Educating patients on osteoporosis and bone health: Can "ChatGPT" provide high-quality content?

PURPOSE: The rise of artificial intelligence (AI) models like ChatGPT offers potential for varied applications, including patient education in healthcare. With gaps in osteoporosis and bone health knowledge and adherence to prevention and treatment, this study aims to evaluate the accuracy of ChatGPT in delivering evidence-based information related to osteoporosis. METHODS: Twenty of the most common frequently asked questions (FAQs) related to osteoporosis were subcategorized into diagnosis, diagnostic method, risk factors, and treatment and prevention. These FAQs were sourced online and inputted into ChatGPT-3.5. Three orthopedic surgeons and one advanced practice provider who routinely treat patients with fragility fractures independently reviewed the ChatGPT-generated answers, grading them on a scale from 0 (harmful) to 4 (excellent). Mean response accuracy scores were calculated. To compare the variance of the means across the four categories, a one-way analysis of variance (ANOVA) was used. RESULTS: ChatGPT displayed an overall mean accuracy score of 91%. Its responses were graded as "accurate requiring minimal clarification" or "excellent," with a mean response score ranging from 3.25 to 4. No answers were deemed inaccurate or harmful. No significant difference was observed in the means of responses across the defined categories. CONCLUSION: ChatGPT-3.5 provided high-quality educational content. It showcased a high degree of accuracy in addressing osteoporosis-related questions, aligning closely with expert opinions and current literature, with structured and inclusive answers. However, while AI models can enhance patient information accessibility, they should be used as an adjunct rather than a substitute for human expertise and clinical judgment.

Risk of revision total knee arthroplasty for patients with prior bariatric surgery or class III obesity.

BACKGROUND: Bariatric surgery (BS) is indicated for select class III obesity patients undergoing total knee arthroplasty (TKA) to reduce obesity-related complications. This study assessed the effect of BS on TKA revision rates compared to the general population and class III obesity patients without a history of BS. METHODS: A national database identified patients who had primary TKA. They were divided into two groups: those with BS prior to TKA and those without. Patients without BS formed two control groups, a matched general population, and a matched class III obese cohort. The BS group was matched with controls based on age, Charlson Comorbidity Index (CCI), gender, and diabetes mellitus. Revision rates were analyzed using Kaplan-Meier survival analysis and hazard ratios (HR), calculated using Cox proportional hazard modeling. RESULTS: 14,292 BS patients were compared to 57,006 matched general population controls, and 19,504 BS patients were compared to 77,846 matched class III obesity control patients. BS patients had a higher risk of 5-year all-cause revision (HR: 1.13; P = 0.014) and revision due to periprosthetic fracture (HR: 1.39; P < 0.001) compared to the general population. Compared to class III obesity controls, BS patients had a lower risk of 5-year revision due to prosthetic joint infection (HR: 0.77; P = 0.001), with no difference in all-cause revision (P = 0.362). CONCLUSION: BS does not reduce all-cause TKA revision risk compared to the general or matched class III obesity population. However, it lowers the risk of revision due to prosthetic joint infection when compared to patients with class III obesity. LEVEL OF EVIDENCE: IV.

The Cost-Effectiveness of Smoking Cessation Programs for Prevention of Wound Complications Following Total Ankle Arthroplasty: A Break-Even Analysis.

Background: Tobacco use significantly increases the rate of wound complications in patients undergoing total ankle arthroplasty (TAA). Preoperative optimization through smoking cessation programs significantly minimizes the rate of infection and improves wound healing in arthroplasty procedures. Despite its utility, minimal research has examined the cost-effectiveness of preoperative smoking cessation programs to reduce the need for extracapsular irrigation and debridement (I&D) due to wound complications following TAA. Methods: The cost of an I&D procedure was obtained from our institution's purchasing records. Baseline wound complication rates among tobacco users who have undergone TAA and smoking cessation program cost were obtained from literature. A break-even economic analysis was performed to determine the absolute risk reduction (ARR) to economically justify the implementation of preoperative smoking cessation programs. Different smoking cessation program and I&D costs were tested to account for variations in each factor. ARR was then used to calculate the number needed to treat (NNT) to prevent a single I&D while remaining cost-effective. Results: Smoking cessation programs were determined to be economically justified if it prevents 1 I&D surgery out of 8 TAAs among tobacco users (ARR = 12.66%) in the early postoperative period (<30 days). ARR was the same at the literature high (27.3%) and weighted literature average (13.3%) complication rates when using the cost of I&D surgery at our institution ($1757.13) and the literature value for a smoking cessation program ($222.45). Cost-effectiveness was maintained with higher I&D surgery costs and lower costs of smoking cessation treatment. Conclusion: Our model's input data suggest that the routine use of smoking cessation programs among tobacco users undergoing TAA is cost-effective for risk reduction of I&D surgery in the early postoperative period. This intervention was also found to be economically warranted with higher I&D costs and lower smoking cessation program costs than those found in the literature and at our institution.Level of Evidence: Level III, economic and decision analysis.

Thinner Tibial Spine Fracture Fragments Are Associated With Risk of Fixation Failure.

Purpose: To determine the rate of and risk factors for failure of tibial spine fracture (TSF) repair. Methods: This was a retrospective review of patients aged 18 years or younger with TSF who underwent arthroscopic repair performed by a single orthopaedic surgeon at a large tertiary academic hospital between 2015 and 2022. Demographic, clinical, injury, fracture, and surgical characteristics were collected. Coronal length and sagittal length and height of the fracture fragment were measured on preoperative plain radiographs and magnetic resonance imaging of the knee. Results: Of 25 patients who underwent arthroscopic reduction with internal fixation of TSFs, 2 (8%) experienced fixation failure. In 16 (64%), internal fixation was performed with suture anchors, whereas 8 (32%) underwent internal fixation with screws. There were 19 male patients (76%). There were no differences in demographic factors (age, race, sex, and body mass index), injury characteristics (laterality, mechanism of injury, and activity causing injury), modified Meyers-McKeever fracture classification, or method of internal fixation between the group with fixation failure and the group without failure. Coronal length (14.2 mm vs 18 mm, P = .17) and sagittal length (13.9 mm vs 18.7 mm, P = .17) of the fracture fragment also did not differ significantly between groups. Sagittal height of the fracture fragment was thinner in patients with failure of fixation (4.3 mm) than in those without failure (8 mm) (P = .02). Conclusions: Decreased bone thickness of the displaced fragment was associated with an increased likelihood of fixation failure. Level of Evidence: Level III, retrospective cohort study.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis.

BACKGROUND: There is no clear research showcasing bariatric surgery's (BS's) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. METHODS: Patients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). RESULTS: When compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). CONCLUSIONS: Those who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

Elevated preoperative blood pressure and its relationship to intraoperative mean arterial pressure and blood loss in posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: The relationship between preoperative blood pressure (BP) and intraoperative mean arterial pressure (MAP) and estimated blood loss (EBL) in pediatric spine surgery is currently unknown. The objectives of this study were to determine if elevated preoperative BP is associated with elevated intraoperative MAP, EBL, and percentage estimated blood volume (EBV) lost, and to determine if intraoperative MAP is associated with percentage of EBV lost during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: This is a retrospective cohort analysis of 209 patients undergoing PSF for AIS between 2016 and 2019 by a single surgeon. Data extracted included demographic characteristics, preoperative systolic and diastolic BP, continuous intraoperative MAP measured by arterial line, EBL, radiographic, and surgical characteristics. Time points of interest for MAP included incision and exposure. Elevated BP was defined as > 1 standard deviation above the mean BP of patients included in the study, and elevated MAP was defined as > 65 mmHg. RESULTS: Elevated preoperative systolic BP was associated with elevated MAP at incision (p = 0.002). Patients with elevated preoperative diastolic BP had significantly higher MAP at exposure and throughout the procedure (p = 0.04). MAP > 65 at incision was associated with a 5% increase in EBV lost (p < 0.001). CONCLUSIONS: Patients with elevated preoperative BP parameters have increased MAPs at incision, exposure, and throughout surgery. Elevated MAP at incision is associated with an increased percentage of EBV lost in a small number of patients undergoing PSF for AIS.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion. SUMMARY OF BACKGROUND DATA: Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population. MATERIALS AND METHODS: We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up. RESULTS: Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period. CONCLUSIONS: Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

Impact of Postoperative COVID-19 Infection Status on Outcomes in Elective Primary Total Joint Arthroplasty.

BACKGROUND: Although Coronavirus disease 2019 (COVID-19) infection causes major morbidity and mortality, it is unclear what the impact of postoperative COVID-19 infection is on 30-day outcomes after total joint arthroplasty (TJA). METHODS: There were 2,340 patients who underwent TJA in 2021, identified using the National Surgical Quality Improvement Program database, with 925 total hip arthroplasty (THA) patients (39.5%) and 1,415 total knee arthroplasty (TKA) patients (60.5%), overall. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for postoperative COVID-19-positive and COVID-19-negative patients who underwent TKA or THA. RESULTS: Postoperative COVID-19-positive THA patients were found to have a significantly increased risk of pneumonia (odds ratio [OR] 42.57), sepsis (OR 12.77), readmission (OR 12.06), non-home discharge (OR 3.78), and longer length of stay (hazard ratio 1.62). Postoperative COVID-19-positive TKA patients had an increased risk of 30-day mortality (OR 14.17), superficial infection (OR 3.17), pneumonia (OR 34.68), unplanned intubation (OR 18.31), ventilator use for more than 48 hours (OR 18.31), pulmonary embolism (OR 11.98), urinary tract infection (OR 5.16), myocardial infarction (OR 16.02), deep vein thrombosis (OR 4.69), non-home discharge (OR 1.79), reoperation (OR 3.17), readmission (OR 9.61), and longer length of stay (hazard ratio 1.49). CONCLUSIONS: Patients who contracted COVID-19 within 30 days after TJA were at increased risk of mortalities, medical complications, readmissions, reoperations, and non-home discharges. It is important for orthopedic surgeons to understand these adverse outcomes to better counsel patients and mitigate these risks, particularly in higher risk populations.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery.

OBJECTIVES: Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN: Retrospective propensity score matched cohort. METHODS: Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts. RESULTS: After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06). CONCLUSIONS: Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population. LEVEL OF EVIDENCE: III.

A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective cost-utility analysis. OBJECTIVE: To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon. SUMMARY OF BACKGROUND DATA: SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence. MATERIALS AND METHODS: A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model. RESULTS: The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty. CONCLUSION: Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.

Effect of Faculty Diversity on Minority Student Populations Matching into Orthopaedic Surgery Residency Programs.

Greater faculty diversity within orthopaedic residency programs has been associated with an increased application rate from students of similarly diverse demographic backgrounds. It is unknown whether these underrepresented student populations have an equitable likelihood of being highly ranked and matching at these programs. Thus, we sought to evaluate the relationship between faculty and resident diversity, with a specific focus on sex, racial/ethnic groups that are underrepresented in medicine (URiM), and international medical graduates (IMGs). Methods: The American Orthopaedic Association's Orthopaedic Residency Information Network database was used to collect demographic data on 172 US residency programs. Linear regression analyses were performed to determine the relationship between the proportion of female or URiM attendings at a program and the proportion of female, URiM, or IMG residents or top-ranked applicants (≥25 rank). URiM was defined as "racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." Results: A mean of 13.55% of attendings were female and 14.14% were URiM. A larger fraction of female attendings was a positive predictor of female residents (p < 0.001). Similarly, a larger percentage of URiM attendings was a positive predictor of URiM residents (p < 0.001), as well as of URiM (p < 0.001) and IMG (p < 0.01) students being ranked highly. There was no significant association between URiM attendings and female residents/overall top-ranked applicants, or vice versa. Conclusions: Residency programs with more female attendings were more likely to match female residents, and programs with more URiM attendings were more likely to highly rank URiM and IMG applicants as well as match URiM residents. Our findings indicate that orthopaedic surgery residencies may be more likely to rank and match female or URiM students at similar proportions to that of their faculty. This may reflect minority students preferentially applying to programs with more diverse faculty because they feel a better sense of fit and are likely to benefit from a stronger support system. Level of Evidence: III.

Risk Factors for Readmission following Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to identify risk factors for readmission after anterior cruciate ligament (ACL) reconstruction and to determine costs associated with readmission. Using a private insurance claims' database, we identified patients who underwent ACL reconstruction from 2010 to 2015 using the International Classification of Diseases, Version 9 (ICD-9) and Current Procedural Terminology (CPT) codes. Univariate analysis was performed on demographic data, surgical characteristics, and comorbidities. Variables with p < 0.10 were added to a multivariate logistic regression model which was created to identify independent risk factors for all-cause readmission within 90 days postoperatively. Significance was considered at p < 0.05. Overall, 90,263 patients were included (average age: 29 ± 13 years, 44% female), and 1,066 (1.2%) of patients had a hospital readmission within 90 days following surgery. Risk factors for hospital readmission included cerebrovascular disease (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 1.9, 6.2), diabetes mellitus (OR = 2.6, 95% CI: 1.9, 3.5), concomitant medial collateral ligament (MCL) or lateral collateral ligament (LCL) reconstruction (OR = 2.5, 95% CI: 1.9, 3.3), concomitant posterior cruciate ligament (PCL) reconstruction (OR = 2.2, 95% CI: 1.4, 3.3), age between 44 and 65 years (OR = 2.1, 95% CI: 1.6, 2.9), and depression (OR = 1.88, 95% CI: 1.49, 2.38, p < 0.001). Female sex was associated with decreased odds of 90-day hospital readmission (OR = 0.8, 95% CI: 0.7, 0.9). Each hospital readmission accounted for an estimated $17,841 (95% CI: $17,173, 18,509) in gross health care payments, and patients with readmissions had substantially higher 1-year cumulative health care costs. Readmission after ACL reconstruction was 1.2%. The strongest risk factors for 90-day readmission include cerebrovascular disease, diabetes mellitus, concomitant MCL/LCL reconstruction, concomitant PCL reconstruction, and age between 44 and 65 years. Readmission was associated with substantial health care costs.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Background: The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA). Methods: Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery. Results: A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group. Conclusion: Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.

Outcomes for patients with infantile idiopathic scoliosis by casting table type.

Purpose: Serial casting is an effective treatment for infantile idiopathic scoliosis. The most common casting table types are Mehta, Risser, and spica tables. We compared major curve correction between patients with infantile idiopathic scoliosis treated using pediatric hip spica tables versus Risser or Mehta tables. Methods: In this multicenter retrospective study, we included 52 children younger than 3 years (mean ± standard deviation age, 1.6 ± 0.68 years) treated with ≥2 consecutive casts for infantile idiopathic scoliosis between September 2011 and July 2018. We compared major curve angle (measured using the Cobb method) before and after treatment and improvement in curve angle between the spica tables group (n = 12) and the Risser or Mehta tables group (n = 40). The primary outcome was the difference in percentage correction of the major curve according to radiographs taken after first casting and at final follow-up. Results: The mean major curve was 47° ± 18° before casting. A median of six casts (range: 2-14) were applied. Mean follow-up after treatment initiation was 22 months (range: 7-86 months). At baseline, the major curve was significantly larger in the spica tables group (58°) than in the Risser or Mehta tables group (43°) (p = 0.01). We found no differences in the percentage curve correction in the spica tables group versus Risser or Mehta tables group after first casting or at final follow-up. Conclusion: Serial casting was associated with substantial major curve correction in patients with infantile idiopathic scoliosis. Curve correction did not differ between patients treated with a spica table versus a Risser or Mehta table. Level of Evidence: Level III, retrospective cohort study.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database.

BACKGROUND: Early initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending. METHODS: Using the Truven MarketScan database, we identified nearly 980,000 US adults ages 18-64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05. RESULTS: At 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40-0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47-0.51), emergency department visits (OR = 0.51, 95% CI = 0.49-0.54), advanced imaging (OR = 0.57, 95% CI = 0.56-0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66-0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65-0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4-25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to -$410; P < 0.001). CONCLUSION: Early PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state. LEVEL OF EVIDENCE: IV.

Minimizing the Risk of Vascular Injury: Anatomy of the Popliteal Artery in the Pediatric Knee.

BACKGROUND: Displaced pediatric tibial tubercle fractures are commonly stabilized with screws directed posteriorly toward neurovascular structures. Here, we (1) characterize the variation of the popliteal artery among pediatric patients; and (2) recommend a safe screw trajectory for fixation of tibial tubercle fractures. METHODS: We retrospectively identified 42 patients (42 knees; 29 female) aged 12-17 years with lower-extremity magnetic resonance imaging (MRI) at a tertiary academic center. The mean patient age was 14.5 (range: 12-17) years, and the mean body mass index value was 19.1 (range: 14.9-25.1). We included patients with open physes or visible physeal scars and excluded those with prior instrumentation or lower-extremity injury. Using sagittal MRI, we measured the distances from 5 levels each on the anterior and posterior tibial cortex to the popliteal artery (level 1, midpoint of proximal tibial epiphysis; level 2, the proximal extent of the tubercle; level 3, tubercle prominence; level 4, 2 cm distal to the proximal extent of the tubercle; level 5, 4 cm distal to the proximal extent of the tubercle). Using coronal MRI, we measured the width of the tibia at each level and the distance from the lateral-most and medial-most cortex to the artery. RESULTS: The popliteal artery was laterally positioned in all knees. The mean distance between the artery and lateral-most aspect of the tibia at each level ranged from 1.9 to 2.4 cm, and from 2.3 to 3.9 cm from the medial-most aspect of the tibia. The mean distance that a screw can advance before vascular injury was 5.1 cm at level 1. The shortest mean distance to the popliteal artery was 1.7 cm, at level 5. There is minimal distance between the posterior tibial cortex and the artery at all levels. CONCLUSIONS: Understanding the position of the popliteal artery in pediatric patients can help when stabilizing tibial tubercle fractures. Because the artery is close to the posterior cortex, a drill exiting in line with the popliteal artery risks vascular injury. Therefore, we recommend that screws exit within the medial 60% of the tibia. LEVEL OF EVIDENCE: IV.

Evaluation of a Slipped Capital Femoral Epiphysis Virtual Reality Surgical Simulation for the Orthopaedic Trainee.

OBJECTIVE: The purpose of this study was to compare outcomes between orthopaedic trainees using various preoperative training platforms (physical simulation [PS], virtual reality [VR], and reading/videos) in a slipped capital femoral epiphysis model. METHODS: Participants were randomly assigned to one of the three groups: (1) reading/video control group (n = 7), (2) VR group (n = 7), or (3) PS group (n = 7). Participants in the VR group completed a VR slipped capital femoral epiphysis module while participants in the PS group practiced the placement of a screw in the physical module before evaluation of percutaneous screw placement in the PS model. Outcomes evaluated included overall surgical time, amount of fluoroscopy, Global Rating Scale score, radiographic screw position, physical screw accuracy, presence of breeching of the articular surface or femoral neck, and overall platform rating (0 to 10). RESULTS: No difference was observed in surgical time, Global Rating Scale score, radiographic or physical accuracy of screw position, or articular surface breaching between the groups. Subjectively, there was a difference in utility of platform rating between the groups (PS: 10 ± 0, VR: 7 ± 2, and control: 6 ± 1, P = 0.001). CONCLUSION: Training with VR was subjectively rated higher in value compared with reading/video methods and had similar performance outcomes compared with training with PS.

Ambulatory Surgery Centers Versus Hospital Outpatient Departments for Orthopaedic Surgeries.

BACKGROUND: The goals of this study were to compare the utilization and costs of ambulatory surgery centers (ASCs) versus hospital outpatient department (HOPD) for commonly performed outpatient orthopaedic surgical procedures. METHODS: Commercially insured patients undergoing elective, outpatient orthopaedic surgery were queried using an administrative claims database. We queried the following surgeries: carpal tunnel release, lumbar microdiskectomy, anterior cruciate ligament reconstruction, knee arthroscopy, arthroscopic rotator cuff repair, and bunion repair. Total costs were defined as the sum of all payments for a surgical episode. Professional fees were defined as payments to the primary orthopaedic surgeon and technical fees as all other payments. Comparisons between ASC and HOPD reimbursements were conducted using bivariate statistics and generalized linear models controlling for patient age, sex, and Elixhauser comorbidity index. RESULTS: Among 990,980 cases of outpatient orthopaedic surgery done from 2013 to 2018, the utilization rate of ASCs increased from 31% to 34% across all procedures assessed: compound annual growth rate of 3.3% for lumbar microdiscectomy, 1.8% for knee arthroscopy, 1.4% for anterior cruciate ligament, 1.4% for carpal tunnel release, 1.2% for arthroscopic rotator cuff repair, and 0.5% for bunion repair (P < 0.001 for all). The average total costs were 26% lower at ASCs than HOPDs (P < 0.001 for each procedure). The average technical fees were 33% lower at ASCs than HOPDs (P < 0.001 for each procedure). Both total costs and technical fees were less for ASCs than HOPDs after controlling for patient age, sex, and Elixhauser comorbidity index (P < 0.001 for each procedure). Over the study period, the mean total costs at HOPDs increased by 2.5% yearly, whereas the mean total costs at ASCs decreased by 0.1% yearly. The average surgeon professional fees declined in both care settings over time. CONCLUSION: From 2013 to 2018, there was an increase in ASC utilization for common outpatient orthopaedic surgeries. ASCs were overall less costly than HOPDs for outpatient orthopaedic surgeries. LEVEL OF EVIDENCE: IV.

Connective Tissue Disease Patients Maintain Greater Distraction During Growth Friendly Surgery.

STUDY DESIGN: Multicenter retrospective study. BACKGROUND: Recent studies have demonstrated diminishing returns in patients with early onset scoliosis (EOS) undergoing repeated lengthening of growing rods. Little is known about whether this same phenomenon occurs in patients with lax connective tissue disease (CTD). The primary purpose of this study is to investigate whether EOS patients with connective tissue laxity disorders have diminishing returns during growth friendly surgery. METHODS: CTD EOS patients below 10 years old, underwent growth friendly spine surgery with distal anchors and at least 1 proximal spine anchor, and had minimum follow-up of 5 years were included in this study. Coronal T1-S1 height at preindex surgery, postindex, and every available lengthening was assessed. Mean coronal height change during early set distractions and late set distractions were calculated for the cohort. To account for varying distraction intervals, we normalized the distractions by the time interval. The outcome parameter was T1-S1 height gain, mm/year. RESULTS: Twenty-one CTD patients were included in this study. Total coronal height (T1-S1) was 26.7MHCcm before index, 32.2 cm at D1-D3, 34.7 cm at D4-D6, and 36.7 cm at D7-L10. There were no significant differences in coronal height gains between early and late distractions (P=0.70). Moreover, when normalized for time, there was no significant difference in net gain per year at different lengthening time points for the CTD group, P=0.59. CONCLUSION: There is no evidence of diminishing returns in coronal T1-S1 height gain in patients with EOS in the setting of CTD. LEVEL OF EVIDENCE: Level III.

Can magnetically controlled growing rods be successfully salvaged after deep surgical site infection?

PURPOSE: The purpose is to compare the rate of recurrent deep wound infection in patients who retained MCGRs versus those who underwent implant removal and exchange following index deep wound infection. METHODS: Using a multicenter registry, we identified patients with EOS who underwent surgical correction with MCGR. We defined deep SSI as any infection that required subsequent I&D and antibiotic therapy. Recurrent infection was defined as any additional deep SSI following treatment of index deep infection. We considered MCGR to be salvaged if implant exchange or removal was not performed for at least 1 year following date of infection. Bivariate statistical analyses were performed. RESULTS: 992 EOS patients were identified, of whom 33 (3.3%) developed deep SSI. The mean time between initial surgery and first deep SSI was 13.1 months (Interquartile range [IQR]: 1 to 25 months. Infection rates by EOS diagnosis were as follows: 13/354 patients (3.6%) had neuromuscular scoliosis (NMS), 9/225 (4.0%) syndromic, 6/248 (2.4%) idiopathic, 3/135 congenital (2.2%), and 2/30 (6.6%) unknown etiology. MCGR was salvaged in 69% of NMS patients, 77% of syndromic patients, 100% of congenital patients, and 83% of idiopathic patients (83%). There were only four recurrent infections (2/13 NMS, 2/9 syndromic) and no differences in rates of recurrent infection between salvaged or replaced/exchanged MCGR. (p = 0.97). CONCLUSION: Deep wound infection occurred in 3% of MCGR patients at a mean of 13.1 months. There were no significant differences in rates of recurrent infection between salvaged implants and those removed or exchanged.