O2156: Who’s Being Left Out? Hispanic Underrepresentation in the Pediatric Orthopaedic Literature

Background: The inclusion of minority populations as subjects in clinical research studies ensures the generalizability of findings. The purpose of this study was to investigate the representation of minority groups in pediatric orthopaedic studies conducted in the U.S. over multiple decades.

Methods: Pediatric orthopaedic studies conducted entirely in the United States and published in years 2000, 2005, 2010, 2015, 2020, and 2023 were reviewed systematically. Pediatric studies queried in Web of Science were selected from 11 leading orthopaedic surgery journals. All prospective studies and up to 100 of the most cited retrospective studies in each year were included in the dataset. Studies that were not open to all sex, race, and ethnic groups were excluded. The number of subjects in each racial or ethnic group were aggregated across studies, and proportions were calculated relative to the total number of subjects. The proportions were compared to the U.S. Census using a Z-test.

Results: 773 studies were included in the analysis with a total of 185,172 subjects enrolled across all studies. Only 92 (11.9%) studies reported the subjects’ race while 73 (9.4%) reported ethnicity. The proportion of studies that reported race and ethnicity was lowest in 2005 (3.5% and 1.7%, respectively). The proportion of studies reporting race increased steadily after 2005, peaking at 32% in 2023. Studies reporting ethnicity increased to 3.8% in 2010, then decreased to 2.9% in 2015 before increasing each subsequent study year, peaking at 28.7% in 2023 (Figure 1). Among studies reporting ethnicity (n=46,705 subjects), Hispanic subjects were significantly underrepresented when compared to the U.S. Census (16.2% vs. 25.8%, p < 0.001) (Figure 2). Additionally, 45 (60.8%) out of the 73 studies reporting ethnicity incorrectly classified Hispanic identity as a race rather than an ethnicity. Notably, only 20 studies (2.6%) reported the inclusion or exclusion of non-English speaking patients and only 6 studies (1.3%) explicitly indicated the enrollment of non-English speaking subjects. When examining studies reporting race (n = 51,629 subjects), Black subjects were not underrepresented when compared to the Census (16.9% vs 13.5%, p < 0.001). White subjects were proportionally represented compared to the Census (59.4% vs 59.2%, p = 0.476).

Conclusion: Hispanic subjects were significantly underrepresented in pediatric orthopedic literature, highlighting the need for improved diversity within clinical research. Alongside the underrepresentation and misclassification of certain ethnic groups, the lack of race and ethnicity reporting further limits the generalizability of study findings. Few studies documented the inclusion of non-English speakers, indicating potential language-based disparities in study enrollment and thus potentially contributing to the lack of Hispanic representation. Until pediatric orthopedic research better reflects U.S. demographics, researchers and surgeons must evaluate the applicability of study findings to their patient populations and work toward improving diversity and inclusion in clinical studies.