Examining the Relationship Between Value and Patient Satisfaction With Treatment in Total Joint Arthroplasty.

Background: A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods: Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome. Results: This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001). Conclusions: This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Does Preoperative Opioid Consumption Increase the Risk of Chronic Postoperative Opioid Use After Total Joint Arthroplasty?

BACKGROUND: Risk-factor identification related to chronic opioid use after surgery may facilitate interventions mitigating postoperative opioid consumption. We evaluated the relationship between opioid use preceding total hip arthroplasty (THA) and total knee arthroplasty (TKA), and chronic use postoperatively, and the risk of chronic opioid use after total joint arthroplasty. METHODS: All primary THAs and TKAs performed during a 6-month period were identified. Opioid prescription and utilization data (in oxycodone equivalents) were determined via survey and electronic records. Relationship between preoperative opioid use and continued use >90 days after surgery was assessed via Chi-square, with significance set at P < .05. RESULTS: A total of 415 patients met inclusion criteria (240 THAs and 175 TKAs). Of the 240 THAs, 199 (82.9%) patients and of the 175 TKAs, 144 (82.3%) patients agreed to participate. Forty-three of 199 (21.6%) THA patients and 22 of 144 (15.3%) TKA patients used opioids within 30 days preoperatively. Nine of 199 (4.5%) THA and 10 of 144 (6.9%) TKA patients had continued use of opioids for >90 days postoperatively. Preoperative opioid consumption was significantly associated with chronic use postoperatively for THA (P = .011) and TKA (P = .024). Five of 43 (11.6%) THA and 4 of 22 (18.2%) TKA patients with preoperative opioid use had continued use for >90 days postoperatively. For opioid naïve patients, 2.6% (4/156) of THA and 4.9% (6/122) of TKA patients had chronic use postoperatively. CONCLUSIONS: Preoperative opioid use was associated with nearly 5-fold and 4-fold increase in percentage of patients with chronic opioid use after THA and TKA, respectively. Surgeons should counsel patients regarding this risk and consider strategies to eliminate preoperative opioid use.

Tobacco Exposure Is Associated With Extremely Low Polyethylene Oxidation in Total Knee Arthroplasty Components.

BACKGROUND: We evaluate whether patient exposures such as tobacco use are associated with high systemic or local in vivo oxidative state and with increased in vivo polyethylene oxidation. METHODS: We performed a case-control study which evaluated clinical factors associated with high systemic or local in vivo oxidative state among patients whose implants have been identified as demonstrating either extreme or minimal oxidation by our implant retrieval laboratory. Analysis of more than 2500 tibial inserts from explanted total knee arthroplasty demonstrated a wide spectrum of polyethylene oxidation. Components from some patients exhibited extremely high oxidation rates (super-oxidizers), and components from other patients demonstrated negligible oxidation (nonoxidizers). Patients' clinical data were retrospectively investigated from a prospectively collected institutional database. RESULTS: Eighteen patients met criteria as either super-oxidizers (9) or nonoxidizers (9). Average time in vivo was 6.6 (±4.4) years. Reasons for removal were aseptic loosening (10), instability (3), infection (2), component malposition (1), massive osteolysis (1), and other (1). Chi-square for categorical predictors demonstrated that nonoxidizer patients were significantly more likely to be current smokers than super-oxidizers (6 vs 0, P = .012). No other free radical-associated variables were significantly different across oxidation groups. CONCLUSION: There was a significant association between extremely low ultra-high-molecular-weight polyethylene oxidation and current smoking.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients. METHODS: We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions. RESULTS: For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation. CONCLUSIONS: Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does the Impact of Joint Arthroplasty Extend Beyond the Patient? The Effect of Total Joint Arthroplasty on Patient's Significant Others.

BACKGROUND: This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs). METHODS: Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores. RESULTS: Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains. CONCLUSION: SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery.

What Happens to Unused Opioids After Total Joint Arthroplasty? An Evaluation of Unused Postoperative Opioid Disposal Practices.

BACKGROUND: This study evaluates the fate of unused opioids after total hip arthroplasty (THA) and total knee arthroplasty (TKA) at our facility. METHODS: Medication disposal after primary elective THA and TKA was classified as appropriate (in accordance with United States Food and Drug Administration guidelines) or inappropriate for all patients undergoing these procedures during the second half of the fiscal year 2015. RESULTS: In total, 199 THAs and 144 TKAs met inclusion criteria. Total pills prescribed were 55,635. Approximately 8925 (16%) of pills were unused. About 39.9% of patients disposed of unused opioids appropriately, while 60.1% of patients reported still having (18.5%), not knowing where they were (8.2%), or other (33.4%). There was no significant association with the type of opioid prescribed. CONCLUSION: A large volume of unused opioids were improperly disposed of after total joint arthroplasty.

A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis.

BACKGROUND: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. METHODS: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. RESULTS: Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively. CONCLUSIONS: As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly. CLINICAL RELEVANCE: Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.

Duration of military service is associated with decision quality in Veterans considering total knee replacement: case series.

PURPOSE: Due to the nature of military service, the patient-physician relationship in Veterans is unlike that seen in civilian life. The structure of the military is hypothesized to result in barriers to open patient-physician communication and patient participation in elective care decision-making. Decision quality is a measure of concordance between a chosen treatment and the aspects of medical care that matter most to an informed patient; high decision quality is synonymous with patient-centered care. While past research has examined how age and other demographic factors affect decision quality in Veterans, duration of military service, rank at discharge, and years since discharge have not been studied. PATIENTS AND METHODS: We enrolled 25 Veterans with knee osteoarthritis at a VA hospital. Enrollees completed a survey with demographic, military service, and decision-making preference questions and the Hip-Knee Decision Quality Instrument (HK-DQI), which measures patients' knowledge about their disease process, concordance of their treatment decision, and the considered elements in their decision-making process. RESULTS: The HK-DQI knowledge score had a significant, positive correlation with duration of military service (R2=0.36, p=0.004). Rank at discharge and years since discharge did not show a significant correlation with decision quality (p=0.500 and p=0.317, respectively). The concordance score did not show a statistically significant correlation with rank, duration of service, and years since discharge (p=0.640, p=0.486 and p=0.795, respectively). Additionally, decision process score was not significantly associated with rank, duration of military service, and years since discharge (p=0.380, p=0.885, and p=0.474, respectively). CONCLUSION: Decision quality in Veterans considering treatment for knee osteoarthritis appears to be correlated positively with duration of military service. These findings may present an opportunity for identification of Veterans at most risk of low decision quality and customization of shared decision-making methods for Veterans by characteristics of military service.

A comparison of radiographic leg-length and offset discrepancies between 2 intraoperative measurement techniques in anterior total hip arthroplasty.

BACKGROUND: Anterior total hip arthroplasty (THA) allows the use of intraoperative fluoroscopy to assess leg-length and offset discrepancies. Two techniques to accomplish this are the transverse rod method and the radiographic overlay method. The aim of this study was to determine if they are equally effective options for minimizing postoperative radiologic discrepancies. METHODS: We completed a retrospective cohort study comparing 106 anterior THAs from 1 surgeon using the transverse rod technique to 94 anterior THAs from another surgeon using the radiograph overlay technique. Radiographic leg-length discrepancy (LLD) and offset discrepancy (OD) were measured independently on postoperative radiographs. Parametric, nonparametric, and categorical statistical tests were used to compare LLD and OD between groups. RESULTS: Baseline characteristics were similar between groups. The mean LLD of 4.8 mm in the radiograph overlay group was not significantly different from the 4.4 mm mean discrepancy in the transverse rod group (P = .424), and the rates of LLD < 5 mm and LLD < 10 mm were not significantly different (P = .772, P = .179). The mean OD of 5.1 mm in the radiograph overlay group was not significantly different from the 4.8 mm mean discrepancy in the transverse rod group (P = .668), and there was no significant difference in the rates of OD < 5 mm and OD < 10 mm (P = .488, P = .878). CONCLUSIONS: There was no difference between the measured LLD and OD by the 2 surgeons, suggesting that the techniques are equally effective options.

Next-Generation Sequencing vs Culture-Based Methods for Diagnosing Periprosthetic Joint Infection After Total Knee Arthroplasty: A Cost-Effectiveness Analysis.

BACKGROUND: Periprosthetic joint infection (PJI) after total knee arthroplasty is challenging to diagnose. Compared with culture-based techniques, next-generation sequencing (NGS) is more sensitive for identifying organisms but is also less specific and more expensive. To date, there has been no study comparing the cost-effectiveness of these two methods to diagnose PJI after total knee arthroplasty. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine the cost-effectiveness from a societal perspective. The primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base case values, culture was not determined to be cost-effective compared to NGS, with an incremental cost-effectiveness ratio of $422,784 per QALY. One-way sensitivity analyses found NGS to be the cost-effective choice above a pretest probability of 45.5% for PJI. In addition, NGS was cost-effective if its sensitivity was greater than 70.0% and its specificity greater than 94.1%. Two-way sensitivity analyses revealed that the pretest probability and test performance parameters (sensitivity and specificity) were the largest factors for identifying whether a particular strategy was cost-effective. CONCLUSION: The results of our model suggest that the cost-effectiveness of NGS to diagnose PJI depends primarily on the pretest probability of PJI and the performance characteristics of the NGS technology. Our results are consistent with the idea that NGS should be reserved for clinical contexts with a high pretest probability of PJI. Further study is required to determine the indications and subgroups for which NGS offers clinical benefit.

Association of Hospital Employee Satisfaction with Patient Safety and Satisfaction within Veterans Affairs Medical Centers.

BACKGROUND: Employee satisfaction is thought to impact performance. However, which aspects of employee satisfaction matter most is unknown. We utilized data from the Veterans Affairs Medical Centers(VAMC) via their Strategic Analytics for Improvement and Learning program to examine the association between organizational satisfaction as well as job-specific satisfaction with measures of patient safety, patient satisfaction, and hospital rating. METHODS: The correlation between employee satisfaction with their organization and with their specific job were examined across indicators of patient care using Pearson and Spearman's correlation. Employee satisfaction data were obtained from the All Employee Survey. RESULTS: We found that employee job-specific satisfaction does not correlate with patient outcomes, whereas higher satisfaction with the organization is associated with improved patient safety (ρ = -0.19, P < .05) and correlates with all aspects of patient satisfaction ("top box" ratings of hospital [r = 0.30, P < 0.005], primary care [r = 0.25, P < 0.005], and specialty care [r = 0.14, P < 0.005]). Further, employees are more satisfied with their job and organization when they work at a VAMC with a higher Star rating. CONCLUSION: Employee organizational satisfaction and job-specific satisfaction are distinct metrics, and it is higher organizational satisfaction that is associated with improved patient care.

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures.

BACKGROUND: Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices. METHODS: We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids. RESULTS: Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills. CONCLUSIONS: Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.

A systematic review and meta-analysis of the direct anterior approach for hemiarthroplasty for femoral neck fracture.

BACKGROUND: We performed a systematic review and meta-analysis to assess whether the direct anterior approach (DAA) is associated with improved functional and clinical outcomes compared to other surgical approaches for hemiarthroplasty for displaced femoral neck fractures. MATERIALS AND METHODS: Randomized trials and cohort studies of hemiarthroplasty performed via DAA versus another surgical approach (anterolateral, lateral, posterolateral, posterior) were included. Our primary outcome was postoperative functional mobility. Secondary outcomes included overall complication rate, dislocation rate, perioperative fracture, infection rate, re-operation rate, overall mortality, operative time, pain, intra-operative blood loss, and length of stay. RESULTS: Nine studies met inclusion criteria, comprising a total of 698 hips (330 direct anterior, 57 anterolateral, 89 lateral, 114 posterolateral, 108 posterior approach). With regard to functional mobility, DAA was favored in 4 studies, and no study favored another approach over DAA. DAA had a significantly lower dislocation rate compared to posterior capsular approaches. Analysis of other secondary outcomes did not identify statistically significant differences. CONCLUSION: This is the first systematic review and meta-analysis of the DAA for hemiarthroplasty. Available evidence suggests superior early functional mobility with the DAA. The DAA is associated with a significantly lower dislocation rate compared to posterior capsular approaches for hemiarthroplasty.

Residents' Impressions of the Impact of Advanced Practice Providers on Surgical Training.

BACKGROUND: To ensure that residents are appropriately trained in the era of the 80-hour work-week, training programs have restructured resident duties and hired advanced practice providers (APPs). However, the effect of APPs on surgical training remains unknown. STUDY DESIGN: We created a survey using a modified Delphi technique to examine the interaction between residents and APPs across practice settings (inpatient, outpatient, and operating room). We identified the following domains: administrative tasks, clinical experience, operative experience, and overall impressions. We administered the survey to residents across 7 surgical training programs at a single institution and assessed internal reliability with Cronbach's α. RESULTS: Fifty residents responded (77% participation rate). The majority reported APPs reduced the time spent on administrative tasks, such as completing documentation (96%) and answering pages (88%). For clinical experience, 62% of residents thought that APPs had no impact on the amount of time spent evaluating consult patients, and 80% reported no difference in the number of bedside procedures performed. However, 77% of residents reported a reduction in the time spent counseling patients. When APPs worked in the inpatient setting, 90% of residents reported leaving the operating room less frequently to manage patients. When APPs were present in the operating room, 34% of residents thought they were less likely to perform key parts of the case. Cronbach's α showed excellent to good reliability for the administrative tasks (0.96), clinical experience (0.76), operative experience (0.69), and overall impressions (0.66) domains. CONCLUSIONS: Most residents report that the integration of APPs has decreased the administrative burden. The reduction in patient counseling might be an unrecognized and unintended consequence of implementing APPs. The perceived effect on operative experience is dependent on the role of the APPs.

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older.

BACKGROUND: This study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine cost-effectiveness from a societal perspective. Costs (in 2016 US dollars), health state utilities, and state transition probabilities were obtained from published literature. Primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base-case values, THA was cost-effective compared to non-operative treatment with a total lifetime accrued cost of $186,444 vs $182,732, and a higher lifetime accrued utility (5.60 vs 5.09). Cost per QALY for THA was $33,318 vs $35,914 for non-operative management, and the incremental cost-effectiveness ratio was $7307 per QALY. Sensitivity analysis demonstrated THA to be cost-effective with a utility of successful primary THA above 0.67, a peri-operative mortality risk below 0.14, and a risk of primary THA failure below 0.14. Analysis further demonstrated that THA is a cost-effective option below a base-rate mortality threshold of 0.19, corresponding to the average base-rate mortality of a 93-year-old individual. Markov cohort analysis indicated that for patients undergoing THA at age 80 there was an approximate 28% reduction in total lifetime long-term assisted living expenditure compared to non-operatively managed patients with end-stage hip osteoarthritis. CONCLUSION: The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients ≥80 years old. This analysis may inform policy regarding THA in elderly patients.

Clinical research fails to support more aggressive management of pediatric upper extremity fractures.

BACKGROUND: Recent years have seen a trend toward more operative treatment of upper extremity fractures in children. The current study examines clinical research regarding pediatric upper extremity fracture treatment over the past twenty years in an attempt to identify research-based support for the increasingly aggressive treatment of these fractures. METHODS: Accepted abstracts on pediatric upper extremity fracture treatment presented at the Pediatric Orthopaedic Society of North America (POSNA) and the American Academy of Orthopaedic Surgeons (AAOS) annual meetings from 1993 through 2012 were reviewed. Abstracts were chosen rather than publications because of the larger number of abstracts that are available and because abstracts offer a more global representation of the research being performed by and presented to the members of these societies. The treatment recommendations of authors were classified as more aggressive, less aggressive, or neutral by two attending surgeons on the basis of which treatment was favored in comparative studies or how treatments in single-group studies compared with the standard of care at the time. Abstracts without treatment recommendations were excluded. Relationships between level of evidence, fracture location, and treatment recommendation were statistically evaluated with use of Spearman correlations and logistic regression analysis. RESULTS: Overall, a higher proportion of studies gave less aggressive (47%, ninety of 190) or neutral (27%, fifty-one of 190) recommendations than more aggressive treatment recommendations (26%, forty-nine of 190). Only 24% of operative studies and 11% of nonoperative studies recommended more aggressive treatment (p = 0.001). Case series were more likely to recommend more aggressive treatments than comparative studies (30% versus 17%, p = 0.025). Also, studies with a smaller sample size were more likely to recommend more aggressive treatments (p = 0.006). The great majority of level-I and level-II (91%, ten of eleven), level-III (81%, thirty-nine of forty-eight), and level-IV (70%, ninety-two of 131) studies, however, provided either neutral or less-aggressive treatment recommendations. CONCLUSIONS: The majority of research presented at POSNA and AAOS meetings over the past two decades fails to support the trend toward increasingly aggressive treatment of pediatric upper extremity fractures. This dichotomy between clinical research and the direction of clinical treatment must be explored in our efforts to provide evidence-based care of pediatric upper extremity fractures.