Introduction: When orthopaedic surgeons begin or relocate their careers, they must communicate effectively about their instrumentation and equipment needs. ‘Preference Cards’ or ‘Pick Lists’ are generated by and for individual surgeons at the time of hire and can be updated over time to reflect their needs for common cases. Currently, such decisions are made without formal guidance or preparation. Body: Surgeons must consider and plan for their operating room needs. Health system and industry factors affect these decisions, as do surgeons' unique interests, preferences, and biases. Orthopaedic surgeons currently face challenges: formal education is deficient in this space, material and reprocessing costs are not transparent, relationships and contracts with industry are complex, and few health systems have mechanisms to support preference card optimization. This complex landscape influences utilization decisions and leaves opportunities for integration, collaboration, and innovation. Summary: Choices about instrument and resource utilization in the OR have wide-reaching impacts on costs, waste generation, OR efficiency, sterile processing, and industry trends. Surgeons and their teams have much to gain by making intentional choices and pursuing both individual and systematic improvements in this space.

Background: There are few reports on the surgical management of early-onset scoliosis (EOS) associated with Marfan syndrome (MFS). Affected patients tend to have more rapid curve progression than those with idiopathic EOS, and their course is further complicated by medical comorbidities. As surgical techniques and implants for growing spines become more widely applied, this study seeks to better delineate the safety and efficacy of growth-friendly spinal instrumentation in treating this population. Methods: A prospective registry of children treated for EOS was queried for MFS patients treated between 1996 and 2016. Forty-two patients underwent rib-based or spine-based growing instrumentation and were assessed on preoperative, surgical, and postoperative clinical and radiographic parameters including complications and reoperations. Subgroup analysis was performed based on spine-based versus rib-based fixation. Results: Patients underwent their index surgery at a mean age of 5.5 years, when the major coronal curve and kyphosis measured 77 and 50 degrees, respectively. Over half were treated with traditional growing rods. Patients underwent 7.2 total surgical procedures—4.7 lengthening and 1.9 revision surgeries not including conversion to fusion—over a follow-up of 6.5 (±4.1) years. Radiographic correction was greatest at index surgery but maintained over time, with a final thoracic height measuring 23.8 cm. Patients experienced a mean of 2.6 complications over the course of the study period; however, a small group of 6 patients experienced ≥6 complications while over half of patients experienced 0 or 1. Implant failures represented 42% of all complications with infection and pulmonary complications following. Conclusions: This is the largest report on patients with EOS and MFS. All subtypes of growth-friendly constructs reduced curve progression in this cohort, but complications and reoperations were nearly universal; patients were particularly plagued by implant failure and migration. Further collaborations are needed to enhance understanding of optimal timing and fixation constructs for those with MFS and other connective tissue diseases.

Removal of hardware (ROH) represents the third most common procedure performed by pediatric orthopaedic surgeons. When indicating patients, surgeons must balance the benefits of ROH against its burdens, including patient risk, cost, access, and waste. This study aims to quantify and characterize the waste generated in pediatric ROH surgery to better understand how it contributes to healthcare waste and associated impacts on patient and population health. A total of 10 pediatric ROH cases were audited at a tertiary care pediatric hospital between January and May 2025. All intraoperative waste was collected, categorized, and weighed. Waste was classified as unused, used but not visibly soiled, or used and visibly soiled. The presence or absence of recycling or other disposal labels was recorded. Waste was evaluated by case and collectively to assess trends, with subgroup analysis performed by waste stream, labeling, and usage. An average of 6.8 kg of solid waste was generated per case, with top contributors being drapes (1.2 kg) and hard plastics (1.14 kg). Waste ranged from 5.3 to 8.1 kg per case. Only 11% (0.24 kg) of plastic waste items included recycling labels, while 7.76 kg of waste went unused (ranging from 5% to 22% of waste per case). Analysis of inter-surgeon variation identified gown and drape quantities as potential targets for waste reduction. Pediatric ROH generates significant waste and cost. Expanding these findings to ROH generally, annual projected waste attributable to ROH in pediatric orthopaedic patients would exceed 450,000 pounds in the United States each year. Landfill waste reduction may be significantly facilitated by greater inclusion of clear recycling labels by manufacturers, regular revision of procedure packs, and avoidance of excessive draping. Surgeons should strive to balance potential harms and surgical risks with the benefits of ROH in each case to promote high-value care. (1) Pediatric hardware removal surgeries generate significant intraoperative waste, averaging 6.8 kg per case. (2) Over 13% of discarded materials go unused, suggesting that a portion of waste is excessive and unnecessary to the provision of patient care. (3) Only 11% of plastic waste was observed to have recycling labels, underscoring logistical hurdles to appropriately sorting operating room waste. (4) Extrapolated nationally, pediatric ROH procedures are estimated to contribute more than 450,000 pounds of waste annually in the United States, raising important considerations for high-value, sustainable care at scale. (5) Interventions such as clearer labeling, pack optimization, materials innovation, and re-evaluation of procedural indications could meaningfully reduce environmental and financial burdens at scale. Level II

Background: Children are particularly vulnerable to the effects of environmental degradation and pollution, particularly those living in low-income areas. Although interest in reducing healthcare's environmental impact is growing, systemic top-down reforms often face substantial barriers that limit progress. By contrast, surgeon-led, bottom-up initiatives have been highly effective in improving patient outcomes and reducing surgical cost. This study evaluates the opportunities and challenges encountered by pediatric orthopaedic surgeons in implementing sustainable practices within their local health systems. Methods: Pediatric orthopaedic surgeons from the United States and Europe were recruited using snowball sampling and interviewed using a semistructured questionnaire. Interviews were recorded, and transcribed verbatim then coded and analyzed using thematic analysis. Geographic subgroup analyses were performed. Results: Interviews were conducted with 25 surgeons. All participants reported personal environmentally conscious personal behaviors. Only 4 American and 3 European surgeons stated their health systems prioritize sustainability. Education and awareness campaigns were identified as top enablers of sustainable change among surgeons, with financial incentives and promotion of temporal efficiency perceived as health system enablers. Intergenerational differences and lack of transparency were identified as challenges and sources of friction to change, both between surgeons and with hospital leadership. Conclusions: Pediatric orthopaedic surgeons share a desire to promote environmental stewardship but are challenged by surgical culture, time and resource constraints, and lack of knowledge and awareness. Sustainability efforts contribute to tensions between individual and organizational values, with implications for health system allegiance, physician burnout, and distrust related to greenwashing. Attention and action to control the environmental harm generated by healthcare activities will shape future pediatric population health outcomes. Level of Evidence: Level III qualitative study (descriptive study, narrowly defined study population). See Instructions for Authors for a complete description of levels of evidence.