Management Principles and Current Debates Surrounding Common Pediatric Elbow Fractures.

Elbow fractures are among the most common fractures sustained in pediatric patients. A specific set of pediatric elbow fractures (olecranon, radial neck, and lateral condyle fractures) comprises the ones that occur most often. It is important to review commonly accepted principles in the evaluation and treatment of these injuries as well as highlight some debates that exist within the literature regarding the optimal management of these injuries. Although management of pediatric olecranon, radial neck, and lateral condyle fractures has been well described, controversy persists among orthopaedic surgeons regarding the surgical indications and preferred fixation techniques for these injuries.

Risk of Acute Compartment Syndrome in Pediatric Patients With Tibial Tubercle Avulsion Fractures: A Retrospective Review.

OBJECTIVE: Tibial tubercle avulsion fractures (TTAFs) represent 0.4% to 2.7% of pediatric physeal injuries. These injuries are thought to confer a risk of acute compartment syndrome (ACS), and these patients are often admitted for compartment monitoring and, in many cases, undergo prophylactic fasciotomy. This study sought to review our institution's experience with TTAF and associated compartment syndrome in pediatric patients. METHODS: All patients aged 8 to 18 years with TTAF at our institution from January 1, 2017 to January 1, 2023 were retrospectively reviewed. Patient demographics, injury mechanism, fracture morphology, and postinjury course were reviewed. ACS was diagnosed by clinical exam or necessitating therapeutic compartment fasciotomy. RESULTS: A total of 49 TTAFs in 47 patients were included in the final analysis. The mean age was 14.5 ± 1.2 years (range: 11 to 17), and males were significantly older than females (14.6 ± 1.1 vs 13.3 ± 1.3 y, P = 0.01). The average body mass index was 27.1 ± 7.0, and males had a significantly lower body mass index than females (26.3 ± 6.5 vs 34.1 ± 8.5, P = 0.03). Basketball was the most common mechanism of injury (49%), followed by soccer (13%), football (11%), trampoline (6%), fall (6%), jumping (4%), lacrosse (4%), running (4%), and softball (2%). The Ogden fracture types were as follows: I: 10%; II: 16%; III: 41%; IV: 24%; V: 8%. Thirty-four patients (69%) were admitted to the hospital for at least one night after presentation. Forty-six (96%) underwent surgical fixation an average of 3.5 days after injury. No patients developed ACS during their post-injury or postoperative course. Three patients underwent the removal of hardware. No other complications were observed. The average follow-up duration was 238 days. CONCLUSIONS: The results of this study suggest that the risk of ACS in pediatric patients with TTAF may be small enough to allow for same-day discharge after diagnosis or operative management in patients deemed to be sufficiently low risk by clinical judgment. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients.

INTRODUCTION: Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution. METHODS: We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships. RESULTS: Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10. CONCLUSIONS: We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Fluoroscopy as Definitive Postreduction Imaging of Pediatric Wrist and Forearm Fractures Is Safe and Saves Time.

BACKGROUND: Recent studies indicate that formal postreduction radiographs may be unnecessary for closed, isolated pediatric wrist, and forearm when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol to reflect this by allowing orthopaedic providers to determine if fluoroscopy was acceptable to assess fracture reduction. We hypothesized that using fluoroscopy as definitive postreduction imaging would decrease total encounter time, without an increase in the rate of rereduction or surgery. METHODS: Patients with closed, isolated distal radius/distal ulna (DR/DU) or both bone forearm (BBFA) fractures that required sedation and reduction under mini C-arm fluoroscopy at our Level 1 pediatric ED were reviewed for 6 months both before and after this policy change. Before, all patients had formal postreduction radiographs; after, the decision was left to the orthopaedic physician. Timestamp data were collected, as was the need for rereduction or surgery. In addition to descriptive statistics, between-group differences were analyzed with the Student t test, χ test, and multivariable regression as appropriate. RESULTS: A total of 243 patients (119 before, 124 after) had 165 DR/DU and 78 BBFA fractures. Demographic data were similar before and after. After protocol implementation, univariable analysis (Student t test) showed that sedation times were longer, while total ED time and the time from sedation beginning to discharge were similar. The proportion of patients requiring rereduction or surgery were similar.After multivariable regression, "fluoroscopy as definitive imaging" was the only independent determinant of the time intervals compared with using conventional radiography. Sedation was an average of 13.8 minutes longer (P<0.001), while the interval from sedation beginning to discharge was 15.8 minutes shorter (P=0.007), and total ED time was 33.0 minutes shorter (P=0.018). Fluoroscopy as definitive imaging was not a predictor of surgery (odds ratio=0.63, P=0.520), although having a BBFA increased the likelihood (odds ratio=4.50, P=0.008). CONCLUSIONS: Implementing a protocol in which the provider could use mini C-arm fluoroscopy for definitive postreduction imaging did not result in increased rates remanipulation or need for surgery. Regression analysis further demonstrated time savings associated with foregoing conventional radiographs. LEVEL OF EVIDENCE: Level III-therapeutic.

Pediatric Polytrauma: What Is the Role of Damage Control Orthopaedics in the Pediatric Population?

Severe pediatric trauma can be complicated for clinicians to manage because it is unusual and behaves somewhat differently from severe trauma in adults. Damage control orthopaedics is a philosophy that has gained traction in the past 30 years and has become standard in unstable adult trauma patients. Studies have failed to demonstrate clear utility for this approach in pediatric patients. Clinicians should understand the concepts of early total care and damage control orthopaedics for the patient with polytrauma, the physiologic factors associated with trauma in both children and adults who sustain severe trauma, and the role of early total care versus damage control orthopaedics in the treatment of the pediatric patient with polytrauma.

Fracture Remodeling in Children: Which Fractures Remodel and Which Do Not?

Children have the capacity to remodel fractures because of their active physis and periosteum. Orthopaedic surgeons should be aware of the general guidelines that injuries in younger children, children with less displaced fractures, and children with injuries closer to the growth plate are likely to remodel better than in older children with injuries more distant from the growth plate and with more initial deformity. It is also important to recognize that deformity in the plane of motion is generally better tolerated than deformity outside the plane of motion. Rotational malalignment tends to remodel poorly if at all. When evaluating an injury, the physician should consider the growth potential of the physes in the area local to the injury and their likely contribution to the remodeling and healing process when deciding what management is right and what reduction is acceptable.

The Cost and Utility of Postreduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures.

BACKGROUND: Formal radiographs are frequently obtained after reduction of closed pediatric wrist and forearm fracture performed under mini C-arm fluoroscopy. However, their utility has not been clearly demonstrated to justify the increased time, cost, and radiation exposure. We hypothesized that formal postreduction radiographs do not affect the rereduction rate of pediatric wrist and forearm fractures. We further sought to determine the time, monetary, and opportunity costs associated with obtaining these radiographs. METHODS: A total of 119 patients presented to our urban, level I pediatric trauma center from April 2015 to September 2015 with isolated, closed wrist and forearm fractures who underwent sedation and reduction using mini C-arm fluoroscopy. Demographic and injury variables were collected, along with incidence of rereduction and need for future surgery. Time intervals for sedation, awaiting x-ray, and total encounter periods were noted, and total direct and variable indirect costs for each encounter were obtained from our institution's cost accounting and billing databases. Marginal time and monetary costs were noted and further calculated as a percentage of the total encounter. Opportunity costs were calculated for the time spent obtaining the postreduction radiographs. RESULTS: Of 119 patients with isolated, closed wrist or forearm fractures, none required rereduction after initial reduction using sedation and mini C-arm fluoroscopy. Postreduction radiographs required an average of 26.2 minutes beyond the end of sedation, or 7.3% of the encounter time and cost. The direct cost of the x-ray was 2.6% of the encounter cost. With our institution's annual volume, this time could have been used to see an additional 656 patients per year. CONCLUSIONS: Postreduction formal radiographs did not result in changes in management. There are significant direct and opportunity costs for each patient who undergoes additional formal radiographs. Pediatric patients with isolated, closed wrist or forearm fractures do not routinely need formal radiographs after reduction under mini C-arm fluoroscopy. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Avoiding Errors in the Management of Pediatric Polytrauma Patients.

Management of pediatric polytrauma patients is one of the most difficult challenges for orthopaedic surgeons. Multisystem injuries frequently include complex orthopaedic surgical problems that require intervention. The physiology and anatomy of children and adolescent trauma patients differ from the physiology and anatomy of an adult trauma patient, which alters the types of injuries sustained and the ideal methods for management. Errors of pediatric polytrauma care are included in two broad categories: missed injuries and inadequate fracture treatment. Diagnoses may be missed most frequently because of a surgeon's inability to reliably assess patients who have traumatic brain injuries and painful distracting injuries. Cervical spine injuries are particularly difficult to identify in a child with polytrauma and may have devastating consequences. In children who have multiple injuries, the stabilization of long bone fractures with pediatric fixation techniques, such as elastic nails and other implants, allows for easier care and more rapid mobilization compared with cast treatments. Adolescent polytrauma patients who are approaching skeletal maturity, however, are ideally treated as adults to avoid complications, such as loss of fixation, and to speed rehabilitation.

Common Errors in the Management of Pediatric Supracondylar Humerus Fractures and Lateral Condyle Fractures.

Supracondylar humerus fractures and lateral condyle fractures are the two most common pediatric elbow fractures that require surgical intervention. Although most surgeons are familiar with supracondylar humerus fractures and lateral condyle fractures, these injuries present challenges that may lead to common errors in evaluation and management and, thus, compromise outcomes. It is well agreed upon that nondisplaced supracondylar fractures (Gartland type I) are best managed nonsurgically with cast immobilization. Errors may be made, however, in the treatment of type II fractures because the extent of displacement and instability are difficult to assess. Although some type II fractures are stable after closed reduction, many are not and benefit from closed reduction and percutaneous pinning to prevent late displacement and cubitus varus deformity. Stable fixation must be achieved and errors related to pin placement must be avoided to prevent the failure of type III fractures after closed reduction and percutaneous pinning. Many potential errors and pitfalls also are seen in the management of lateral condyle fractures. Radiographic assessment of displacement can be improved by obtaining an internal oblique view of the elbow. Surgical treatment with closed reduction and percutaneous pinning may be indicated for minimally displaced fractures (2 to 4 mm) that show evidence of increasing displacement over time or demonstrate intra-articular extension on an arthrogram. Displaced fractures are best treated with open reduction and internal fixation. Errors in surgical dissection, fracture reduction, and fixation are common and may result in osteonecrosis, malunion, and nonunion.

Pediatric Monteggia Fracture-Dislocations: Avoiding Problems and Managing Complications.

Monteggia fracture-dislocations typically involve a dislocation of the radial head with an associated fracture of the ulnar shaft. The prompt diagnosis and treatment of these acute injuries result in excellent outcomes. Unfortunately, a Monteggia fracture-dislocation is often missed during diagnostic testing and results in a chronic Monteggia fracture-dislocation. The subsequent timing and treatment of chronic Monteggia fracture-dislocations are debatable because outcomes are suboptimal. Therefore, it is critical that the initial injury be correctly diagnosed and treated as close to the time of injury as possible to ensure excellent outcomes.

Procedural sedation in the emergency department.

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

J-splint use for temporizing management of pediatric femur fractures: a review of 18 cases.

OBJECTIVES: Pediatric femoral fractures are common injuries encountered in the field and in emergency departments. Currently described temporizing management strategies include skeletal traction, skin traction, traction splinting, and posterior splinting, all of which are suboptimal in some instances. J-splinting femur fractures may be advantageous in temporizing management of pediatric femur fractures. The objective of this study was to evaluate the safety and effectiveness of J-splint use for temporizing management of pediatric femur fractures. METHODS: This study used a retrospective review of 18 pediatric patients with femur fractures treated with J-splinting in the emergency department. Patient age, weight, and presplinting and postsplinting pain scale ratings were recorded, as well as presplint and postsplint anteroposterior and lateral radiographic fracture angulation. Pain before and after J-splinting was compared using a paired t test. RESULTS: The mean age of this cohort was 5.4 years (range, 6 months-13 y), with a mean weight of 21.1 kg (range, 7.7-57 kg). In this cohort, there was a significant reduction in pain after reduction and splinting from a mean of 6 to a mean of 1 (P < 0.001). No significant difference in fracture alignment was noted after J-splinting. No complications were noted. CONCLUSIONS: The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and downfalls of other described temporizing measures and helps to provide excellent pain management in the acute setting.

Evaluating the hematoma block as an adjunct to procedural sedation for closed reduction of distal forearm fractures.

OBJECTIVES: Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure. METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam. RESULTS: Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups. CONCLUSIONS: The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.

Pediatric thoracolumbar spine trauma.

Thoracolumbar spine trauma is an important cause of morbidity and mortality in pediatric patients. Special attention to this population is necessary because several unique features of the growing pediatric spine separate these patients from adult patients. These injuries are frequently associated with high-energy trauma and concurrent thoracic or abdominal injuries that require coordinated multidisciplinary care. Thoracolumbar spine trauma in pediatric patients may lead to compression fractures, burst fractures, flexion-distraction injuries (ie, Chance fracture), fracture-dislocation injuries, apophyseal fractures/herniations, and spinous process and transverse process fractures. Depending on the nature of the injury and the patient's level of skeletal maturity, thoracolumbar spinal injuries may have substantial ability to heal and remodel. Because the impact of thoracolumbar spinal injury on pediatric patients can be devastating, appropriate early diagnosis and management, as well as long-term follow-up, are imperative.

Adolescent patellar osteochondral fracture following patellar dislocation.

PURPOSE: Patellar dislocations in adolescents may cause osteochondral fractures of the patella. The aim of this study was to review the outcomes of adolescent patients who underwent surgical intervention for patellar osteochondral fracture following patellar dislocation. METHODS: Nine patients who underwent surgery for osteochondral fracture of the patella following dislocation were identified retrospectively. Following arthroscopic examination, if the fragment was large enough to support fixation, headless screws or bioabsorbable pins were used. Otherwise, the loose body was excised, and the donor site was managed with a microfracture. Postoperatively, patients were assessed using the International Knee Documentation Committee (IKDC) and Knee injury and Osteoarthritis Outcome Score (KOOS) outcome measures. RESULTS: The average age of the patients was 14.6 with average follow-up 30.2 months. Four of the nine patients underwent fixation, while five patients underwent removal of loose body with microfracture. The average defect size in the nonfixation group was 1.2 cm(2) compared with 3.2 cm(2) in the fixation group. The IKDC scores for fixation and nonfixation groups were 63.9 (SD = 18) and 76.1 (SD = 11.7), respectively. The KOOS subscale scores for symptoms, function in sports and recreation, and knee-related quality of life were higher for the nonfixation group when compared to the fixation group. CONCLUSIONS: This is the first known series examining surgical outcomes of osteochondral fractures of the patella following patellar dislocations in the adolescent population. While patients without fixation were less symptomatic in this series, this may be attributable to more severe injuries in patients undergoing fracture fixation. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Bilateral Tibial Tubercle Avulsion Fractures With an Associated Patellar Tendon Avulsion in an Adolescent Patient.

Tibial tubercle fractures in pediatric patients are increasing in frequency as more children participate in sports. These injuries are often seen in boys engaging in jumping activities before closure of their proximal tibial physis. Bilateral tibial tubercle fractures have been reported in the literature, but less frequent are associated patellar tendon ruptures with fracture of the tubercle. In this case report, we present an 11-year-old girl who sustained bilateral tibial tubercle fractures, including an associated patellar tendon rupture from the tubercle on the right lower extremity. We describe our technique for the management of both injuries, which included a primary patellar tendon repair for the right leg and Kirschner wire fixation of the displaced tubercle for the left leg. The patient ultimately had a successful outcome at the final follow-up with healed fractures and full range of motion of both knees. In this case report, we also present similar cases from the literature and the differing treatment strategies.

A Comparison of Match Rates to Orthopaedic Surgery Residency Programs Between First-Time Versus Repeat Applicants: An Analysis of the National Resident Matching Program Data from 2018 to 2022.

Orthopaedic surgery has become one of the most competitive specialties to match into among medical students applying to residency. The purpose of this study was to compare match rates to orthopaedic surgery residency programs among first-time vs. repeat applicants. Methods: Data were obtained from the National Resident Matching Program from 2018 to 2022. For each year, the total number of applicants to orthopaedic surgery residency programs was obtained, as well as the number of applicants who successfully matched into orthopaedics. The match rate was compared between first-time vs repeat applicants. A subanalysis was performed on allopathic graduates (MDs) and osteopathic graduates (DOs)/international medical graduates (IMGs). In addition, the match rate for first-time applicants and reapplicants was compared between MD and DO/IMG applicants. Results: Overall, there was a significantly higher match rate among first-time applicants (89.8%) vs. repeat applicants (22.5%, p < 0.0001). When substratified by MD and DO/IMG applicants, first-time applicants still matched at a significantly higher rate than reapplicants within each group (p < 0.0001 for each). Among first-time applicants, MDs (93.1%) matched at a significantly higher rate than DOs/IMGs (68.6%, p < 0.0001). Among reapplicants, DOs/IMGs (25.3%) matched at a significantly higher rate than MDs (20.1%, p < 0.01). Conclusion: First-time applicants to orthopaedic surgery residency programs have a significantly higher rate of matching compared with reapplicants, irrespective of degree. In recent years, first-time MD applicants have matched at a significantly higher rate than first-time DO/IMG applicants.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors.

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted. Methods: This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years. Results: In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05). Conclusion: Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway. Level of Evidence: IV.