Tag: pubmed

Clin Orthop Relat Res. 2025 Apr 15. doi: 10.1097/CORR.0000000000003498. Online ahead of print.

ABSTRACT

BACKGROUND: Lower extremity injuries are common in conflict-related trauma, with gunshot wounds (GSWs) causing localized damage and explosive trauma leading to extensive tissue injuries. Existing research lacks direct comparisons of injury severity and treatment outcomes between GSWs and explosive trauma in modern conflicts. This study clarifies these differences to improve triage strategies, surgical planning, and rehabilitation protocols.

QUESTIONS/PURPOSES: (1) How did GSWs and explosive trauma differ in terms of injury severity, including the proportion of patients in each group who experienced open fractures, neurovascular injuries, and amputations, during the Israel-Gaza conflict? (2) What was the comparative frequency and type of surgical intervention performed for GSWs versus explosive trauma in lower extremities?

METHODS: Between October 7, 2023, and December 31, 2023, a total of 1815 patients were entered into the Israel National Trauma Registry (INTR) as having been injured during the Israel-Gaza conflict. The INTR is a comprehensive national database that collects standardized injury and treatment information from all Level 1 and Level 2 trauma centers in Israel, ensuring high-quality, consistent reporting of war-related injuries. Of these, we considered patients with lower extremity injuries and ICD-9 E-codes E979 and E990-E999 (terror and war-related injuries) as potentially eligible. Based on this criterion, 1318 patients sustained extremity injuries, and 51% (674) met our inclusion criteria for this study. Among them, 53% (357 of 674) sustained GSWs and 47% (317) suffered explosive injuries. The groups did not differ in terms of mean ± SD ages (gunshot 28.5 ± 11.7 years, explosive 28.0 ± 11.4 years; p = 0.61). Most patients in both groups were men (gunshot 91%, explosive 95%; p = 0.09), with no between-group difference in terms of the proportion of patients who were men. Missing data were minimal in both groups, with complete data sets available for all primary outcomes. Comparisons were made between the two groups regarding the severity of injuries (such as open fractures and amputations), frequency and type of surgical interventions, and associated injuries (including those to the chest, abdomen, and face). Statistical analysis included chi-square tests for categorical variables and independent t-tests for continuous variables, with a significance threshold of p < 0.01 because of the large number of comparisons made.

RESULTS: GSWs resulted in a higher proportion of patients with open fractures (32% [115 of 357] versus 20% [64 of 317]; p = 0.001), particularly in the tibia and fibula (17% [62 of 357] versus 10% [33 of 317]; p = 0.01), whereas explosive injuries led to more amputations (10% [31 of 317] versus 3% [11 of 357]; p < 0.001); neurovascular injuries did not differ (p = 0.14 for nerve and p = 0.54 for vascular). A higher proportion of gunshot injuries were treated surgically (73% versus 59%; p < 0.001).

CONCLUSION: Understanding the distinct injury patterns and outcomes of GSWs and explosive trauma is essential for improving patient care and resource allocation during conflicts. Given the high amputation rates in blast injuries, early rehabilitation and prosthetic support should be prioritized, while gunshot-related open fractures often call for expanded orthopaedic fixation and infection control. Trauma training should emphasize early surgery for GSWs and hemorrhage control for blast injuries. Future research should focus on long-term functional outcomes, protective gear efficacy, and improved battlefield evacuation strategies to enhance survivability and recovery.

LEVEL OF EVIDENCE: Level III, therapeutic study.

PMID:40258172 | DOI:10.1097/CORR.0000000000003498

J Am Acad Orthop Surg Glob Res Rev. 2025 Apr 15;9(4). doi: 10.5435/JAAOSGlobal-D-24-00262. eCollection 2025 Apr 1.

ABSTRACT

INTRODUCTION: Increasingly ambulatory surgery centers (ASC) are being used for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to evaluate the effect of transitioning TJAs to a newly opened ASC on hospital quality measures of patients undergoing TJA in the hospital.

METHODS: A retrospective review of 7,775 patients undergoing TJA at a single hospital from January 2018 to October 2023 was performed. Overall, 4,554 cases who underwent TJA in the hospital from 2018 to 2019, before the ASC opening, were compared with 3,221 cases who underwent TJA in the hospital from 2022 to 2023, post ASC opening. Univariate statistics were used to examine differences between the groups.

RESULTS: Post ASC opening, patients were older (69.8 vs. 66.8 years; P < 0.001) and a higher percentage of patients had an American Society of Anesthesiologists score of 3+ (50.6% vs. 41.7%; P < 0.001). Post ASC opening, more patients had 0-day length of stay (16.5% vs. 6.3%; P < 0.001), fewer were discharged to skilled nursing facility (6.9% vs. 9.3%; P = 0.002), and total charge was lower ($12,095.6 vs. $12,555.1 USD; P = 0.001).

CONCLUSION: Following the opening of an ASC, the acuity of TJAs performed in the hospital increased, but outcomes remained consistent or improved. The use of a coordinated clinical TJA pathway can potentially mitigate the adverse effects of increased hospital acuity after shifting appropriate patients to ASCs.

PMID:40257832 | DOI:10.5435/JAAOSGlobal-D-24-00262

J Am Acad Orthop Surg Glob Res Rev. 2025 Apr 21;9(4). doi: 10.5435/JAAOSGlobal-D-24-00288. eCollection 2025 Apr 1.

ABSTRACT

INTRODUCTION: Despite increasing numbers of female medical students, there is low female representation in orthopaedic residencies across the globe. It is unknown whether female representation in orthopaedics is lower than other specialties and whether regional presence relates to patient population or residency positions.

METHODS: The provider directory from the United States Centers for Medicare and Medicaid Services was reviewed from 2018 to 2023. Data for eight specialty subgroups (anesthesia, family medicine, gastroenterology, general surgery, internal medicine, obstetrics/gynecology, orthopaedics, and urology) were examined and grouped according to regions depicted by the Electronic Residency Application Service.

RESULTS: The mean percentage of female orthopaedic Centers for Medicare and Medicaid Services providers increased 1.49% over the 6-year period, at a markedly lower rate compared with general surgery (3.7%, P = 0.018) and obstetrics and gynecology (4.7%, P = 0.012). It was also lower compared with gastroenterology (3.73%), family medicine (3.52%), urology (3.10%), internal medicine (1.82%), and anesthesia (1.66%). Pacific-West and South-Atlantic regions demonstrated the greatest increase in representation. The number of female orthopaedic surgeons and growth in all orthopaedic surgeons in a state correlated with increased representation, whereas residency positions and patient population did not. Graduation year was 6 years later for female versus male students.

DISCUSSION: This study demonstrated a statistically significantly lower rate of change in female representation within orthopaedics compared with other specialties. Presence of practicing female orthopaedic surgeons was associated with growth in certain geographic regions. Future work should investigate factors associated with regional growth if specialties seek to move toward sex representation that reflects the United States population.

PMID:40257831 | DOI:10.5435/JAAOSGlobal-D-24-00288

JAMA Netw Open. 2025 Apr 1;8(4):e251608. doi: 10.1001/jamanetworkopen.2025.1608.

ABSTRACT

IMPORTANCE: State abortion policies may influence the practice locations of obstetricians and gynecologists (OBGYNs), having potentially significant implications for access to and quality of reproductive health care.

OBJECTIVE: To explore changes in OBGYN practice locations from before to after the Dobbs v Jackson Women’s Health Organization US Supreme Court decision in June 2022.

DESIGN, SETTING, AND PARTICIPANTS: National Plan & Provider Enumeration System data files were used in a descriptive cohort study assessing the association between state abortion policy environments and OBGYN practice locations in the US from January 1, 2018, to September 30, 2024, for all OBGYNs listed in the data files during the study period.

MAIN OUTCOME AND MEASURES: The number of OBGYNs practicing in states with differing abortion laws and the movement of OBGYNs between these states before and after the Dobbs decision.

RESULTS: The sample included 60 085 OBGYNs (59.7% women), of whom 3.8% were maternal-fetal medicine specialists and 12.9% were recent residency graduates. The mean increase in the per-quarter number of OBGYNs from before to after Dobbs was 8.3% (95% CI, 6.6%-10.1%) in states with total abortion bans, 10.5% (95% CI, 8.1%-13.0%) in states with gestational age limits or threatened bans, and 7.7% (95% CI, 5.9%-9.4%) in states with abortion protections. From the quarter immediately before Dobbs to the end of the study period, 95.8% of OBGYNs remained in protected states, 94.8% (95% CI, 94.3%-95.2%) remained in states threatening bans, and 94.2% (95% CI, 93.7%-94.7%) remained in states with abortion bans.

CONCLUSIONS AND RELEVANCE: In this descriptive cohort study, there were no significant differences in trends in OBGYNs’ practice locations across states with different abortion-related policy environments after the Dobbs decision. Although these findings do not provide insight into changes in the quality of care provided, they suggest that there are no major changes in the supply of OBGYNs associated with the Dobbs decision.

PMID:40257800 | DOI:10.1001/jamanetworkopen.2025.1608

JAMA Netw Open. 2025 Apr 1;8(4):e255954. doi: 10.1001/jamanetworkopen.2025.5954.

ABSTRACT

IMPORTANCE: Burnout among health care workers is a widespread concern in health care both before and since the COVID-19 pandemic, yet little is known about health care workers’ burnout levels across occupations and settings.

OBJECTIVE: To examine trends in burnout and professional stress reported among health care workers working at the US Veterans Health Administration (VHA) and identify occupations that experienced notable changes and the factors associated with changes.

DESIGN, SETTING, AND PARTICIPANTS: This survey study used a retrospective cohort design grouped by key factors associated with burnout and professional stress. Responses to an annual organization-wide survey at 140 medical centers from 2018 to 2023 were used.

EXPOSURES: Respondents self-reported on 2 burnout items (ie, “I feel burned out from my work” and “I worry that this job is hardening me emotionally”) from the Maslach Burnout Inventory during all study years and professional stress (moderate or lower vs high or extreme) from COVID-19 from 2020 to 2023.

MAIN OUTCOME AND MEASURES: Trends by occupation, telework status, and geographic region were examined, as well as the general pattern over time and the change in burnout and stress rates in the years following the start of the pandemic.

RESULTS: In 2018, the sample was 71.6% female, with an estimated mean (SD) age of 46.31 (12.11) years, and estimated mean (SD) VA tenure of 8.54 (7.33) years. Totals of health care worker respondents identified from 140 medical centers ranged from 123 271 in 2018 to 169 448 in 2023. Annual burnout rates were 30.4% for 2018, 31.3% for 2019, 30.9% for 2020, 35.4% for 2021, 39.8% for 2022, and 35.4% for 2023. Rates of professional stress from COVID-19 were 32.0% for 2020, 26.9% for 2021, 29.2% for 2022, and 21.4% for 2023. Both measures showed a decrease following the official public health emergency ending in 2023. Primary care physicians reported the highest burnout levels compared with other service areas, ranging from 46.2% in 2018 to 57.6% in 2022. Several service areas saw a relative increase of 10% or more in burnout between 2018 and 2023, with mental health, dental, and rehabilitation service employees reporting the highest increases in burnout rates over this time. Burnout levels for respondents who teleworked most of the time were lower than those for respondents who did not telework.

CONCLUSIONS AND RELEVANCE: In this survey study of VHA health care workers, burnout and professional stress decreased on average following the pandemic, but burnout levels remain elevated compared with prepandemic levels. The VHA has made several efforts to reduce burnout and stress, and results showed some promise, but exploration of ways to reduce burnout to prepandemic levels is needed.

PMID:40257797 | DOI:10.1001/jamanetworkopen.2025.5954

JAMA Netw Open. 2025 Apr 1;8(4):e255984. doi: 10.1001/jamanetworkopen.2025.5984.

ABSTRACT

IMPORTANCE: There is a paucity of data comparing patient-reported outcomes across surgeon age. Prior work has focused on adverse event rates for surgeon age across a variety of surgical procedures.

OBJECTIVE: To compare patient-reported outcomes, expectation fulfillment, and satisfaction measures after spine surgery across surgeon age categories.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at multicentered tertiary referral centers across Canada. Patients with degenerative conditions of the spine were enrolled in a national research network from January 2015 to August 2020. Patients were linked to a demographic survey distributed to spine surgeons who enrolled the patients. Elective surgery for degenerative spine conditions were followed up for a minimum of 1 year after operation. The data were analyzed in January 2024.

EXPOSURE: Surgeons were classified according to their age: younger (age 35-44 years), middle age (45-59 years), and older (≥60 years).

MAIN OUTCOME AND MEASURES: The primary outcomes were the Ostwestry Disability Index (ODI) and Neck Disability Index (NDI), numerical pain scores, expectation fulfillment, and overall satisfaction with spine surgery. Baseline demographic and clinical data and surgical procedure complexity were collected. Multivariate logistic regression models were employed, using generalized estimating equations to account for clustering within surgeons, to compare patient outcomes, expectation fulfillment, and satisfaction by surgeon age.

RESULTS: A total of 3421 patients (1236 [36.1%] aged 65 years or older; 1603 female [46.9%]) were included in the study for analysis, with 811 (23.7%) treated by younger surgeons, 1643 (48.0%) by middle-age surgeons, and 967 (28.3%) by older surgeons. There were 2857 procedures of the lumbar spine (83.5%). After accounting for patient demographic, clinical, surgical, and surgeon characteristics, there were no significant differences in disability and pain (ODI and NDI or pain score) at 12 months among younger (mean ODI and NDI score, 25.6; 95% CI, 24.3-26.9; mean pain score, 3.4; 95% CI, 3.2-3.6), middle-age (mean ODI and NDI score, 25.8; 95% CI, 24.9-26.8; mean pain score, 3.3; 95% CI, 3.2-3.4), and older (mean ODI and NDI score, 24.6; 95% CI, 23.4-25.8; mean pain score, 3.4; 95% CI, 3.2-3.6) surgeons. Patients treated by younger (adjusted odds ratio [aOR], 1.57; 95% CI, 1.02-2.40) and middle-age (aOR, 1.41; 95% CI, 1.06-1.86) surgeons reported having all their expectations fulfilled compared with older surgeons. Additionally, patients treated by younger surgeons reported higher satisfaction levels (aOR, 1.29; 95% CI, 1.01-1.69) compared with middle-aged and older surgeons.

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of patients who underwent elective spine surgery, there was no difference in outcomes by surgeon age at 1 year, but patients treated by younger surgeons reported higher levels of satisfaction and expectation fulfillment. These findings suggest that spine surgeons of all ages are a valuable resource given similar patient outcomes for all groups.

PMID:40257796 | DOI:10.1001/jamanetworkopen.2025.5984

JAMA Netw Open. 2025 Apr 1;8(4):e255999. doi: 10.1001/jamanetworkopen.2025.5999.

ABSTRACT

IMPORTANCE: Addressing social risk factors (eg, food insecurity) during the perinatal period has the potential to improve pregnancy-related outcomes. While social risk factor diagnosis codes (ie, International Statistical Classification of Diseases, Tenth Revision, Z codes) were introduced in 2016, adoption in claims has been slow. In 2018, Massachusetts’ Medicaid program implemented an accountable care organization (ACO) model, including a requirement that all ACOs screen for social risks.

OBJECTIVE: To assess claims documentation of Z codes in the perinatal period for Medicaid enrollees and evaluate changes in documentation following implementation of Massachusetts’ Medicaid ACO program.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used the Massachusetts All-Payer Claims Database to identify all Medicaid-enrolled live deliveries between January 31, 2016, and December 31, 2020, among people 18 years or older. A difference-in-differences (DiD) approach was used to compare Z code documentation before (2016-2017) vs after (2018-2020) ACO implementation for Medicaid ACO vs non-ACO deliveries. Data were analyzed between August 23, 2024, and January 27, 2025.

EXPOSURES: Attribution to a Medicaid ACO (vs non-ACO), determined based on whether an enrollee’s primary care physician participated in an ACO.

MAIN OUTCOMES AND MEASURES: The primary outcome was claims documentation of any Z code, measured separately for the prenatal period, 60 days post partum, 12 months post partum, and the full perinatal period. Secondary outcomes included documentation of specific Z codes (eg, housing, food insecurity).

RESULTS: The study sample included 79 293 deliveries (mean [SD] age of Medicaid-enrolled pregnant people, 28.2 [5.7] years), of which 69 535 (87.7%) were in a Medicaid ACO. Among all Medicaid deliveries from 2016 to 2020, 4.45% had claims documentation of a Z code in the prenatal period; 1.14%, within 60 days post partum; and 3.31%, within 12 months post partum. Within the prenatal period, Medicaid ACO implementation was associated with statistically significant increases in documentation of any Z code (DiD, 1.09 [95% CI, 0.38-1.80] percentage points [PP]), housing or economic circumstances codes (DiD, 1.52 [95% CI, 1.07-1.97] PP), and food insecurity codes (DiD, 0.58 [95% CI, 0.42-0.73] PP). The Medicaid ACO was associated with few changes in Z code documentation in the postpartum period.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of Medicaid-enrolled live births in Massachusetts, ACO implementation was associated with increased claims documentation of Z codes during the perinatal period, driven by increases in the prenatal period. While Z code documentation remains low, implementation of care delivery models that incentivize screening and documentation of social risk factors among Medicaid enrollees may help to identify the care needs of pregnant and postpartum people.

PMID:40257795 | DOI:10.1001/jamanetworkopen.2025.5999

JAMA Netw Open. 2025 Apr 1;8(4):e256069. doi: 10.1001/jamanetworkopen.2025.6069.

ABSTRACT

IMPORTANCE: Treatment retention for pregnant individuals with opioid use disorder (OUD) is critical, especially during the high-potency synthetic opioid (HPSO) era. Current data on the relationship between medication for opioid use disorder (MOUD) receipt in specialty substance use treatment facilities and retention are needed for this population.

OBJECTIVE: To examine the association between MOUD inclusion in treatment and 6-month treatment retention among pregnant individuals with OUD in publicly funded specialty treatment facilities during the HPSO era.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study pooled data from January 1, 2015, to December 31, 2021, from the Treatment Episode Data Set-Discharges, a national dataset managed by the Substance Abuse and Mental Health Services Administration that tracks annual discharges from state-licensed, publicly funded substance use treatment facilities. Individuals who were pregnant at the time of admission, reported an opioid (heroin, nonprescription methadone, or other opiates and synthetics) as their primary substance, and were discharged from ambulatory, nonintensive outpatient facilities were included. Data were analyzed November 2023 to April 2024.

EXPOSURE: MOUD inclusion in a treatment episode.

MAIN OUTCOMES AND MEASURES: The main outcome was treatment retention (length of stay >6 months vs ≤6 months). To account for the nonrandom assignment to MOUD, inverse probability of treatment-weighted logistic regression models were estimated adjusting for sociodemographics; substance use, mental health, and treatment history; treatment admission-related variables; census division; state policy characteristics; and year fixed effects.

RESULTS: Of 29 981 treatment episodes, most involved individuals aged 25 to 34 years (19 106 [63.7%]). Approximately two-thirds of 29 071 episodes in the final analysis (19 884 [68.4%]) included MOUD across all study years. From 2015 to 2021, MOUD inclusion in treatment episodes increased by 9.1 percentage points, from 65.0% to 74.1%. Treatment episodes with MOUD were associated with greater odds of 6-month treatment retention compared with those without MOUD (adjusted odds ratio, 1.86 [95% CI, 1.72-2.01]). This finding translated to an estimated 14.2 percentage point greater adjusted probability of 6-month retention among treatment episodes with MOUD (43.1%) vs those without it (28.9%).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of treatment episodes from ambulatory, nonintensive facilities, MOUD inclusion among pregnant individuals was associated with significant improvements in treatment retention. However, retention remained low during the HPSO era. These findings underscore the importance of MOUD in improving OUD-related outcomes in this high-risk population.

PMID:40257794 | DOI:10.1001/jamanetworkopen.2025.6069

JAMA Netw Open. 2025 Apr 1;8(4):e256193. doi: 10.1001/jamanetworkopen.2025.6193.

ABSTRACT

IMPORTANCE: Excess cryopreserved embryos present financial, logistical, and ethical constraints on patients and fertility clinics that are further complicated by the recently evolving US judicial landscape that may alter the legal status of frozen embryos and limit disposition options. It is therefore important to consider limiting the number of supernumerary embryos created from fresh donor oocytes.

OBJECTIVE: To determine the optimal number of fresh donor oocytes to fertilize to achieve 1 live birth while minimizing supernumerary blastocysts.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from recipients of fresh donor oocytes at member clinics of the Society for Assisted Reproductive Technology Clinic Outcomes Report System (SART CORS) between January 1, 2016, and December 31, 2020. Data were analyzed between August 2023 and June 2024.

MAIN OUTCOMES AND MEASURES: The number of supernumerary blastocysts for a given number of fresh donor oocytes retrieved.

RESULTS: There were 9395 fresh donor oocyte recipients included. The median (IQR) oocyte donor age at oocyte retrieval was 26 years (24-28 years), and the median (IQR) patient age at cycle start was 42 years (38-45 years). The median (IQR) number of oocytes retrieved was 20 (14-28), fertilized oocytes (2 pronuclei [2PN]) was 11 (7-17), usable embryos was 6 (3-10), and supernumerary blastocysts was 5 (2-8). When patients were divided evenly into quartiles based on the number of fresh donor oocytes retrieved (14 or fewer, 15 to 20, 21 to 28, 29 or more), it was associated with a significant increase in the number of cryopreserved supernumerary blastocysts (median [IQR] blastocysts by quartile: 2 [1-4] vs 4 [2-7] vs 6 [3-9] vs 9 [4-14], respectively; P < .001). However, the live birth rate was lower only for those in the first quartile receiving 14 or fewer oocytes (50.8% [1207 of 2376] vs 64.1% [1497 of 2336] vs 67.9% [1631 of 2401] vs 67.9% [1550 of 2282]; P < .001).

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of fresh donor oocyte cycles, the number of supernumerary blastocysts to achieve 1 live birth for a given number of fresh donor oocytes exposed to sperm was approximated, which may be valuable for counseling patients.

PMID:40257793 | DOI:10.1001/jamanetworkopen.2025.6193

JAMA Pediatr. 2025 Apr 21. doi: 10.1001/jamapediatrics.2025.0560. Online ahead of print.

ABSTRACT

IMPORTANCE: Toddler’s fractures (TF) of the tibia are commonly treated with casts and fracture clinic follow-up. However, a prefabricated removable boot might be sufficient and reduce unnecessary follow-up.

OBJECTIVES: To determine whether pain in children with TF treated with a removable boot is not worse than those managed with a circumferential cast at 4 weeks postinjury.

DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, multicenter, assessor-blinded, noninferiority randomized clinical trial was conducted between October 2019 and February 2024 at 4 urban, tertiary care, pediatric Canadian emergency departments. Children aged between 9 months and 4 years with a radiograph-visible TF were eligible for inclusion.

INTERVENTIONS: Prefabricated walking boot for up to 3 weeks (removable at caregivers’ discretion) vs circumferential cast immobilization (site standard of care) for 3 weeks.

MAIN OUTCOMES AND MEASURE: The primary outcome was pain score, measured with the Evaluation Enfant Douleur (EVENDOL) scale (maximum score: 15). Additional outcomes included return to baseline activities, complications, parental satisfaction and care burden.

RESULTS: In 129 enrolled children, the mean (SD) age was 2.2 (0.8) years, and 56 children (43%) were female. Of these, 118 children (92%) completed the 4-week follow-up, and the boot (n = 64) vs cast (n = 54) groups demonstrated mean (SD) EVENDOL pain scores of 1.21 (1.54) and 1.76 (2.13), respectively (difference, -0.55; 95% CI, -1.23 to 0.13). The percentage of participants who returned to baseline activities “almost all of the time” was 49 of 64 children (77%) in the boot group and 22 of 54 (41%) in the cast group (difference, 36%; 95% CI, 9%-63%). Skin complications occurred in both groups (boot: 46 total complications [72%], with 5 stage 1 pressure sores; cast: 27 total complications (50%), with 1 pressure sore]; difference, 22%; 95% CI, -6% to 50%). There was no statistically significant difference in the percentage of caregivers who were satisfied or very satisfied with the treatment (difference, 9%; 95% CI, -24% to 43%). Fewer caregivers reported bathing care burden (difference, -32%; 95% CI, -47% to -18%) and challenges with carrying the child (difference, -21%; 95% CI, -27% to -15%) in the boot vs cast group.

CONCLUSIONS AND RELEVANCE: In this multicenter randomized clinical trial examining the management of children with TF, a removable boot without physician follow-up was noninferior to circumferential casting with respect to pain recovery. While there was a clinically relevant but not statistically significant trend toward more skin complications in the boot group, there was no difference in caregiver satisfaction, and the boot strategy demonstrated reduced childcare-related challenges.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03971448.

PMID:40257790 | DOI:10.1001/jamapediatrics.2025.0560