Interobserver reliability for femoral tunnel placement will be higher in adult knees compared with pediatric knees. STUDY DESIGN: Cross-sectional study (diagnosis); Level of evidence, 3. METHODS: We selected 30 perfect lateral radiographs for this study: 20 from pediatric knees (mean patient age, 10 years; range, 8-11 years) and 10 from adult knees (mean patient age, 18.5 years; range, 18-23 years). Six observers with varying levels of clinical experience evaluated each radiograph and approximated the site of the MPFL femoral tunnel using the Schöttle technique. Intra- and interobserver reliabilities for femoral tunnel placement were evaluated. Statistical analysis was used to compare measurements. RESULTS: During initial interobserver measurements, the diameter of the composite perfect circles averaged 9.0 and 6.8 mm in adult and pediatric knees, respectively (P = .004). At repeat measurement, circles averaged 9.8 and 7.3 mm in adult and pediatric knees, respectively (P = .0001). Femoral tunnel placement intraobserver variance averaged 2.9 mm in adult knees (range, 1.9-4.0 mm) and 2.3 mm in pediatric knees (range, 1.9-2.9 mm). This difference was not significant (P = .14). CONCLUSION: This study demonstrated that interobserver variance is actually greater in adult knees compared with pediatric knees, although interobserver variance was significantly different for both populations. Additionally, intraobserver variance is small on repeat measures, demonstrating that the Schöttle technique is reproducible for individual observers. Sources of this increased variance between observers are differences in agreement on the bony landmarks required for the Schöttle technique. Due to this variability in tunnel placement, we recommend caution when the Schöttle technique is used in pediatric knees to avoid iatrogenic injury to the distal femoral physis during femoral tunnel placement.

Incorporating patient preference into the management of infertility in women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a heterogeneous condition characterized by anovulation, hyperandrogenism, and polycystic ovaries. Because of the heterogeneous nature of PCOS, women affected by the condition often require a customized approach for ovulation induction when trying to conceive. Treating symptoms of PCOS in overweight and obese women should always incorporate lifestyle changes with the goal of weight-loss, as many women with PCOS will ovulate after losing 5%-10% of their body weight. On the other hand, other factors must be considered including the woman's age, age-related decline in fertility, and previous treatments she may have already tried. Fortunately, multiple options for ovulation induction exist for women with PCOS. This paper reviews specific ovulation induction options available for women with PCOS, the benefits and efficacy of these options, and the related side effects and risks women can anticipate with the various options that may affect treatment adherence. The paper also reviews the recommended evidence-based strategies for treating PCOS-related infertility that allow for incorporation of the patient's preference. Finally, it briefly reviews emerging data and ongoing studies regarding newer agents that have shown great promise as first-line agents for the treatment of infertility in women with PCOS.