Modern Internet Search Analytics: Is There a Difference in What Patients are Searching Regarding the Operative and Nonoperative Management of Scoliosis?

STUDY DESIGN: Observational Study. OBJECTIVES: This study aimed to investigate the most searched types of questions and online resources implicated in the operative and nonoperative management of scoliosis. METHODS: Six terms related to operative and nonoperative scoliosis treatment were searched on Google's People Also Ask section on October 12, 2023. The Rothwell classification was used to sort questions into fact, policy, or value categories, and associated websites were classified by type. Fischer's exact tests compared question type and websites encountered between operative and nonoperative questions. Statistical significance was set at the .05 level. RESULTS: The most common questions concerning operative and nonoperative management were fact (53.4%) and value (35.5%) questions, respectively. The most common subcategory pertaining to operative and nonoperative questions were specific activities/restrictions (21.7%) and evaluation of treatment (33.3%), respectively. Questions on indications/management (13.2% vs 31.2%, P < .001) and evaluation of treatment (10.1% vs 33.3%, P < .001) were associated with nonoperative scoliosis management. Medical practice websites were the most common website to which questions concerning operative (31.9%) and nonoperative (51.4%) management were directed to. Operative questions were more likely to be directed to academic websites (21.7% vs 10.0%, P = .037) and less likely to be directed to medical practice websites (31.9% vs 51.4%, P = .007) than nonoperative questions. CONCLUSIONS: During scoliosis consultations, spine surgeons should emphasize the postoperative recovery process and efficacy of conservative treatment modalities for the operative and nonoperative management of scoliosis, respectively. Future research should assess the impact of website encounters on patients' decision-making.

GPT-4 as a Source of Patient Information for Anterior Cervical Discectomy and Fusion: A Comparative Analysis Against Google Web Search.

STUDY DESIGN: Comparative study. OBJECTIVES: This study aims to compare Google and GPT-4 in terms of (1) question types, (2) response readability, (3) source quality, and (4) numerical response accuracy for the top 10 most frequently asked questions (FAQs) about anterior cervical discectomy and fusion (ACDF). METHODS: "Anterior cervical discectomy and fusion" was searched on Google and GPT-4 on December 18, 2023. Top 10 FAQs were classified according to the Rothwell system. Source quality was evaluated using JAMA benchmark criteria and readability was assessed using Flesch Reading Ease and Flesch-Kincaid grade level. Differences in JAMA scores, Flesch-Kincaid grade level, Flesch Reading Ease, and word count between platforms were analyzed using Student's t-tests. Statistical significance was set at the .05 level. RESULTS: Frequently asked questions from Google were varied, while GPT-4 focused on technical details and indications/management. GPT-4 showed a higher Flesch-Kincaid grade level (12.96 vs 9.28, P = .003), lower Flesch Reading Ease score (37.07 vs 54.85, P = .005), and higher JAMA scores for source quality (3.333 vs 1.800, P = .016). Numerically, 6 out of 10 responses varied between platforms, with GPT-4 providing broader recovery timelines for ACDF. CONCLUSIONS: This study demonstrates GPT-4's ability to elevate patient education by providing high-quality, diverse information tailored to those with advanced literacy levels. As AI technology evolves, refining these tools for accuracy and user-friendliness remains crucial, catering to patients' varying literacy levels and information needs in spine surgery.

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs. BACKGROUND: Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression. METHODS: A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P-value<0.001 was considered statistically significant. RESULTS: Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss (P<0.0001). Mean same-day total costs ($17,920 vs. $8204, P<0.001) and mean 90-day costs ($46,050 vs. $15,200, P<0.001) were significantly higher in the readmission group. CONCLUSION: A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

Mindfulness Applications: Can They Serve as a Stress, Anxiety, and Burnout Reduction Tool in Orthopaedic Surgery Training? A Randomized Control Trial.

Stress and burnout are prevalent within the orthopaedic surgery community. Mindfulness techniques have been shown to improve wellness, yet traditional courses are generally time-intensive with low surgeon utilization. We sought to determine whether the introduction of a simple mindfulness-based phone application would help decrease stress, anxiety, and burnout in orthopaedic surgery residents. Methods: Twenty-four residents participated in this prospective, randomized controlled trial. After simple 1:1 randomization, the treatment group received access to a mindfulness-based phone application for 2 months while the control group did not receive access. All participants completed the Perceived Stress Scale, Generalized Anxiety Disorder-7, and Maslach Burnout Inventory with emotional exhaustion (EE), depersonalization (DP), and personal accomplishment subscores to measure stress, anxiety, and burnout at baseline and after 2 months. Paired t tests were used to compare baseline scores and conclusion scores for both groups. Results: There was no difference in baseline burnout scores between groups, but the treatment group had higher stress and anxiety scores at baseline. On average, the treatment group spent approximately 8 minutes per day, 2 days per week using the mindfulness application. After 2 months, the treatment group had significantly decreased stress (mean = -7.42, p = 0.002), anxiety (mean = -6.16, p = 0.01), EE (mean = -10.83 ± 10.72, p = 0.005), and DP (mean = -5.17 ± 5.51, p = 0.01). The control group did not have any significant differences in stress, anxiety, or burnout subscores. Conclusions: Use of a mindfulness-based phone app for 2 months led to significant reductions in stress, anxiety, and burnout scores in orthopaedic surgery residents. Our results support the use of a mindfulness-based app to help decrease orthopaedic resident stress, anxiety, and burnout. Benefits were seen with only modest use, suggesting that intensive mindfulness training programs may not be necessary to effect a change in well-being. The higher baseline stress and anxiety in the treatment group may suggest that mindfulness techniques are particularly effective in those who perceive residency to be more stressful. Level of Evidence: I.

Marijuana Use is Not a Contraindication for Tranexamic Acid Utilization in Lumbar Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to evaluate safety in lumbar spinal fusion with tranexamic acid (TXA) utilization in patients using marijuana. METHODS: This was a retrospective cohort study involving a single surgeon's cases of 1 to 4 level lumbar fusion procedures. Two hundred and ninety-four patients were followed for ninety days post-operatively. Consecutive patients were self-reported for daily marijuana use (n = 146) and compared to a similar cohort of patients who denied usage of marijuana (n = 146). Outcomes were collected, which included length of stay (LOS), estimated blood loss (EBL), post-operative myocardial infarction, seizures, deep venous thrombosis, pulmonary embolus, death, readmission, need for further surgery, infection, anaphylaxis, acute renal injury, and need for blood product transfusion. RESULTS: Patients in the marijuana usage cohort had similar age (58.9 years ±12.9 vs 58.7 years ±14.8, P = .903) and distribution of levels fused (P = .431) compared to the non-usage cohort. Thromboembolic events were rare in both groups (marijuana usage: 1 vs non-usage: 2). Compared to the non-usage cohort, the marijuana usage cohort had a similar average EBL (329.9 ± 298.5 mL vs 374.5 ± 363.8 mL; P = .254). Multivariate regression modeling demonstrated that neither EBL (OR 1.27, 95% CI 0.64-2.49) nor need for transfusion (OR 1.56, 95% CI 0.43-5.72) varied between cohorts. The non-usage cohort had twice the risk of prolonged LOS compared to the marijuana usage cohort (OR 2.05, 95% CI 1.15-3.63). CONCLUSION: Marijuana use should not be considered a contraindication for TXA utilization in lumbar spine surgery.

Association of Thoracic MRI Findings With Specialty and Training.

STUDY DESIGN: Retrospective. OBJECTIVE: To compare the rate of positive pathology on thoracic MRI ordered by surgical spine specialists to those ordered by nonsurgical spine specialists. METHODS: Outpatient thoracic MRIs from January-March 2019 were evaluated from a single academic health care system. Studies without a known ordering provider, imaging report, or patients with known presence of malignancy, multiple sclerosis, recent trauma, or surgery were excluded (n = 320). Imaging studies were categorized by type of provider placing the order (resident, attending, or advanced practice practitioner) and department. MRIs were deemed positive if they showed relevant pathology that correlated with indication for exam as determined by a radiologist. One-sided chi-squared analysis was performed to determine statistical significance. RESULTS: Overall, our data demonstrated 17.2% of studies with positive pathology. Compared to nonspecialty clinicians, subspecialists showed 35/184 (19.0%) positivity rate versus the non-specialist with 20/136 (14.7%) positivity rate (P = .156). Posthoc analysis demonstrated that surgical specialists who order thoracic MRIs yield significantly higher positivity rates at 19/79 (24.0%) compared to nonsurgical specialists at 36/241 (14.9%) (P < .05). Overall, neurosurgery demonstrated the highest rate of positive thoracic MRIs at 14/40 (35.0%). Comparison between the rate of positivity between physicians and advanced practitioners was insignificant (P > .05). CONCLUSIONS: Clinical diagnosis of symptomatic thoracic spine degenerative disease requires an expert physical exam combined with careful attention to radiology findings. Although the percent of relevant pathology on thoracic MRI is low, our data suggests evaluation by a surgical specialist should precede ordering a thoracic spine MRI.

The Rise and Fall of Bone Morphogenetic Protein 2 Throughout the United States.

STUDY DESIGN: Retrospective Database Study. OBJECTIVE: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014. SUMMARY OF BACKGROUND DATA: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued. METHODS: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year. RESULTS: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863). CONCLUSIONS: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends.

The Cost-Effectiveness of Vancomycin Powder in Lumbar Laminectomy.

STUDY DESIGN: Break-even cost analysis. OBJECTIVE: The goal of this study is to examine the cost-effectiveness of vancomycin powder for preventing infection following lumbar laminectomy. METHODS: The product cost of vancomycin powder was obtained from our institution's purchasing records. Infection rates and revision costs for lumbar laminectomy and lumbar laminectomy with fusion were obtained from the literature. A break-even analysis was then performed to determine the absolute risk reduction (ARR) in infection rate to make prophylactic application of vancomycin powder cost-effective. Analysis of lumbar laminectomy with fusion was performed for comparison. RESULTS: Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in lumbar laminectomy if the infection rate of 4.2% decreased by an ARR of 0.015%. Laminectomy with fusion was also determined to be cost-effective at the same cost of vancomycin powder if the infection rate of 8.5% decreased by an ARR of 0.0034%. The current highest cost reported in the literature, $44.00 per gram of vancomycin powder, remained cost-effective with ARRs of 0.21% and 0.048% for laminectomy and laminectomy with fusion, respectively. Varying the baseline infection rate did not influence the ARR for either procedure when the analysis was performed using the product cost of vancomycin at our institution. CONCLUSIONS: This break-even analysis demonstrates that prophylactic vancomycin powder can be highly cost-effective for lumbar laminectomy. At our institution, vancomycin powder is economically justified if it prevents at least one infection out of 6700 lumbar laminectomy surgeries.

Low Socioeconomic Status Is Associated With Increased Complication Rates: Are Risk Adjustment Models Necessary in Cervical Spine Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The objective of this study was to determine whether lower socioeconomic status was associated with increased resource utilization following anterior discectomy and fusion (ACDF). METHODS: The National Inpatient Sample database was queried for patients who underwent a primary, 1- to 2-level ACDF between 2005 and 2014. Trauma, malignancy, infection, and revision surgery were excluded. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay, complications, and hospital cost were compared between patients of top and bottom income quartiles. RESULTS: A total of 69 844 cases were included. The bottom income quartile had a similar mean hospital stay (2.04 vs 1.77 days, P = .412), more complications (2.45% vs 1.77%, P < .001), and a higher mortality rate (0.18% vs 0.11%, P = .016). Multivariate analysis revealed bottom income quartile was an independent risk factor for complications (odds ratio = 1.135, confidence interval = 1.02-1.26). Interestingly, the bottom income quartile experienced lower mean hospital costs ($17 041 vs $17 958, P < .001). CONCLUSION: Patients in the lowest income group experienced more complications even after adjusting for comorbidities. Therefore, risk adjustment models, including socioeconomic status, may be necessary to avoid potential problems with access to orthopedic spine care for this patient population.

Acute Opioid Withdrawal Mimicking Postoperative Joint Infection Following anterior cruciate ligament (ACL) Reconstruction: A Case Report.

BACKGROUND A short course of opioid narcotics is often prescribed for postoperative anterior cruciate ligament (ACL) reconstruction pain management. Unfortunately, there is a well-documented incidence of opioid withdrawal syndrome (OWS) following short-term use of these medications. OWS can present with symptoms such as influenza-like illness. It is important to differentiate OWS from infectious illnesses, especially after surgery. CASE REPORT We present a case of OWS in a patient who underwent ACL reconstruction 7 days prior. The patient's OWS symptoms were similar to symptoms of a postoperative infection. The knee was aspirated, and the analysis of the aspirate was not concerning for an infection. The patient's symptoms spontaneously resolved on postoperative day 10. This is the first documented case of OWS mimicking ACL reconstruction joint infection. CONCLUSIONS OWS after surgery may present with symptoms similar to joint infection. It is important to consider OWS as a potential complication after surgery and differentiate it from infection to avoid any further unnecessary invasive treatments for the patient.

The Effects of Marijuana Use on Lumbar Spinal Fusion.

MINI: This study compared clinical and patient-reported outcomes following transforaminal lumbar interbody fusion between patients who use or do not use marijuana. We found that patients who use marijuana are younger, but do not demonstrate any differences in preoperative or postoperative Oswestry disability index scores or rates of fusion. STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The purpose of this study was to evaluate marijuana usage and its effect on outcomes following transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA: As marijuana becomes legalized throughout the United States, its medicinal and recreational usage is becoming more mainstream. Clinicians currently have little guidance regarding both short-term and long-term effects of marijuana usage on surgical interventions. While the rate of lumbar spinal fusion in the United States continues to grow, the effect of marijuana usage on fusion remains uncertain. METHODS: One hundred two patients who underwent TLIF performed by the same surgeon were followed for 12 months. Patients were self-reported for marijuana usage (n = 36). Patient reported outcome measures included preoperative Oswestry disability index (ODI), 6-month ODI, and 12-month ODI, as well as length of stay (LOS), complications, return to operating room (OR), revision surgery, and confirmed fusion. Continuous variables were compared using the independent two-sample t test or analysis of variance (ANOVA), whereas categorical variables were analyzed using the chi-square or Fischer exact tests. Adjusted analysis was performed using a multivariate logistic regression model. RESULTS: Marijuana usage was associated with a younger population (P < 0.001), but showed no difference regarding sex or body mass index compared with the non-usage group. There was no statistically significant difference in complications, return to OR, or revision surgery between groups. When controlling for factors such as age and preoperative ODI, multivariate analysis demonstrated that marijuana usage did not limit postoperative ODI reduction. The marijuana usage group demonstrated shorter LOS (2.42 vs. 3.00 d, P = 0.020). Fusion rates at 12 months were similar between groups (96% vs. 92.3%, P = 0.678). ODI was similar between groups at all time points. CONCLUSION: Perioperative outcomes were similar in patients who underwent TLIF regardless of marijuana usage. LEVEL OF EVIDENCE: 3.

A retrospective cohort study. The purpose of this study was to evaluate marijuana usage and its effect on outcomes following transforaminal lumbar interbody fusion (TLIF). As marijuana becomes legalized throughout the United States, its medicinal and recreational usage is becoming more mainstream. Clinicians currently have little guidance regarding both short-term and long-term effects of marijuana usage on surgical interventions. While the rate of lumbar spinal fusion in the United States continues to grow, the effect of marijuana usage on fusion remains uncertain. One hundred two patients who underwent TLIF performed by the same surgeon were followed for 12 months. Patients were self-reported for marijuana usage (n = 36). Patient reported outcome measures included preoperative Oswestry disability index (ODI), 6-month ODI, and 12-month ODI, as well as length of stay (LOS), complications, return to operating room (OR), revision surgery, and confirmed fusion. Continuous variables were compared using the independent two-sample t test or analysis of variance (ANOVA), whereas categorical variables were analyzed using the chi-square or Fischer exact tests. Adjusted analysis was performed using a multivariate logistic regression model. Marijuana usage was associated with a younger population (P < 0.001), but showed no difference regarding sex or body mass index compared with the non-usage group. There was no statistically significant difference in complications, return to OR, or revision surgery between groups. When controlling for factors such as age and preoperative ODI, multivariate analysis demonstrated that marijuana usage did not limit postoperative ODI reduction. The marijuana usage group demonstrated shorter LOS (2.42 vs. 3.00 d, P = 0.020). Fusion rates at 12 months were similar between groups (96% vs. 92.3%, P = 0.678). ODI was similar between groups at all time points. Perioperative outcomes were similar in patients who underwent TLIF regardless of marijuana usage. Level of Evidence: 3.

Industry Consulting Payments to Orthopedic Surgeons Are Associated With Increased Publications.

In accordance with the Physician Payment Sunshine Act, all industry payments to physicians in the United States have become publicly available. Previous research has indicated that orthopedic surgeons receive the greatest amount of industry compensation compared with other surgical subspecialists. However, the relationship between this compensation and research productivity is less clear. This study sought to investigate the relationship between consulting fees paid to orthopedic surgeons and academic productivity. Using the Centers for Medicare & Medicaid Services Open Payments Database, this study identified 2555 orthopedic surgeons who received at least one industry consulting fee in 2015. Physicians who received total consulting fees of at least $20,000 (US) were stratified into the high payment group. The number of publications and the h-index for each physician were used as metrics of scholarly impact. Mean publication number and h-index for the high payment group were compared with all other physicians in the sample using an independent-samples t test. A total of 2555 orthopedic surgeons received consulting payments totaling $62,323,143 in 2015. The mean consulting payment was $24,393 (SD, $45,465). The publication number was greater for the high payment group (mean, 61.6; SD, 135.6) compared with all other physicians in the sample (mean, 36.1; SD, 95.6). Additionally, the mean h-index for the high payment group was 13.7 (SD, 14.3) compared with 10.0 (SD, 11.6) for all other orthopedic surgeons. These findings indicate that the orthopedic surgeons who receive more in industry consulting fees are also those who contribute most substantially to the body of orthopedic literature. [Orthopedics. 2019; 42(3):137-142.].

Resting Pain Level as a Preoperative Predictor of Success With Indirect Decompression for Lumbar Spinal Stenosis: A Pilot Study.

STUDY DESIGN: Retrospective review of a single institution. OBJECTIVE: To determine if resting leg pain level is a predictor of success for indirect decompression in the setting of lumbar spinal stenosis, with lower levels of rest pain correlating with greater likelihood of successful indirect decompression. METHODS: Reviewed anterior or lateral lumbar interbody fusions from T12 to L5-S1 patients with a posterior-based pedicle screw-rod construct. Patients were separated into 2 groups based on a preoperative response to Oswestry Disability Index (ODI) Question 7 regarding level of pain at rest in the supine position. Responses of 0 to 2 (minimal rest pain) were group 1 (n = 54) and responses of 3 to 5 (significant rest pain) were group 2 (n = 16). RESULTS: Preoperative difference was detected between groups 1 and 2, in ODI (38 vs 63, P < .001) and Numeric Rating Scale (NRS) back (6.8 vs 7.9, P = .023). Three-month NRS leg and back scores were significantly lower in group 1 (leg, 1.9 vs 4.8, P < .001; back, 3.5 vs 6.4, P = .001). A significant difference was further noted in the percentage decrease in NRS leg and back scores from pre- to 3 months postoperatively between groups 1 and 2 (leg, 68.4% vs 22.7%, P < .001; back, 40.0% vs 7.4%, P = .012). Group 1 reached minimal clinically important difference for leg pain more often than group 2 (83.3% vs 43.8%, P = .001). CONCLUSION: Preoperative assessment of rest pain level in the supine position has a significant association with reduction in NRS leg and back scores in patients undergoing indirect decompression for lumbar spinal stenosis. This tool may successfully indicate which patients will be candidates for indirect decompression with interbody fusion from an anterior or lateral approach.

Robotic-assisted pedicle screw placement fails to reduce overall postoperative complications in fusion surgery.

BACKGROUND CONTEXT: Surgeons have increasingly adopted robotic-assisted lumbar spinal fusion due to indications that robotic-assisted surgery can reduce pedicle screw misplacement. However, the impact of robotic-assisted spinal fusion on patient outcomes is less clear. PURPOSE: This study aimed to compare rates of perioperative complications between robotic-assisted and conventional lumbar spinal fusion. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 520 patients undergoing lumbar fusion were analyzed. The average ages of patients in the robotic-assisted versus conventional groups were 60.33 and 60.31, respectively (p=.987). Patients with a diagnosis of fracture, traumatic spinal cord injury, spina bifida, neoplasia, or infection were excluded. OUTCOME MEASURES: This study compared the rates perioperative major and minor complications for elective lumbar fusion between each cohort. METHODS: This study screened hospital discharges in the United States from 2010 to 2014 using the National Inpatient Sample and the Nationwide Inpatient Sample (NIS). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 209,073 patients who underwent conventional lumbar fusion (ICD 81.04-8) and 279 patients who underwent robotic-assisted lumbar fusion (ICD 81.04-8 and ICD 17.41, 17.49). Major and minor complications were identified using ICD-9-CM diagnosis codes. The robotic-assisted and conventional fusion groups were statistically matched on age, year, sex, indication, race, hospital type, and comorbidities. Univariate and multivariate logistic regression were used to compare risks of major and minor complications. RESULTS: We matched 257 (92.11%) robotic-assisted patients with an equal number of patients undergoing conventional lumbar fusion. Minor complications occurred in 16.73% of cases in the conventional group and 31.91% of cases in the robotic-assisted group (p<.001). Major complications occurred in 6.61% of the conventional cases compared to 8.17% of robotic-assisted cases (p=.533). For robotic-assisted fusion, multivariate analysis revealed that there was no difference in the likelihood of major complications (OR=0.834, 95% CI=0.214-3.251) or minor complications (OR = 1.450, 95% CI=0.653-3.220). CONCLUSIONS: In a statistically matched cohort, patients who underwent robotic-assisted lumbar fusion had similar rates of major and minor complications compared to patients who underwent conventional lumbar fusion.

Variability in Assessing Spinopelvic Parameters With Lumbosacral Transitional Vertebrae: Inter- and Intraobserver Reliability Among Spine Surgeons.

STUDY DESIGN: Prospectively collected survey study OBJECTIVE.: The aim of this study was to determine the consistency with which spinopelvic parameters (SPP) are determined in patients with lumbosacral transitional vertebrae (LSTV). SUMMARY OF BACKGROUND DATA: The incidence of LSTV in the general population is as high as 35.6%. The often fixed nature of LSTV relative to the pelvis, but lumbar-type appearance, may lead to differential use of the S1 endplate when performing SPP assessment. This could have significant impact on SPP derived from these landmarks, resulting in considerable variation in surgical planning and decision-making. METHODS: Twenty patients demonstrating LSTV on standing lateral 36-inch spinal radiographs were randomly arranged and independently analyzed by 16 experienced spine surgeons using the same computer software. Pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), and T1 pelvic angle (TPA) were captured. Two weeks after the first assessment, surgeons repeated the measurements after image sequence re-randomization. Intraclass correlation coefficient (ICC) was calculated to evaluate interobserver reliability (IOR) for each SPP. Intraobserver reliability (IAOR) was assessed through an average Pearson correlation coefficient for each parameter for each surgeon. RESULTS: Sixteen surgeons completed initial measurements. IOR was poor for TPA (0.35, 95% confidence interval [CI] 0.20, 0.58) and PI (0.42, 95% CI 0.26, 0.65) and fair for LL (0.67, 95% CI 0.51, 0.82), and PT (0.63, 95% CI 0.47, 0.81). Fourteen surgeons completed phase-2 measurements to assess IAOR. Average parameter PPC showed excellent IAOR (LL 0.86, TPA 0.77, PI 0.78, PT 0.86). Kappa coefficient showed fair agreement for raters choosing the same endplate for measurement (Phase 1: 0.38, Phase 2: 0.32). By patient, the percentage of raters that chose the S1 endplate for measurement varied from 6.3% to 85.7%. CONCLUSION: Significant variability exists when surgeons measure SPP in patients with LSTV. These parameters are critical in determining the goals of surgical reconstruction and such variability may have considerable implications for radiographic goals and outcomes of surgical reconstruction. LEVEL OF EVIDENCE: 4.

Novel case of Trevor's disease: Adult onset and later recurrence.

Dysplasia epiphysealis hemimelica (DEH), or Trevor's disease, is an osteocartilaginous epiphyseal overgrowth typically occurring in children. The literature reports 6 adult cases and none describe recurrence requiring additional procedures. We present a new-onset proximal tibial DEH in an adult recurring approximately 3 years after open excision. A 39-year-old female presented with a history of right knee pain, swelling, and instability. Physical examination revealed a firm proximal tibial mass. Computed tomography (CT) imaging showed an exophytic, lobulated, sclerotic mass involving the anterolateral margin of the lateral tibial plateau. Magnetic resonance imaging was suggestive of an osteochondroma. The patient underwent curettage of the lesion due to its periarticular location. Histology revealed benign and reactive bone and cartilage consistent with periosteal chondroma. Two and a half years later, the patient presented with a firm, palpable mass larger than the initial lesion. CT revealed a lateral tibial plateau sclerotic mass consistent with recurrent intra-articular DEH. A complete excision was performed and histology showed sclerotic bone with overlying cartilage consistent with exostosis. DEH is a rare epiphyseal osteocartilaginous outgrowth frequently occurring in the long bones of children less than 8 years old. DEH resembles an osteochondroma due to its pediatric presentation and similar histologic appearance. Adult-onset cases comprise less than 1% of reported cases. Recurrence rate after surgical intervention is unknown. Only 1 such case, occurring in a child, has been described. Clinicians contemplating operative treatment for DEH should note the potential for recurrence and consider complete excision. A follow-up period of several years may be warranted to identify recurrent lesions.

Does Knowledge of Implant Cost Affect Fixation Method Choice in the Management of Stable Intertrochanteric Hip Fractures?

We conducted a study to determine if knowledge of implant cost affects fixation method choice in the management of stable intertrochanteric hip fractures. We retrospectively reviewed the cases of 119 patients treated with a sliding hip screw (SHS; Versafix), a short Gamma nail (SGN), or a long Gamma nail (LGN). Of the 119 fractures, 71 were treated before implant costs were revealed, and 48 afterward. The 2 groups were similar in age, sex, fracture types, American Society of Anesthesiologists physical status classification, and preinjury ambulatory status. SHS was used in 38.0% of the before cases and 27.1% of the after cases, SGN in 29.6% of the before cases and 45.8% of the after cases, and LGN in 32.4% of the before cases and 27.1% of the after cases. Changes in implant use were not statistically significant. SHS was favored for 31-A1.1, 31-A1.2, and 31-A2.1 fractures in the before group but only for 31-A1.2 fractures in the after group. Gamma nails of both sizes were preferred in the after group for 31-A1.1, 31-A1.3, and 31-A2.1 fractures. At our institution, surgeon knowledge of implant cost did not affect fixation method choice in the management of stable intertrochanteric hip fractures.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes.

BACKGROUND AND PURPOSE: Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. PATIENTS AND METHODS: A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. RESULTS: 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant. INTERPRETATION: This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Influence of BMI on level of circulating progenitor cells.

Obesity complicates a number of diseases through mechanisms that are poorly defined. Mobilization and recruitment of progenitor cells to pathological sites is an important factor in disease progression. Here, we analyzed the influence of obesity on the systemic circulation of CD34(+) cell populations and correlated frequencies of cells displaying previously established cell marker signatures with the BMI. Comparative analysis of peripheral blood mononuclear cells (PBMC) from 12 nonobese (BMI <30 kg/m(2)) and 14 obese (BMI >30 kg/m(2)) disease-free donors by flow cytometry revealed that obesity is associated with a fivefold increased frequency of circulating progenitor cells (CPC), a population consisting of hematopoietic and endothelial precursors. Our data also indicate that obesity is associated with increased frequency of circulating mesenchymal stromal progenitor cells (MSC). In contrast, the frequencies of mature endothelial cells (EC) and CD34-bright leukocytes are unaffected by obesity. Combined, our results indicate that obesity promotes mobilization of progenitor cells, which may have clinical relevance.