Orthopedic Surgery Residents: How Much Do They Know About Occupational Therapy?

Background Orthopedic hand surgeons rely on occupational therapy (OT) as a crucial part of rehabilitation following injury or surgery. Therefore, orthopedic surgeons should understand the full range of OT services. There is limited prior research on orthopedic residents' understanding of OT in the United States. The main goal of this study is to examine how well orthopedic surgery residents grasp and perceive the role of OT, particularly in hand surgery, as integrated into their educational curriculum. Methods The study included all orthopedic surgery residents from a single institution (Columbia University, New York) during 2022-2023. We obtained permission from the Institutional Review Board, Department Chair, and Program Director to recruit participants. Eligible residents who agreed to participate completed questionnaires regarding their understanding of the role of OT in orthopedic surgery. Results Thirty subjects met the inclusion criteria. The total response rate from the residents was 14/30 (47%). The residents reported a mediocre level of familiarity with OT while also rating 4.5/5 the importance of OT in hand surgery without significant difference between postgraduate year groups. 11/14 residents reported no formal training concerning the role of OT in hand surgery. 12/14 residents reported that it would be helpful to spend time with an occupational therapist. Conclusions This study revealed the lack of confidence residents expressed regarding occupational therapists' roles. All residents recognized the importance of OT in hand surgery and expressed interest in shadowing occupational therapists. Residents of all levels acknowledge the crucial partnership between orthopedists and occupational therapists but lack formal education about the therapist's scope and role.

A Prolonged Case of Severe Mpox as an Opportunistic Infection in Advanced AIDS.

The case report discusses a 29-year-old male with advanced HIV who experienced one of the longest, confirmed cases of monkeypox (mpox) infection. Despite treatment with antivirals and supportive care, including intravenous tecovirimat and vaccinia immune globulin, the patient's condition worsened over a six-and-a-half-month period. He suffered from widespread ulcerative, necrotic lesions and multiple complications, including acute kidney injury, multi-drug resistant bacterial infections, and respiratory failure. Despite repeated treatments, including brincidofovir, the patient remained PCR-positive for monkeypox virus (MPXV) with low cycle threshold (Ct) values, indicating active infection. The case underscores the severity of mpox in immunocompromised individuals, particularly those with advanced HIV, and highlights the challenges in managing such cases. The patient's persistently low CD4 count and unsuppressed HIV viral load likely contributed to the inability to clear the virus. The report emphasizes the need for further research to optimize treatment strategies for MPXV infection, especially in people living with HIV.

Improvement in axial rotation with bracing reduces the risk of curve progression in patients with adolescent idiopathic scoliosis.

PURPOSE: New evidence highlights the significance of 3D in-brace correction for Adolescent Idiopathic Scoliosis (AIS) patients. This study explores how axial parameters relate to treatment failure in braced AIS patients. METHODS: AIS patients (Sanders 1-5) undergoing Rigo-Chêneau bracing at a single institution were included. Axial vertebral rotation (AVR) was determined by utilizing pre-brace and in-brace 3D reconstructions from EOS® radiographs. The primary outcome was treatment failure: surgery or coronal curve progression > 5°. Minimum follow-up was two years. RESULTS: 75 patients (81% female) were included. Mean age at bracing initiation was 12.8 ± 1.3 years and patients had a pre-brace major curve of 31.0° ± 6.5°. 25 patients (76% female) experienced curve progression > 5°, and 18/25 required surgical intervention. The treatment failure group had larger in-brace AVR than the success group (5.8° ± 4.1° vs. 9.9° ± 7.6°, p = 0.003), but also larger initial coronal curve measures. In-brace AVR did not appear to be associated with treatment failure after adjusting for the pre-brace major curve (Hazard Ratio (HR):0.99, 95% Confidence Interval (CI):0.94-1.05, p = 0.833). Adjusting for pre-brace major curve, patients with AVR improvement with bracing had an 85% risk reduction in treatment failure versus those without (HR:0.15, 95% CI:0.02-1.13, p = 0.066). At the final follow-up, 42/50 (84%) patients without progression had Sanders ≥ 7. CONCLUSIONS: While in-brace rotation was not an independent predictor of curve progression (due to its correlation with curve magnitude), improved AVR with bracing was a significant predictor of curve progression. This study is the first step toward investigating the interplay between 3D parameters, skeletal maturity, compliance, and brace efficacy, allowing a future prospective multicenter study. LEVEL OF EVIDENCE: Retrospective study; Level III.

Utilizing a comprehensive machine learning approach to identify patients at high risk for extended length of stay following spinal deformity surgery in pediatric patients with early onset scoliosis.

PURPOSE: Early onset scoliosis (EOS) patient diversity makes outcome prediction challenging. Machine learning offers an innovative approach to analyze patient data and predict results, including LOS in pediatric spinal deformity surgery. METHODS: Children under 10 with EOS were chosen from the American College of Surgeon's NSQIP database. Extended LOS, defined as over 5 days, was predicted using feature selection and machine learning in Python. The best model, determined by the area under the curve (AUC), was optimized and used to create a risk calculator for prolonged LOS. RESULTS: The study included 1587 patients, mostly young (average age: 6.94 ± 2.58 years), with 33.1% experiencing prolonged LOS (n = 526). Most patients were female (59.2%, n = 940), with an average BMI of 17.0 ± 8.7. Factors influencing LOS were operative time, age, BMI, ASA class, levels operated on, etiology, nutritional support, pulmonary and neurologic comorbidities. The gradient boosting model performed best with a test accuracy of 0.723, AUC of 0.630, and a Brier score of 0.189, leading to a patient-specific risk calculator for prolonged LOS. CONCLUSIONS: Machine learning algorithms accurately predict extended LOS across a national patient cohort and characterize key preoperative drivers of increased LOS after PSIF in pediatric patients with EOS.

Innovative technologies in thoracolumbar and lumbar spine surgery failing to reach standard of care: state-of-art review.

PURPOSE: To evaluate previously popular technologies in the field of spine surgery, and to better understand their advantages and limitations to the current standards of care. Spine surgery is an ever-evolving field that serves to resolve various spinal pathologies in patients of all ages. While there are established treatments for various conditions, such as lumbar spinal stenosis, idiopathic scoliosis, and degenerative lumbar disease, there is always further research and development in these areas to produce innovative technologies that can lead to better outcomes. As this process progresses, we must remind ourselves of previously tried and tested inventions and their outcomes that have fallen short of becoming a standard to ensure we are able to learn lessons from the past. METHODS: A thorough literature review was conducted with the aim of compiling literature of previously utilized technologies in spine surgery. Biomedical databases were utilized to gather relevant articles including PubMed, MEDLINE, and EMBASE. Emphasis was placed on gathering articles with technologies or therapeutics aimed at treating common spinal pathologies including lumbar spinal stenosis (LSS), adolescent idiopathic scoliosis (AIS), and other degenerative lumbar spine diseases. The keywords used were: "failed technologies", "historical technologies", "spine surgery", "spinal stenosis", "adolescent idiopathic scoliosis", and "degenerative lumbar spine disease". A total of 47 articles were gathered after initial review. RESULTS: Different technologies pertaining to spine surgery were identified and critically evaluated. Some of these technologies included X-STOP, Vertiflex, Vertebral Body Stapling, and Dynesys. These technologies were evaluated for their strengths and limitations across their spinal pathology applications. While each type of technology had their benefits, the data tended to be mixed with various limitations across studies. CONCLUSION: These technologies have been trialed in the field of spine surgery across various spinal pathologies, but still prove of limited efficacy and shortcomings to the current standards of care.

Preoperative Echocardiogram Does Not Contribute to Surgical Risk Assessment in Patients With Large Curve Scoliosis and No Cardiac Risk Factors.

OBJECTIVE: Severe scoliosis can affect thoracic organs, potentially leading to cardiovascular abnormalities. Thus, echocardiograms have been suggested for use in preoperative screening in patients with significant scoliosis. However, the utility of preoperative heart screenings in patients without known or suspected heart problems is not well understood. This study aims to find the incidence of cardiac findings in patients with severe scoliosis ≥90° without cardiac history. METHODS: A single-institution retrospective chart review was performed. Inclusion criteria were scoliosis patients with curves ≥90 degrees and a screening echocardiogram performed within 6 months of spine surgery. Patients with a previous cardiac history, diagnosis associated with cardiac comorbidities (eg, connective tissue disease), or major coronal curves <90 degrees were excluded. Echocardiogram reports and perioperative clinical notes from involved services (including orthopaedics, cardiology, and anesthesia) were reviewed. Any postoperative use of vasopressors and reasons for their use were recorded. RESULTS: Overall, 50 patients met the inclusion criteria. The mean age at surgery was 14.0 ± 4.9 years old (range: 2 to 33). The mean major curve was 108 ± 19 degrees (range: 90 to 160 degrees). A normal echocardiogram was seen in 38 (76%), whereas 6 patients (12%) had mild dilation of the aortic sinus or root, 4 (8%) had mild valvular regurgitation, 1 patient had a small atrial septal defect, and 1 had a trace pericardial effusion. No patient had any changes made to their perioperative plan and one patient was advised to see a cardiologist postoperatively. Postoperatively, 8 patients (16%) received vasopressors to raise blood pressure to meet preset goal MAP, but only one of these 8 had a positive echocardiogram (mild valvular insufficiency), which was not seen as a contributing factor to the use of pressors. CONCLUSIONS: This study suggests that screening echocardiograms for patients without a cardiac history or related symptoms does not contribute to the evaluation of perioperative risk or anesthetic management. Creating clear, evidence-based guidelines for the utilization of perioperative testing, like echocardiograms, can reduce the social, time, and financial burdens on families. Such guidelines are vital for appropriate risk assessment and proper utilization of health care resources. LEVEL OF EVIDENCE: Level III.

Characteristics of Spinal Morphology According to the Global Alignment and Proportion (GAP) Score in a Diverse, Asymptomatic Cohort: Multi-Ethnic Alignment Normative Study.

STUDY DESIGN: Multi-Ethnic Alignment Normative Study (MEANS) cohort: prospective, cross-sectional, multicenter. OBJECTIVE: To analyze the distribution of GAP scores in the MEANS cohort and compare the spinal shape via stratification by GAP alignment category, age, and country. SUMMARY OF BACKGROUND DATA: The GAP score has been used to categorize spinal morphology and prognosticate adult spinal deformity surgical outcomes and mechanical complications. We analyzed a large, multiethnic, asymptomatic cohort to assess the distribution of GAP scores. METHODS: Four hundred sixty-seven healthy volunteers without spinal disorders were recruited in five countries. Sagittal radiographic parameters were measured via the EOS imaging system. The GAP total and constituent factor scores were calculated for each patient. Kruskal-Wallis rank sum test was performed to compare variables across groups, followed by the post hoc Games-Howell test. Fisher exact test was used to compare categorical variables. The significance level was set to P <0.05. RESULTS: In the MEANS cohort, 13.7% (64/467) of volunteers were ≥60 years old, and 86.3% (403/467) were <60 years old. 76.9% (359/467) was proportioned, 19.5% (91/467) was moderately disproportioned, and 3.6% (17/467) was severely disproportioned. There was no significant difference in the frequency of proportioned, moderately, or severely disproportioned GAP between subjects from different countries ( P =0.060). Those with severely disproportioned GAP alignment were on average 14.5 years older ( P =0.016), had 23.1° lower magnitude lumbar lordosis (LL) ( P <0.001), 14.2° higher pelvic tilt ( P <0.001), 13.3° lower sacral slope ( P <0.001), and 24.1° higher pelvic-incidence (PI)-LL mismatch ( P <0.001), 18.2° higher global tilt ( P <0.001) than those with proportioned GAP; thoracic kyphosis and PI were not significantly different ( P >0.05). CONCLUSIONS: The GAP system applies to a large, multiethnic, asymptomatic cohort. Spinal alignment should be considered on a spectrum, as 19.5% of the asymptomatic volunteers were classified as moderately disproportioned and 3.6% severely disproportioned. Radiographic malalignment does not always indicate symptoms or pathology. LEVEL OF EVIDENCE: 3.

Characteristics of Spinal Morphology According to the "Current" and "Theoretical" Roussouly Classification Systems in a Diverse, Asymptomatic Cohort: Multi-Ethnic Alignment Normative Study (MEANS).

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVE: To classify spinal morphology using the "current" and "theoretical" Roussouly systems and assess sagittal alignment in an asymptomatic cohort. METHODS: 467 asymptomatic volunteers were recruited from 5 countries. Radiographic parameters were measured via the EOS imaging system. "Current" and "theoretical" Roussouly classification was assigned with sagittal whole spine imaging using sacral slope (SS), pelvic incidence (PI), and the lumbar apex. One-way analysis of variance (ANOVA) was performed to compare subject characteristics across Roussouly types, followed by post hoc Bonferroni correction. RESULTS: Volunteers were categorized into 4 groups (Types 1-4) and 1 subgroup (Type 3 AP) using the "current" and "theoretical" Roussouly systems. The mean PI in "current" Roussouly groups was 40.8° (Type 1), 43.6° (Type 2), 52.4° (Type 3), 62.4° (Type 4), and 43.7° (Type 3AP). The mean PI in "theoretical" Roussouly groups was 36.5° (Type 1), 39.1°(Type 2), 52.5° (Type 3), 67.3° (Type 4), and 51.0° (Type 3AP). The difference in PI between "current" and "theoretical" Roussouly types was significant for Type 1 (P = .02), Type 2 (P < .001), Type 4 (P < .001), and Type 3AP (P < .001). 34.7% of subjects had a "current" Roussouly type different from the "theoretical" type. Type 3 theoretical shape had the most frequent mismatch, constituting 61.1% of the mismatched subjects. 51.5% of mismatched Type 3 become "current" Type 4. CONCLUSION: The distribution of Roussouly types differs depending on whether the "current" or "theoretical" classification are employed. A sizeable proportion of volunteers exhibited current and theoretical type mismatch, highlighting the need to interpret sagittal alignment cautiously when utilizing the Roussouly system.

Institutional Variability in Anesthesia Time for Mehta Casting in Early-Onset Scoliosis (EOS).

PURPOSE: Mehta casting is a potentially curative intervention for early-onset scoliosis (EOS) that typically requires multiple anesthetics. The Food and Drug Administration (FDA) reported that >3 hours of anesthesia under the age of 3 years old may alter brain development; however, no standard exists for the duration of anesthesia during casting. The purpose of this study is to quantify the variability in anesthesia during Mehta casting. We hypothesize that significant institutional variability exists and may be attributed to modifiable factors. METHODS: An EOS registry was used to identify patients who underwent at least one Mehta casting procedure. Anesthesia exposure was quantified, and site variability was assessed by patient characteristics, cast placement, procedure type, and equipment used. RESULTS: Our cohort consisted of 208 patients from 5 institutions (age 2.6±1.4 y). There were 1097 Mehta casting procedures, with 5.4±3.6 castings per patient. Of these patients, 106 (51%) were female, with an average age of 2.11±1.29 years old at the time casting was initiated. Patient etiologies included 154 idiopathic (74.0%), 22 syndromic (10.6%), 18 congenital (8.7%), 11 neuromuscular (5.3%), and 3 unknown (1.4%). Anesthesia time was 69±31 minutes and varied significantly between sites (59±14 to 117±46 min; P <0.001). Cumulative anesthesia time for patients under 3 years was 320±197 minutes with 120/161 (74.5%) patients exceeding 3 hours. Anesthesia time was lower after the FDA warning in 2016 compared with pre-2016 (71±30 vs. 66±32, P =0.008). CONCLUSIONS: Patients undergoing Mehta casting are at significant risk of exceeding 3 hours of anesthesia, which the FDA has stated may be harmful for children <3 years. Significant site variability indicates that standardization protocols should be developed to encourage best practices and minimize anesthetic times. LEVEL OF EVIDENCE: Prognostic Level II.

Practical Methods of Assessing Coronal Alignment and Outcomes in Adult Spinal Deformity Surgery: A Comparative Analysis.

STUDY DESIGN: Asymptomatic cohort: prospective, cross-sectional, multicenter. Symptomatic: retrospective, multisurgeon, single-center. OBJECTIVE: To assess the association between cranial coronal alignment and adult spinal deformity (ASD) surgical risk and outcomes. SUMMARY OF BACKGROUND DATA: ASD leads to decreased quality of life. Studies have shown that coronal malignment (CM) is associated with worse surgical outcomes. MATERIALS AND METHODS: A total of 468 adult participants were prospectively enrolled in the asymptomatic cohort. Totally, 172 symptomatic ASD patients with 2-year follow-ups were retrospectively enrolled in the symptomatic cohort. Three cranial plumb line parameters: the positions of the plumb lines from the midpoint between the medial orbital rims (ORB-L5), the odontoid (OD-L5), and the C7 centroid (C7-L5) relative to the L5 pedicle, were measured. Each subject had plumb line medial (M), touching (T), or lateral (L) to either pedicle. The association between each group of patients and radiographic parameters, intraoperative variables, patient-reported outcomes, and clinical outcomes were analyzed. RESULTS: In the asymptomatic cohort, OD-L5 was medial to or touching the L5 pedicle in 98.3% of volunteers. In the symptomatic patients, preoperative OD-L5-L exhibited higher mean age (56.2±14.0), odontoid-coronal vertical axis (OD-CVA) (5.5±3.3 cm), Oswestry disability index (ODI) score (40.6±18.4), pelvic fixation rate (56/62, 90.3%), OR time (528.4±144.6 min), median estimated blood loss (1300 ml), and durotomy rate (24/62, 38.7%). A similar pattern of higher CVA, preoperative ODI, intraoperative pelvic fixation rate, OR time, estimated blood loss, and durotomy rate was observed in ORB-L5-L and C7-L5-L patients. Final follow-up postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis (13.0%) and pseudarthrosis (17.4%). CONCLUSION: Preoperative OD-L5, ORB-L5, and C7-L5 lateral to pedicles were associated with worse preoperative ODI and higher intraoperative complexity. Postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis and pseudarthrosis. Postoperative CM, approximated by the cranial plumb line lateral to the L5 pedicles, was associated with sagittal plane complications.

Comparison of the Odontoid and Orbital-Coronal Vertical Axis Lines in Evaluating Coronal Alignment and Outcomes in Adult Spinal Deformity Surgery.

STUDY DESIGN: Asymptomatic Multi-Ethnic Alignment Normative Study (MEANS) cohort: cross-sectional, multi-center. Symptomatic cohort: retrospective, multi-surgeon, single-center. OBJECTIVE: To assess the association of odontoid-coronal vertical axis (OD-CVA) and orbital-coronal vertical axis (ORB-CVA) with radiographic parameters, patient-reported outcomes (PROs), and clinical outcomes. SUMMARY OF BACKGROUND DATA: Previous literature studied the OD-CVA in an asymptomatic cohort and ORB-CVA in a symptomatic cohort, demonstrating their correlations with radiographic parameters and ORB-CVA with outcomes. METHODS: 468 asymptomatic adult participants were prospectively enrolled in the MEANS cohort. 174 symptomatic ASD patients with 6 fused levels and 2-year follow-ups were retrospectively enrolled in the symptomatic cohort. The association between OD-CVA and ORB-CVA, and radiographic parameters, perioperative variables, PROs, and outcomes were analyzed. Pearson's correlation was used to assess correlation and logistic regression odds of outcomes. RESULTS: In the MEANS cohort, the ORB-CVA correlated with C7-CVA (r=0.58) and OD-CVA (r=0.74). In the symptomatic cohort, preoperative ORB-CVA correlated better with leg length discrepancy (LLD) (r=0.17, P=0.029) while preoperative OD-CVA correlated better with C7-CVA (r=0.90, P<0.001). Postoperative ORB-CVA correlated with postoperative C7-CVA (r=0.66, P<0.001) and postoperative OD-CVA correlated stronger with postoperative C7-CVA (r=0.81, P<0.001). Both preoperative OD-CVA (r=0.199) and ORB-CVA (r=0.208) correlated with preoperative Oswestry Disability Index (ODI). ORB-CVA correlated better than OD-CVA in the preoperative SRS-22r pain category but worse in total and other subcategories. Preoperative ORB-CVA was associated with increased odds of intraoperative complication (OR=1.28, 1.01-1.22), like OD-CVA (OR=1.30, 1.12-1.53). Neither preoperative ORB-CVA nor OD-CVA was associated with reoperations and readmissions after multivariate analysis. Preoperative OD-ORB mismatch >1.5 cm was not associated with increased odds of intraoperative and postoperative complications, reoperations, or readmissions. CONCLUSION: ORB-CVA and OD-CVA correlated with radiographic parameters, PROs, and intraoperative complications. ORB-CVA and OD-CVA can be used interchangeably as cranial coronal parameters in ASD surgery.

The Thoracolumbar Inflection Point in a Population of Asymptomatic Volunteers: A Multi-Ethnic Alignment Normative Study Cohort Study.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To show population variance in the Inflection Point (IP) and its role in defining maximum Thoracic Kyphosis (TK) and Lumbar Lordosis (LL). METHODS: 468 asymptomatic adult volunteers were included in the Multi-Ethnic Normative Alignment Study (MEANS). To find parameters correlating with IP, the vertebrae and discs were numbered such that C7 was 0, T1 was 1, with T1-T2 disc being 1.5, etc. Statistical analysis was performed by a correlation matrix for IP and the 9 other selected parameters along with linear regressions. RESULTS: The overall mean IP was 12.44 approximately corresponding to T12-L1 disc with the median being 12.50, range was T8-L4. The cohort was then stratified by sex and ethnicity, but there was no significant difference in IP between groups. IP in younger subjects was 13 (L1), compared to 12.5 (T12-L1 disc) in older subjects (P < .05). IP was moderately correlated with the TK apex (r = .66). No strong correlation was found between IP and LL magnitude or apex, TK magnitude, sacral slope, or Pelvic Incidence (PI). In terms of other sagittal parameters, PI and LL demonstrated a significant positive correlation. PI and TK did not have a strong association. CONCLUSIONS: The mean IP was at the T12-L1 disc, however IP ranged from T8 to L4. Older subjects tended to have a relatively more cephalad IP. No radiographic variable was found to be a strong predictor of the IP. TK apex was found to have a moderate correlation.