Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy.

PURPOSE: Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury. METHODS: Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors. RESULTS: The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher. CONCLUSIONS: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Potential Financial Conflict of Interest Among Physician Editorial Board Members of Orthopaedic Surgery Journals.

BACKGROUND: The practice of medicine is based on evidence from peer-reviewed literature. As can occur with author-related funding, the integrity of the process by which manuscripts are reviewed, edited, and approved for publication may be at risk due to financial conflict of interest. The purpose of our study was to assess potential financial conflict of interest among physician editorial board members of orthopaedic surgery journals. METHODS: We identified the physician editorial board members of 15 orthopaedic surgery journals and searched the 2014 payments that were archived in the Centers for Medicare & Medicaid Services Open Payments system (mandated by the Physician Payments Sunshine Act). Total dollar values were calculated and tabulated in a multilevel fashion: nothing reported, >$0 and ≤$10,000, >$10,000, >$250,000, and >$950,000. RESULTS: We identified 908 physician editors of 15 orthopaedic surgery journals. Something of financial value was received by 78% (712 of 908) of these individuals. Rates of editorial board potential financial conflict of interest for individual journals ranged from 4% to 73% in the >$10,000 category. At the >$250,000 mark, rates ranged from 0% (2 journals) to 31%. When applying the >$950,000 criterion, physician potential conflict of interest ranged from 0% (5 journals) to 13%. CONCLUSIONS: Editor-related potential financial conflicts of interest exist in the orthopaedic surgery journals that we analyzed. These potential financial conflicts could possibly impact reviews.

The impact of pediatric brachial plexus injury on families.

PURPOSE: To determine the impact of brachial plexus injuries on families to best meet their clinical and social needs. METHODS: Our cross-sectional study included families with children between the ages of 1 and 18 years with birth or non-neonatal brachial plexus injuries (BPIs). The consenting parent or guardian completed a demographic questionnaire and the validated Impact on Family Scale during a single assessment. Total scores can range from 0 to 100, with the higher the score indicating a higher impact on the family. Factor analysis and item-total correlations were used to examine structure, individual items, and dimensions of family impact. RESULTS: A total of 102 caregivers participated. Overall, families perceived various dimensions of impact on having a child with a BPI. Total family impact was 43. The 2 individual items correlating most strongly with the overall total score were from the financial dimension of the Impact on Family Scale. The strongest demographic relationship was traveling nationally for care and treatment of the BPI. Severity of injury was marginally correlated with impact on the family. Parent-child agreement about the severity of the illness was relatively high. CONCLUSIONS: Caretakers of children with a BPI perceived impact on their families in the form of personal strain, family/social factors, financial stress, and mastery. A multidisciplinary clinical care team should address the various realms of impact on family throughout the course of treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Access to care for the adolescent anterior cruciate ligament patient with Medicaid versus private insurance.

PURPOSE: To determine the potential impact of type of health insurance on access to outpatient orthopaedic care for an adolescent patient with an acute anterior cruciate ligament (ACL) tear. METHODS: The offices of 42 orthopaedic surgeons in the Greater Cincinnati area, to include Ohio, Indiana, and Kentucky were contacted on 2 separate occasions describing a fictitious 14-year-old male with an acute ACL tear. The 2 calls were separated by a period of 2 to 4 weeks. The independent variable was the patient's insurance status, reported as either Medicaid or private insurance. Statistical comparison of the rates of successful appointment scheduling was performed through the Fisher exact test. RESULTS: Thirty-eight of 42 Orthopaedic surgery practices (90%) offered the privately insured 14-year-old ACL patient an appointment within 2 weeks, while only 6 of 42 (14%) offered the Medicaid patient such an appointment. The difference in these rates was statistically significant (P<0.0001) with the odds of getting an appointment with private insurance being 57 times higher than that with Medicaid (95% confidence interval: 12.87, 288.62). CONCLUSIONS: Access to orthopaedic care for children on Medicaid continues to be a problem in the United States. Previous pediatric studies have documented that the reason for these discrepancies in access are related primarily to Medicaid reimbursement rates (approximately 23% of private insurance). Ours is the first study to show that these same limitations exist for teenagers with acute knee injuries likely to require surgery.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Level of evidence and conflict of interest disclosure associated with higher citation rates in orthopedics.

OBJECTIVE: To identify the scientific and nonscientific factors associated with rates of citation in the orthopedic literature. STUDY DESIGN AND SETTING: All original clinical articles published in three general orthopedics journals between July 2002 and December 2003 were reviewed. Information was collected on variables plausibly related to rates of citation, including scientific and nonscientific factors. The number of citations at 5 years was ascertained and linear regression was used to identify factors associated with rates of citation. RESULTS: In the multivariate analysis, factors associated with increased rates of citation at 5 years were high level of evidence (22.2 citations for level I or II vs. 10.8 citations for level III or IV; P=0.0001), large sample size (18.8 citations for sample size of 100 or more vs. 7.9 citations for sample size of 25 or fewer; P<0.0001), multiple institutions (15.2 citations for two or more centers vs. 11.1 citations for single center; P=0.023), self-reported conflict of interest disclosure involving a nonprofit organization (17.4 citations for nonprofit disclosure vs. 10.6 citations for no disclosure; P=0.027), and self-reported conflict of interest disclosure involving a for-profit company (26.1 citations for for-profit disclosure vs. 10.6 citations for no disclosure; P=0.011). CONCLUSION: High level of evidence, large sample size, representation from multiple institutions, and conflict of interest disclosure are associated with higher rates of citation in orthopedics.

"Does the outcome of adolescent idiopathic scoliosis surgery justify the rising cost of the procedures?".

BACKGROUND: As the cost of medical care has steady risen, patients, insurance companies, and the government, have all appropriately questioned the benefit of the care provided versus the cost. Expensive treatments such as surgery for spinal deformity have been especially scrutinized. This article reviews the history of spinal implant usage in deformity surgery, including the benefits of these implants to the patient and also the associated costs. The paper was presented at the One Day Course during the 2009 Pediatric Orthopaedic Society of North America annual meeting in Boston. METHODS: A review was conducted regarding the benefits and costs of the care provided to patients as spinal implants became more clinically effective. RESULTS: Compared with postoperative casting, spinal implants provide better deformity correction and better stability of the fusion mass with resulting lower rates of secondary surgery, mostly because of fewer pseudarthoses. Many of these advantages were achieved with the less-expensive second and third-generation implants. Unfortunately, patient outcomes when the latest, most expensive implants are used are not significantly different from outcomes when older, less-expensive implants are used. CONCLUSIONS: Although the cost of spinal deformity surgery has risen the benefit to the patient from modern spinal implants has also increased. Nevertheless, patient outcomes have not improved in proportion to the increase in costs. Outcomes from the newest, all pedicle screw constructs are not significantly better than outcomes from the older, less-expensive hybrid constructs. Rising expenses and dramatic variation in the cost of the same implant have led payors, hospitals, and the government to question the value added to the care of the patient. Some implant costs should fall as hospitals use competitive bidding. Surgeons should help their hospitals in the competitive bidding process and declare a willingness to switch to an equivalent system if price differences are excessive. LEVELS OF EVIDENCE: Level IV Economic Analysis.

Accuracy of conflict-of-interest disclosures reported by physicians.

BACKGROUND: The recent public reporting of payments made to physicians by manufacturers of orthopedic devices provides an opportunity to assess the accuracy of physicians' conflict-of-interest disclosures. METHODS: We analyzed the reports of payments made to physicians by five manufacturers of total hip and knee prostheses in 2007. For each payment recipient who was an author of a presentation or served as a committee member or board member at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons, the disclosure statement was reviewed to determine whether the payment had been disclosed. To ascertain the reasons for nondisclosure, a survey was administered to physicians who had received payments that were not disclosed. RESULTS: The overall rate of disclosure was 71.2% (245 of 344 payments). For payments that were directly related to the topic of the presentation at the meeting, the rate was 79.3% (165 of 208); for payments that were indirectly related, the rate was 50.0% (16 of 32); and for payments that were unrelated, the rate was 49.2% (29 of 59) (P=0.008). In the multivariate analysis, payments were also more likely to have been disclosed if they exceeded $10,000 (P<0.001), were directed toward an individual physician rather than a company or organization (P=0.04), or included an in-kind component (P=0.002). Among the 36 physicians who responded to the survey regarding reasons for nondisclosure (response rate, 39.6%), the reasons most commonly given for nondisclosure were that the payment was unrelated to the topic of presentation at the annual meeting (38.9% of respondents) and that the physician had misunderstood the disclosure requirements (13.9%); 11.1% reported that the payment had been disclosed but was mistakenly omitted from the program. CONCLUSIONS: In this study of self-reported conflict-of-interest disclosure by physicians at a large annual meeting, the rate of disclosure was 79.3% for directly related payments and 50.0% for indirectly related payments.

Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures.

BACKGROUND: In vitro mechanical studies have demonstrated equal or superior fixation of pediatric femoral fractures with use of titanium elastic nails as compared with stainless steel elastic nails, and the biomechanical properties of titanium are often considered to be superior to those of stainless steel for intramedullary fracture fixation. We are not aware of any clinical studies in the literature that have directly compared stainless steel and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of the present study was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures. METHODS: A group of fifty-six children with femoral fractures that were treated with titanium elastic nails was compared with another group of forty-eight children with femoral fractures that were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used. The groups were compared with regard to complications as well as insertion and extraction time. Major complications were defined as malunion with sagittal angulation of >15 degrees and coronal angulation of >10 degrees, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery. RESULTS: The malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from $259 to $328, depending on size, whereas the price of one stainless steel nail would be $78 in current United States dollars. CONCLUSIONS: Our results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

Industry-sponsored research.

Financial conflicts of interest are exceedingly common in biomedical research. Investigators with conflicts of interest are more likely to arrive at positive conclusions, perhaps as a result of biased study design, industry suppression of negative results, preferential funding by industry of projects that are likely to succeed, or biased interpretation of results on the part of investigators. Government and professional organisations have proposed guidelines for managing conflicts of interest, but in practice it is the policies of universities and medical journals that direct the actions of investigators. Academic researchers and the media have expressed concern about the influence of industry sponsorship on biomedical research, while industry is increasingly turning to private entities (such as contract research organisations) to conduct clinical trials. Research participants appear less concerned with conflicts of interest in biomedical research, perhaps due to a faith that such conflicts are being appropriately managed by institutions. After reviewing the literature, we provide recommendations for the ethical conduct of biomedical research in the presence of financial conflicts of interest.

Interstate variability of the statute of limitations for medical liability: a cause for concern?

BACKGROUND: Widespread variation in state laws produces significant differences in state-to-state liability risk and insurance cost. These variations may produce higher medical liability for certain pediatric practitioners because many states have a significantly longer period of potential liability for physicians caring for children. This study reviewed state laws for variability in the period of medical liability for pediatric and adult patients and considered some of the impacts resulting from such variability. METHODS: Statutes of limitations applicable to claims for medical malpractice were reviewed for all 50 states and the District of Columbia, as were laws that affect the statute of limitations based on a patient's age. For each state, the average, minimum, and maximum values for the statute of limitations in years were calculated for the following age groups: newborn, 6, 12, and 25 years. RESULTS: In most states, the length of time a claimant has to bring a claim is longer for the youngest patients and decreases as patients get older. In the United States, the average time to bring a claim in years for a newborn and those aged 6, 12, and 25 years was 12, 8, 5, and 2 years, respectively. The maximum time to bring a claim in years for a newborn and those aged 6, 12, and 25 years was 23, 17, 11, and 5 years, respectively. CONCLUSIONS: States demonstrate significant variability in the duration and application of statutes of limitations, with younger patients typically having a longer period to file a liability lawsuit. In most regions, pediatric practitioners face increased liability risk based upon significantly longer limitation periods for minor patients. Studies have suggested that medical students are considering specialty liability risk when choosing careers. Increased liability risk faced by pediatric specialists may lead to fewer practitioners entering these fields. Extended periods of liability for pediatric specialists need additional study to evaluate the effects on liability insurance, specialty choice, and specialty care access. LEVEL OF EVIDENCE: Descriptive study (audit of existing laws), level of evidence 2.

Conflict of interest in orthopaedic research. An association between findings and funding in scientific presentations.

BACKGROUND: Financial conflict of interest has been associated with an increased likelihood that authors will report positive study outcomes. The purpose of this study was to investigate the association between types of declared conflict of interest and reported study outcomes in orthopaedic research. METHODS: The abstracts of all podium presentations given at the 2001 and 2002 Annual Meetings of the American Academy of Orthopaedic Surgeons were analyzed by three orthopaedic surgeons with advanced training in clinical epidemiology. The findings reported in each abstract were graded as positive, negative, neutral, or not applicable. Self-reported conflict of interest was recorded and classified. RESULTS: Conflicts of interest were reported in 40.8% (212) of 519 abstracts. The interobserver reliability of the grading of the study findings was acceptable (intraclass correlation coefficient, 0.725). Rates of conflict of interest related to royalties, stock options, or consultant or employee status varied significantly by subspecialty field (p < 0.001). The overall rate of positive study findings was 84.0% (436 of the 519 abstracts). Positive findings were more common in studies authored by individuals with a conflict of interest related to royalties (98.4% [sixty of sixty-one] compared with 88.0% [381 of 433] for studies authored by individuals without a conflict of interest related to royalties; relative risk = 1.1 [95% confidence interval = 1.0 to 1.1]; p = 0.02), in studies authored by individuals with a conflict of interest related to stock options (100.0% [twenty-nine of twenty-nine] compared with 84.7% [394 of 465]; relative risk = 1.2 [95% confidence interval = 1.0 to 1.3]; p = 0.04), and in studies authored by individuals with a conflict of interest related to consultant or employee status (97.8% [ninety-one of ninety-three] compared with 89.0% [357 of 401]; relative risk = 1.1 [95% confidence interval = 1.0 to 1.2]; p = 0.01). Positive findings were not more common in studies authored by individuals with a conflict of interest related to research or institutional funding (93.5% [143 of 153] compared with 91.8% [313 of 341]; relative risk = 1.0 [95% confidence interval = 0.95 to 1.5]; p = 0.65). In the multivariate analysis, the factors that remained significant predictors of positive outcomes were royalties (p = 0.002) and consultant or employee status (p = 0.038). CONCLUSIONS: Self-reported conflicts of interest are common in orthopaedic research, particularly in the subspecialty fields of adult reconstruction of the knee, adult reconstruction of the hip, and spine. Presentations authored by individuals with a conflict of interest related to royalties, stock options, or consulting or employee status were significantly more likely to describe positive findings. While there may be distinct benefits associated with industry support of orthopaedic research, safeguards must be established to maintain public trust in the medical research establishment.

Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.

The inherent ability of pediatric metaphyseal radius fractures to heal and remodel made us question the need for immediate anatomic reduction under conscious sedation. We believe that isolated closed distal radius fractures with 15 degrees of angulation and 1 cm of shortening will heal well and remodel completely without clinical or functional sequelae. Time and expense can be decreased by splinting and follow-up without the need for immediate anatomic reduction in the emergency room. In order to answer this question, we retrospectively evaluated 34 pediatric metaphyseal wrist fractures that lost position after attempted reduction and healed in their angulated or shortened position. We looked at the time to healing, time to remodeling and any residual clinical or functional deficits. We then did a comparison cost analysis with time matched patients who had complete but minimally displaced fractures of the distal radius that were treated by immediate splinting with orthopaedic follow-up. Our results showed that skeletally immature patients with open physes, isolated injuries, dorsovolar and radioulnar angulations less than 15 degrees and less than 1 cm of shortening will heal and be out of cast within an average of 6 weeks and completely remodel within an average of 7.5 months. The average time in the emergency room was 2 h less with no reduction. The cost of the emergency room visit with attempted reduction was 50% more than splinting with early referral (US dollars 536 versus US dollars 270). None of our patients had significant clinical deformities or residual functional deficits.

Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing.

BACKGROUND: Treatment of pediatric femoral fractures by 90/90 traction and spica casting (TXN/CST) has begun to be replaced by elastic stable intramedullary nailing (ESIN). The purpose of our study was to perform a cost analysis of TXN/CST versus ESIN in addition to comparing clinical/functional parameters. METHODS: We reviewed all children admitted with femoral shaft fractures between January 1995 and April 1998. Overall cost and clinical/radiographic outcome measures were analyzed, and 60% of patients' parents completed a follow-up telephone interview. Sixty-eight patients representing 71 femoral shaft fractures that had complete data and 1-year follow-up were included. RESULTS: No difference existed between the two groups for standard clinical/functional criteria. ESIN was associated with a lower overall cost than TXN/CST. ESIN also resulted in better scar acceptance, and higher overall parent satisfaction. CONCLUSION: Less cost and comparable clinical outcome make ESIN a better option than traditional TXN/CST for femoral fracture care in the skeletally immature patient.