bluuebunny/crossref_metadata_2025 huggingface dataset:
Rib Fracture Map in High-Energy Injuries
Authors: Thomas Claire N. , Lindquist Timothy J. , Schroder Lisa K. , Cole Peter A.
Published: February 2023

Objectives:

To use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns.

Methods:

Patients between the ages of 18 and 48 years presenting to a Level 1 academic trauma center with ≥2 rib fractures after a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method, and subsequent frequency and heat maps were created.

Results:

Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the rib cage.

Conclusions:

Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury after trauma.

Level of Evidence:

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Biomechanical Evaluation of Transverse Patella Fracture Fixation Using Headless Screws: A Comparison of Suture Versus Cable as a Tension Band
Authors: Bric Justin D. , Martin Jill M. , McGrady Linda M. , Wang Mei , Schmeling Gregory J.
Published: February 2023

Objectives:

To explore the performance of headless screws with FiberWire Suture as a tension band and headless screws with a mini-cable tension band in patella fixation.

Methods:

A transverse osteotomy was created in 6 matched pairs of fresh-frozen cadaver knee joints. One knee was randomly assigned to receive fixation with headless screws plus a cable tension band while the other was fixed with headless screws plus a suture tension band. Using a servo-hydraulic material testing system, the specimens were first tested nondestructively under 20% of the reported mean failure load with a standard technique of cannulated screws with tension band wiring. The specimen was then loaded to 1000 N to test the construct's failure strength. All tests were run under displacement-control with loading threshold. A motion analysis system was used to track the interfragmentary motion to assess fixation stability.

Results:

In the nondestructive loading test, gap displacement under 150 N was 0.10 mm or less for 11 of 12 specimens, and the difference between the 2 groups was not statistically significant. In the destructive test, 3 of 12 specimens maintained reduction (gap <2 mm) at the maximum load of 1000 N. Of the failed specimens, the mean strength was 648 ± 185 N for suture and 784 ± 228 N for cable.

Conclusions:

There was no significant difference in fixation strength or subfailure fragment displacement between the suture and cable tension band techniques when using headless screws.
The Association Between Preoperative International Normalized Ratio Values and Postoperative Outcomes including Mortality in Geriatric Femoral Neck Fractures Treated With Hemiarthroplasty
Authors: Uvodich Mason E. , Dugdale Evan M. , Duong Stephanie Q. , Cancio-Bello Alexandra , Sems Stephen A. , Yuan Brandon J.
Published: February 2023

Objectives:

To evaluate the association between preoperative international normalized ratio (INR) and postoperative mortality and other outcomes after hemiarthroplasty for geriatric femoral neck fractures.

Design:

Retrospective cohort study.

Setting:

A single Level-I trauma center.

Patients/Participants:

Patients ≥55 years of age with OTA/AO 31B proximal femur fractures [1556 patients (1616 hips)]

Intervention:

Hip hemiarthroplasty.

Main Outcome Measurements:

Ninety-day mortality, postoperative transfusion within 72 hours, and 90-day postoperative outcomes.

Results:

Adjusting for confounders, the association of preoperative INR and 90-day mortality was not statistically significant [hazard ratio (HR): 1.3; 95% confidence interval (CI): 0.97, 1.8; P = 0.08]. Dementia (HR: 1.9; 95% CI: 1.4–2.6; P < 0.001), Charlson Comorbidity Index (HR: 1.1; 95% CI: 1.1–1.2; P < 0.001), and age by decade (HR: 1.4; 95% CI: 1.1–1.8; P = 0.002) were associated with 90-day mortality. Increasing INR was significantly associated with blood transfusion [odds ratio (OR) 1.4; 95% CI 1.03–1.6; P = 0.031]. Preoperative hemoglobin <10 g/dL (OR 13.7; 95% CI 8.4–23.3; P < 0.001) was also associated with a postoperative transfusion, whereas intraoperative tranexamic acid use (OR 0.3; 95% CI 0.2–0.5; P < 0.001) was inversely associated with postoperative transfusion rate. INR was associated with superficial wound infection (HR: 2.0; 95% CI: 1.1–3.7; P = 0.02) and noninfected wound complications (HR: 1.6; 95% CI: 1.1–2.4; P = 0.007). Risk of superficial infection increased when INR was >1.8.

Conclusion:

When controlling for confounders, preoperative INR was not significantly associated with 90-day mortality. Underlying medical conditions contribute to postoperative mortality more than an elevated INR. However, INR is associated with superficial wound complications. This risk becomes statistically significant as INR rises above 1.8.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Academic Productivity in Orthopaedic Traumatology Correlates Positively With Industry Compensation
Authors: Flanagan Christopher D. , Walson Francis T. , Dolorit Maykel , Schmidt Christian M. , Frankle Mark A. , Mir Hassan R.
Published: February 2023

Objective:

To determine the association between academic productivity and industry compensation among Orthopaedic Traumatologists.

Design:

Retrospective cohort study.

Setting:

Review of the Centers for Medicaid and Medicare Services Open Payments program from 2016 to 2020.

Participants:

1120 Orthopaedic Traumatologists.

Main Outcome Measurements:

To determine if an Orthopaedic Traumatologist's h-index and m-index, as generated from Web of Science, Scopus, and Google Scholar User Profile databases, correlate with total payments from medical industry in 7 categories, including Royalties and Licensing Fees, Consulting Fees, Gifts, Honoraria, and 3 unique Speaking Fee delineations.

Results:

Of 30,343 Orthopaedic Surgeons in the Open Payments program, 1120 self-identified with the Orthopaedic Trauma taxonomy. From 2016 to 2020, 499 surgeons (44.6%) received compensation in one of the eligible categories, most commonly from Consulting Fees (67.3%), though payments from Royalties provided the greatest gross income (70.4%). Overall, for all 1120 surgeons, h-index (r = 0.253, P < 0.001) and m-index (r = 0.136, P < 0.01) correlated positively with mean annual total industry compensation. The highest annual compensation group had higher h-index ($0 vs. $1–$1k vs. $1k–$10k vs. >$10k: 5.0 vs. 6.6 vs. 9.6 vs. 16.8, P < 0.001) and m-index ($0 vs. $1–$1k vs. $1k–$10k vs. >$10k: 0.48 vs. 0.60 vs. 0.65 vs. 0.89, P < 0.001) scores than either the intermediate or the no compensation groups. Multivariable analysis of factors associated with increased industry compensation, including H-index and years active, identified both as having significant associations with physician payments [H-index (B = 0.073, P < 0.001); years active (B = 0.059, P < 0.001)]. Subgroup analysis of the highest annual earner group (>$250k/year) also demonstrated the highest overall h-index (27.6, P < 0.001) and m-index (1.23, P = 0.047) scores, even when compared with other high-earners ($10k–$50k, $50k–$250k). Overall, each increase in h-index above an h-index of 3 was associated with an additional $1722 (95% CI: $1298–2146) of annual industry compensation.

Conclusions:

Academic productivity metrics have a positive association with industry compensation for Orthopaedic Traumatologists. This may highlight a potential ancillary benefit to scholarly efforts.
Changes of the lower limb deformity in children with FGF23-related hypophosphatemic rickets treated with Burosumab: a single-center prospective study
Authors: Sawamura Kenta , Hamajima Takashi , Izawa Masako , Kaneko Hiroshi , Kitamura Akiko , Kitoh Hiroshi
Published: February 2023

Fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets (HPR) are characterized by excess circulating FGF23 and low concentrations of serum phosphorus, leading to skeletal manifestations of rickets, including lower limb deformities in children. The objective of this study was to prospectively evaluate whether treatment with burosumab, a monoclonal antibody neutralizing FGF23, changes lower limb deformities in HPR. Patients who were 15 years of age or younger with a documented clinical diagnosis of HPR, receiving burosumab treatment, and had a minimum follow-up period of one year were included in the study. Various radiological parameters were measured from anteroposterior and lateral radiographs of the bilateral lower limbs taken before administration of burosumab and at 3, 6, 9, and 12 months after treatment for evaluation of lower limb alignment. Outcome was classified as ‘improvement’, ‘no change’, or ‘deterioration’ after 12 months treatment. Five patients (10 limbs), with a mean age of 7.2 years were included in this study. The outcome was ‘improvement’ in six limbs and ‘no change’ in four limbs. There were no limbs of ‘deterioration’. The improvement in deformities after treatment was more significant in younger patients who originally showed severe lower limb deformities. Older patients with milder deformities, on the other hand, showed less improvement. Burosumab therapy favorably changed lower-limb malalignment in children with FGF23-related HPR.
The Dimeglio Olecranon Method Is Reliable in Diverse, Contemporary Patients for Predicting Future Growth
Authors: O’Marr Jamieson M. , Amick Michael , Yu Kristin E. , Cui Jonathan , Hurley Margaret , Ruzgar Nensi , Greene Janelle D. , Cooperman Daniel R.
Published: February 2023

Background:

Growth assessment, which relies on a combination of radiographic and clinical markers, is an integral part of clinical decision-making in pediatric orthopaedics. The aim of this study is to evaluate the accuracy and reliability of the Diméglio skeletal age system using a modern cohort of pediatric patients.

Methods:

A retrospective review was undertaken of all patients at a large tertiary pediatric hospital who had lateral forearm radiographs (before the age of 14 y for females and before 16 y for males). In addition, all of these patients had height measurements within 60 days of their forearm x-ray and a final height listed in their medical records. The x-rays were graded by 5 reviewers according to the Diméglio skeletal age system. Inter and intraobserver reliability was tested.

Results:

One hundred forty-seven patients with complete radiographs and height data were evaluated by 5 observers ranging in experience from medical students to senior pediatric orthopaedic surgeons. The Diméglio system demonstrated excellent reliability across levels of training with an intraobserver correlation coefficient of 0.995 (95% CI, 0.991-0.997) and an interobserver correlation coefficient of 0.906 (95% CI, 0.857-0.943). When the Diméglio stage was paired with age and sex in a multivariable linear regression model predicting the percent of final height, the adjusted R
2 was 78.7% (model P value <0.001), suggesting a strong relationship between the Diméglio stage (plus age and sex) and percent of final height.

Conclusion:

This unique approach to maturity assessment demonstrates that the Diméglio staging system can be used effectively in a modern, diverse patient population.

Level of Evidence:

Level II; retrospective cohort study.
Patient-reported Outcomes of Adolescents Treated With Guided Growth to Correct Idiopathic Genu Valgum
Authors: Carroll Kristen L. , Stotts Alan K. , Pearson Olivia C. , MacWilliams Bruce A.
Published: February 2023

Background:

Guided growth is commonly used to treat frontal plane alignment deformities in skeletally immature individuals. Treatment aims are to correct the biomechanical loading of the knee and to avoid more invasive surgery that would be required after skeletal maturity. There is little published evidence of pain perception or functional limitations in this population. In addition, the intervention has the potential to worsen pain and function with hardware implantation, and symptoms may not fully resolve after removal. Understanding of pain and function limitations in this population is important to guide the clinical expectations.

Methods:

Individuals with idiopathic knee genu valgum who underwent hemiepiphysiodesis with tension plate constructs were identified through a medical records database search. Patient-reported outcomes measurement information system Physical Function/Mobility and Pain Interference domain scores were assessed before hemiepiphysiodesis, immediately before hardware removal, and after hardware removal. Radiographs were also assessed at these times to record the zones and angles of deformity and correction.

Results:

Twenty-eight subjects (53 operative limbs) contributed to the analysis. Mobility and pain interference as measured by the patient-reported outcomes measurement information system were below typical values in a small percentage of the population studied, only 3.6% scored in the moderate and none in the severe categories for both domains. Valgus by radiographic zone was corrected in all patients without significant rebound at follow-up. Compared with preoperative levels, mobility scores improved before hardware removal. Pain Interference scores improved both before hardware removal and at the final follow-up.

Conclusions:

Frontal plane knee deformities in the idiopathic population do not cause pain or limit mobility in most subjects. This is critical information, emphasizing that surgical decisions may be made based on the deformity alone, presence of symptoms, and possible future morbidity secondary to valgus deformity. If surgery is postponed because an individual is asymptomatic, the window for correction with guided growth may be lost. Individuals undergoing hemiepiphysiodesis can expect that their pain and function will not be worse during the time that hardware is in place and that surgery is likely to improve any pain they may be experiencing.

Level of Evidence:

Level III; retrospective comparative study.
Hydrotherapy for Patients With External Fixation: Effect on Infectious Events
Authors: Goldman Vladimir , Weiss Patrice L. , Weil Yehuda , Eylon Sharon
Published: February 2023

Background:

Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols.

Methods:

In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol.

Results:

The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment).

Conclusions:

This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility.

Level of Evidence:

Level III; retrospective, comparative study.
Prediction of Surgical Outcomes of Radial Polydactyly From the Wassel-Flatt Type and Symmetry of Duplication
Authors: Chen Po An , Sun Wei Chun , Chen Brian Po Rong , Lee Wei Chun , Kao Hsuan Kai , Yang Wen E. , Chang Chia Hsieh
Published: February 2023

Background:

The Wassel classification is commonly used for cases of radial polydactyly but has not been used to predict surgical outcomes. This study aimed to investigate the predictive factors of surgical outcomes using the Wassel type and symmetry of duplication.

Methods:

Forty-five patients with 47 radial polydactylies were reviewed using the Japanese Society for Surgery of the Hand (JSSH) scores 4.6 years after minor thumb excision and reconstructive surgery. The symmetry index was defined as the metaphyseal width ratio of the minor thumb to the dominant thumb. The relationships between the JSSH scores and operation age, sex, side, follow-up duration, Wassel type, symmetric index, divergent angle, and joint angulation were analyzed by linear regression.

Results:

The mean JSSH score of the 47 thumbs was 18.3 points (range, 15–20). Five thumbs had fair or poor outcomes (scores <17), all of which were Wassel type IV. The hypoplastic type had a better JSSH score (19.4) than other Wassel types. The symmetric index had a negative relationship with JSSH scores, especially for Wassel type IV (r=−0.68, P=0.001). Linear regression revealed that the symmetric index was the only independent factor significantly associated with JSSH scores among Wassel type IV polydactylies (P<0.05). The receiver operating characteristic curve suggested a symmetric index <0.74 could predict good or excellent outcomes.

Conclusion:

The symmetry of the 2 duplicated thumbs is an important factor for surgical outcomes. The Wassel type IV polydactylies with a symmetric index >0.74 are at greater risk of fair or poor outcomes after excision and reconstruction, and further studies are warranted to confirm whether the Bilhaut-Cloquet procedure is a good choice.

Level of Evidence:

Level IV—Case-control study.
Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases
Authors: Ferraro Samantha L. , Batty Miles , Heyworth Benton E. , Cook Danielle L. , Miller Patricia E. , Novais Eduardo N.
Published: February 2023

Background:

Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents.

Methods:

A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms.

Results:

Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019.

Conclusions:

Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries.

Level of Evidence:

This is a level III retrospective study.
Perioperative Nutritional Supplementation Decreases Wound Healing Complications Following Elective Lumbar Spine Surgery: A Randomized Controlled Trial
Authors: Saleh Hesham , Williamson Tyler K. , Passias Peter G.
Published: February 2023

Background.

The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality.

Purpose.

To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery.

Study Design/Setting.

A prospective randomized controlled trial.

Materials and Methods.

Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes.

Results.

One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P<0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P<0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P=0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P=0.04).

Conclusions.

Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery.

Level of Evidence.

I.
Surgical Treatment of Scoliosis Lenke Type 5, Anterior Versus Posterior, Which Approach is Better?
Authors: Liang Weishi , Han Bo , Sun Duan , Hai Yong , Yin Peng , Liu Yuzeng , Yang Jincai
Published: February 2023

Study Design.

Systematic review and meta-analysis.

Objective.

This study aimed to compare the radiographical and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in Lenke type 5 adolescence idiopathic scoliosis.

Summary of Background Data.

PSF has been the standard operation for adolescence idiopathic scoliosis. ASF can also achieve a good curve correction effect with fewer fusion segments and minor invasion of paraspinal structures.

Materials and Methods.

A systematic literature research was conducted in PubMed, Embase, Cochrane Library, and Web of Science. Use meta-analysis to compare the changes of thoracolumbar/lumbar and thoracic curves and other important outcomes between ASF and PSF.

Results.

A total of 427 ASF and 392 PSF patients from 12 studies were included. There was no significant difference in the correction degree of thoracolumbar/lumbar and thoracic curve between ASF and PSF (P>0.05), except for PSF had more compensatory correction degree of thoracic curve at postoperation (P<0.05). Besides, the loss of correction in thoracic curve in PSF at the last follow-up was significantly less than that in ASF (P<0.05). PSF presented larger change values of thoracic kyphosis and lumbar lordosis at the last follow-up (P<0.05). PSF showed a better effect in correcting trunk shift distance at the postoperation (P<0.05) but less trunk shift distance correction from postoperation to last follow-up (P<0.05). There was no significant difference in the incidence of proximal junctional kyphosis and estimated blood loss between the two approaches (P>0.05). Moreover, ASF showed fewer fusion segments, but longer operation and hospital stay time (P<0.05).

Conclusion.

ASF is capable of achieving similar correction in coronal curve and balance as PSF with fewer fusion segments. Spine surgeons should select an appropriate approach tailored to individual patients needs while considering procedural risks and benefits.

Level of Evidence.

Level II.
Health-Related Quality of Life of Patients With Adolescent Idiopathic Scoliosis at Least 40 Years After Surgery
Authors: Akazawa Tsutomu , Kotani Toshiaki , Sakuma Tsuyoshi , Iijima Yasushi , Torii Yoshiaki , Ueno Jun , Umehara Tasuku , Iinuma Masahiro , Yoshida Atsuhiro , Tomochika Ken , Orita Sumihisa , Eguchi Yawara , Inage Kazuhide , Shiga Yasuhiro , Nakamura Junichi , Matsuura Yusuke , Suzuki Takane , Niki Hisateru , Ohtori Seiji , Minami Shohei
Published: February 2023

Study Design.

Retrospective study.

Objective.

The aim was to clarify the health-related quality of life (QOL) of patients who had adolescent idiopathic scoliosis (AIS) at a minimum of 40 years after surgery.

Summary of Background Data.

The postoperative health-related QOL of middle-aged patients with AIS has been reported to be good, but that of middle-aged and older patients with AIS has yet to be completely explored.

Materials and Methods.

We included 179 patients with AIS who underwent spinal fusion(s) between 1968 and 1982. We conducted three surveys in 2009, 2014, and 2022. Patients self-administered both the Scoliosis Research Society-22 and the Roland-Morris Disability questionnaires three times (in 2009, 2014, and 2022) and the Oswestry Disability Index (ODI) questionnaire was self-administered in 2014 and 2022. We considered patients who responded to all three surveys in 2009, 2014, and 2022.

Results.

For the Scoliosis Research Society-22 questionnaires, no significant differences were detected among the three time points (2009, 2014, and 2022) for total scores, function domain, pain domain, self-image domain, mental domain, or satisfaction domain. The results of the Roland-Morris Disability Questionnaire were also not significantly different among the surveys over time. The ODI questionnaires revealed a significant worsening of the 2022 results compared with the 2014 results. Eight patients (29.6%) who had an ODI deterioration of 10% or more had numerically fewer mobile lumbar disks than those with <10% deterioration of the ODI, although the difference did not reach statistical significance.

Conclusion.

Among patients with AIS who underwent spinal fusion(s) between 1968 and 1982, we found health-related QOL to be maintained over the last 13 years. Relatively good QOL was appreciated in this population of patients who are now middle-aged and older.
Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis
Authors: Tortolani Paul Justin , Lucas Sarah L. , Pivazyan Gnel , Wang Wenhai , Cunningham Bryan W.
Published: February 2023

Study Design.

Cadaveric study.

Background Context.

Transforaminal lumbar interbody fusion (TLIF) represents a well-documented operative surgical technique utilized in the management of lumbar pathology requiring interbody arthrodesis. The microstructural properties of impaction grafting (IG) after TLIF has yet to be reported.

Purpose.

The current study was designed first, to quantify the degree, to which IG augmentation would increase intrabody final bone volume and bone graft surface contact area with the endplates; secondly to quantify the volumes of locally harvested bone and bone needed for maximal impaction.

Materials and Methods.

Three cadaveric lumbosacral spine specimens were dissected into L1-L2, L3-L4, and L5-S1 motion segments for a total of 9 functional spinal units. Each interbody unit underwent a TLIF procedure with the implantation of an interbody spacer containing autogenous morselized bone. Microcomputed tomography scans were then performed to evaluate the final bone volume and bone surface contact area (BSCA). Subsequently, IG augmented TLIF procedure was carried and microcomputed tomography scans were repeated.

Results.

IG augmentation of TLIF exhibited a 346% increase in final bone volume (TLIF: 0.30 ± 0.07 cm3; IG-TLIF: 1.34 ± 0.42 cm3; P < 0.05) and a 152% increase in BSCA (TLIF: 45.06 ± 15.47%; IG-TLIF: 68.28 ± 6.85%; P < 0.05) when compared with the nonimpacted TLIF treatment. In addition, the average amount of autogenous bone collected was 8.21±2.08 cm3, which sufficiently fulfilled the requirements for bone grafting (TLIF: 1.23 ± 0.40 cm3; IG-TLIF 6.42 ± 1.20 cm3).

Conclusions.

IG augmentation of TLIF significantly improved final bone volume in the disc space and BSCA with vertebral endplates in vitro.

Clinical Significance.

Greater BSCA and final volume of bone graft reflect promisingly on their potential to increase fusion rates. Clinical studies will be needed to corroborate these findings.
Optimizing the Definition of Proximal Junctional Kyphosis: A Sensitivity Analysis
Authors: Lovecchio Francis , Lafage Renaud , Line Breton , Bess Shay , Shaffrey Christopher , Kim Han Jo , Ames Christopher , Burton Douglas , Gupta Munish , Smith Justin S. , Eastlack Robert , Klineberg Eric , Mundis Gregory , Schwab Frank , Lafage Virginie ,   on behalf of the International Spine Study Group ISSG
Published: February 2023

Study Design.

Diagnostic binary threshold analysis.

Objective.

(1) Perform a sensitivity analysis demonstrating the test performance metrics for any combination of proximal junctional angle (PJA) magnitude and change; (2) Propose a new proximal junctional kyphosis (PJK) criteria.

Summary of Background Data.

Previous definitions of PJK have been arbitrarily selected and then tested through retrospective case series, often showing little correlation with clinical outcomes.

Materials and Methods.

Surgically treated adult spinal deformity patients (≥4 levels fused) enrolled into a prospective, multicenter database were evaluated at a minimum 2-year follow-up for proximal junctional failure (PJF). Using PJF as the outcome of interest, test performance metrics including sensitivity, positive predictive value, and F1 metrics (harmonic mean of precision and recall) were calculated for all combinations of PJA magnitude and change using different combinations of perijunctional vertebrae. The combination with the highest F1 score was selected as the new PJK criteria. Performance metrics of previous PJK definitions and the new PJK definition were compared.

Results.

Of the total, 669 patients were reviewed. PJF rate was 10%. Overall, the highest F1 scores were achieved when the upper instrumented vertebrae −1 (UIV−1)/UIV+2 angle was measured. For lower thoracic cases, out of all the PJA and magnitude/change combinations tested, a UIV−1/UIV+2 magnitude of −28° and a change of −20° was associated with the highest F1 score. For upper thoracic cases, a UIV−1/UIV+2 magnitude of −30° and a change of −24° were associated with the highest F1 score. Using PJF as the outcome, patients meeting this new criterion (11.5%) at 6 weeks had the lowest survival rate (74.7%) at 2 years postoperative, compared with Glattes (84.4%) and Bridwell (77.4%).

Conclusions.

Out of all possible PJA magnitude and change combinations, without stratifying by upper thoracic versus lower thoracic fusions, a magnitude of ≤−28° and a change of ≤−22° provide the best test performance metrics for predicting PJF.
Minimal Clinically Important Difference of the 6-Minute Walk Distance in Patients Undergoing Lumbar Spinal Canal Stenosis Surgery: 12 Months Follow-Up
Authors: Takenaka Hiroto , Kamiya Mitsuhiro , Sugiura Hideshi , Nishihama Kasuri , Suzuki Junya , Hanamura Shuntaro
Published: February 2023

Study Design.

Retrospective review of prospectively collected data.

Objective.

We evaluated the responsiveness of the 6-minute walk distance (6MWD) and determined the threshold of the minimal clinically important difference (MCID) in patients who underwent lumbar spinal stenosis (LSS) surgery.

Summary of Background Data.

Little evidence exists on the MCID of 6MWD after LSS surgery. The 6MWD is an objective gait assessment that can be measured quickly.

Materials and Methods.

In total, 126 patients (74 men; average age, 72.2 ± 6.5 yr) were included and assessed preoperatively and at 12 months postoperatively. We used the Oswestry Disability Index (ODI), as an anchor to calculate the MCID for the 6MWD and measured internal and external responsiveness of the 6MWD. The external responsiveness was assessed in 2 ways: (1) One based on the anchoring questionnaire and (2) another based on the scale distribution. The anchor-based approach was evaluated using the Spearman rank correlation coefficient and receiver-operating characteristic curve. The distribution-based approach was evaluated using the minimal detectable change.

Results.

The ODI scores and 6MWD for each anchor significantly improved postoperatively. The change in the 6MWD was significantly correlated with change in the ODI (6 mo, r = −0.45; 12 mo, r = −0.49). The receiver-operating characteristic analysis demonstrated good discriminative properties for the 6MWD using the ODI anchor (6 mo, 0.72; 12 mo, 0.78). The cutoff values for 6MWD were 102.3 and 57.5 at 6 and 12 months, respectively. In the distribution-based approach, the minimal detectable change for the 6MWD was 95.7 m.

Conclusions.

We validated both the internal and external responsiveness of the 6MWD using the ODI and estimated the MCID in the 6MWD for patients undergoing LSS surgery. However, there was lower validity for the MCID among those participants with the high walking ability and low disability at baseline.
Cranially Directed Upper Instrumented Vertebrae Screw Angles Are Associated With Proximal Junctional Kyphosis in Adult Spinal Deformity Surgery
Authors: Chen Jeffrey W. , Longo Michael , Chanbour Hani , LaBarge Matthew E. , Abtahi Amir M. , Stephens Byron F. , Zuckerman Scott L.
Published: February 2023

Study Design.

A retrospective cohort study.

Objective.

To evaluate the impact of the upper instrumented vertebral (UIV) screw angle in adult spinal deformity (ASD) surgery on: (1) proximal junctional kyphosis/failure (PJK/F), (2) mechanical complications and radiographic measurements, and (3) patient-reported outcome measures (PROMs).

Summary of Background Data.

The effect of UIV screw angle in ASD surgery on patient outcomes remains understudied.

Materials and Methods.

A single-institution, retrospective study was undertaken from 2011 to 2017. UIV screw angle was trichotomized into positive: cranially directed screws relative to the superior endplate (2°≤θ), neutral: parallel to the superior endplate (−2°<θ<2°), and negative: caudally directed screws relative to the superior endplate (−2°≥θ). The primary outcome was PJK/F. Secondary outcomes included remaining mechanical complications, reoperation, and PROMs: Oswestry Disability Index, Numeric Rating Scale (NRS) back/leg, and EuroQol. Regression controlled for age, body mass index, postoperative sagittal vertical axis (SVA), and pelvic incidence lumbar-lordosis mismatch.

Results.

Among 145 patients undergoing ASD surgery, UIV screw angles were 35 (24.1%) cranially directed, 24 (16.6%) neutral, and 86 (59.3%) caudally directed. PJK occurred in 47(32.4%) patients. Positive screws were independently associated with increased PJK [odds ratio (OR)=4.88; 95% CI, 1.85–13.5, P=0.002] and PJF (OR=3.06; 95% CI, 1.32–12.30, P=0.015). Among 108 (74.5%) patients with lower thoracic UIV, PJK occurred in 38 (35.1%). Cranially directed screws were independently associated with an increased odds of PJK (OR=5.56; 95% CI, 1.86–17.90, P=0.003) with a threshold of 0.2° (area under the curve =0.65; 95% CI, 0.54–0.76, P<0.001), above which the risk of PJK significantly increased. No association was found between positive screw angle and PJF (OR=3.13; 95% CI, 0.91–11.40, P=0.073). Because of the low number of patients with an upper thoracic UIV (N=37, 25.5%), no meaningful conclusions could be drawn from this subgroup. There was no association between UIV screw angle and remaining mechanical complications, reoperations, postoperative SVA and T1-pelvic angle, or PROMs.

Conclusions.

Cranially directed UIV screw angles increased the odds of PJK in patients with lower thoracic UIV. Meticulous attention should be paid to the lower thoracic UIV screw angle to mitigate the risk of PJK in ASD.
Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations
Authors: Kebaish Kareem J. , Galivanche Anoop R. , Mercier Michael R. , Varthi Arya G. , Rubin Lee E. , Grauer Jonathan N.
Published: February 2023

Study Design:

A retrospective cohort study of a patient undergoing treatment at a single institution’s Spine Center.

Objective:

The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center.

Summary of Background Data:

Spine magnetic resonance imaging (MRI) often requires preauthorization by insurance carriers. While there are potential advantages to ensuring consistent indicators for imaging modalities, previous studies have found that such processes can add administrative burdens and barriers to care.

Methods:

Patients from a single academic institution’s spine center who were covered by commercial insurance and had a spine MRI ordered between January 2013 and December 2019 were identified. The requirement for preauthorization and eventual disposition of each of these studies was tracked. Multivariate logistic regression was used to determine if commercial insurance carriers or anatomic region MRIs were associated with requiring a preauthorization. The eventual disposition of studies associated with this process was tracked.

Results:

In total, 2480 MRI requests were identified, of which preauthorization was needed for 2122 (85.56%). Relative to cervical spine scans, preauthorization had greater odds of being required for thoracic (OR=2.71, P=0.003) and lumbar (OR=2.46, P<0.001) scans. Relative to a reference insurer, 4 of the 5 commercial carriers had statistically significant increased odds of requiring preauthorization (OR=1.54–10.17 P<0.050 for each).

Of the imaging studies requiring preauthorization, peer to peer review was required for 204 (9.61%), and 1,747 (82.33% of all requiring preauthorization) were approved. Of 375 (17.67%) initially cancelled or denied by the preauthorization process, 290 (77.33% of those initially cancelled or denied) were completed within 3 months. In total, only 85 were not eventually approved and completed.

Conclusion:

Of 2480 distinct MRI orders, commercial insurers required preauthorization for 85.56%. Nonetheless, 96.57% of all scans went on to be completed within 3 months, raising questions about the costs, benefits, and overall value of this administrative process.
Intraoperative and Postoperative Management of Incidental Durotomies During Open Degenerative Lumbar Spine Surgery
Authors: Ahmady Arya A. , Butt Bilal B. , Muscateli Stefano , Aleem Ilyas S.
Published: February 2023

Summary of Background Data:

Incidental durotomy is a common intraoperative complication of lumbar spine surgery. Intra and postoperative protocols in the management of this common complication vary considerably, with no consensus in the literature.

Objective:

To systematically review (1) lumbar dural repair techniques for open degenerative procedures; (2) review described postoperative protocols after lumbar dural repairs.

Study Design:

Systematic review.

Materials and Methods:

A systematic review of the literature was performed for all articles published from inception until September 2022 using Pubmed, EMBASE, Medline, and Cochrane databases to identify articles assessing the management of durotomy in open surgery for degenerative diseases of the lumbar spine. Two independent reviewers assessed the articles for inclusion criteria, and disagreements were resolved by consensus. Outcomes included persistent leaks, return to the operating room, recurrent symptoms, medical complications, or patient satisfaction.

Results:

A total of 10,227 articles were initially screened. After inclusion criteria were applied, 9 studies were included (n=1270 patients) for final review. Repair techniques included; no primary repair, suture repair in running or interrupted manner with or without adjunctive sealants, sealants alone, or patch repair with muscle, fat, epidural blood patch, or synthetic graft. Postoperative protocols included the placement of a subfascial drain with varying durations of bed rest. Notable findings included no benefit of prolonged bedrest compared with early ambulation (P=0.4), reduced cerebrospinal fluid leakage with fat graft compared with muscle grafts (P <0.001), and decreased rates of revision surgery in studies that used subfascial drains (1.7%–2.2% vs 4.34%–6.66%).

Conclusions:

Significant variability in intraoperative durotomy repair techniques and postoperative protocols exists. Primary repair with fat graft augmentation seems to have the highest success rate. Postoperatively, the use of a subfascial drain with early ambulation reduces the risk of pseudomenignocele formation, medical complications, and return to the operating room. Further research should focus on prospective studies with the goal to standardize repair techniques and postoperative protocols.
Safety and Efficacy of Local Steroid Application on Dysphagia Following Anterior Cervical Discectomy and Fusion
Authors: Wang Jun-wu , Shi Peng-zhi , Li Kai , Zhu Lei , Feng Xin-min , Zhang Wen-jie , Zhang Liang
Published: February 2023

Study Design:

A systematic review and meta-analysis.

Objective:

To evaluate the safety and efficacy of local steroid application (LSA) on dysphagia after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data:

Dysphagia is one of the most common adverse events in the early postoperative period of ACDF. LSA is reported as an effective method to reduce the swelling of soft tissues, thereby decreasing the incidence of dysphagia. However, the safety and efficacy of LSA on dysphagia after ACDF need to be systematically reviewed and analyzed.

Methods:

A comprehensive literature search was carried out in the database PubMed, Web of Science, EMBASE, Clinical key, Cochrane library, and Wiley Online Library to screen papers that report LSA in ACDF surgery. The Cochrane Collaboration tool and a methodological index for nonrandomized studies were used for the assessment of study quality. Data were analyzed with the Review Manager 5.3 software.

Results:

A total of 10 studies were included. The results revealed no significant differences between the steroid group and the control group in ACDF regarding postoperative drainage, estimated blood loss, and neck disability index score (P > 0.05). LSA significantly alleviates visual analog scale score for neck pain (or odynophagia) (P < 0.05), reduces the length of hospital stay (weighted mean difference, −1.00 (−1.05 to −0.95); P < 0.001), and mitigates dysphagia rate and prevertebral soft-tissue swelling in the early postoperative period (P < 0.05). There seemed to be no significant increase in the complication rate and steroid-related adverse events in the steroid group compared with the control group (P < 0.05).

Conclusions:

LSA shows advantages in reducing the length of hospital stay, decreasing dysphagia rate, and mitigating prevertebral soft-tissue swelling in the early postoperative period of ACDF. Further large-scale studies are urgently required for the development of a standard protocol for LSA and further analysis of potential delay complications.
Cross Screw Fixation for First Metatarsophalangeal Joint Arthrodesis: A Technical Guide
Authors: Sikora Rebecca Rose , Leffler Luke Emerson , Blazek Cody Douglas
Published: February 2023

Background:

First metatarsophalangeal joint (MPJ) arthritis, treatments, and fixation methods have been well described in the literature. Indications for the fusion of the first MPJ include hallux rigidus, severe hallux valgus, failed bunionectomy, failed joint arthroplasty, rheumatoid arthritis, and neuromuscular disorders. Crossing screw fixation has been found to be a stable construct that provides reliable outcomes with high patient satisfaction, specifically for those patients with hallux rigidus and minimal hallux valgus deformity. Crossing screw fixation has also been found to be reliable and more cost-effective than other fixation techniques. However, this method may pose some challenges to novice surgeons and those at academic training institutions.

Objective:

The objective of this technical guide is to propose a reproducible technique to first MPJ fusion with 2 crossing, cannulated screws. This technique is designed to increase the reliability and speed of the crossing screw technique.

Conclusion:

Overall, using this technique with cross screw fixation, we have found decreased operative times, better reproducibility of results, efficiency with use in training with resident learners, and reduced hardware costs.

Levels of Evidence:

Level V, expert opinion