The Dimeglio Olecranon Method Is Reliable in Diverse, Contemporary Patients for Predicting Future Growth.

BACKGROUND: Growth assessment, which relies on a combination of radiographic and clinical markers, is an integral part of clinical decision-making in pediatric orthopaedics. The aim of this study is to evaluate the accuracy and reliability of the Diméglio skeletal age system using a modern cohort of pediatric patients. METHODS: A retrospective review was undertaken of all patients at a large tertiary pediatric hospital who had lateral forearm radiographs (before the age of 14 y for females and before 16 y for males). In addition, all of these patients had height measurements within 60 days of their forearm x-ray and a final height listed in their medical records. The x-rays were graded by 5 reviewers according to the Diméglio skeletal age system. Inter and intraobserver reliability was tested. RESULTS: One hundred forty-seven patients with complete radiographs and height data were evaluated by 5 observers ranging in experience from medical students to senior pediatric orthopaedic surgeons. The Diméglio system demonstrated excellent reliability across levels of training with an intraobserver correlation coefficient of 0.995 (95% CI, 0.991-0.997) and an interobserver correlation coefficient of 0.906 (95% CI, 0.857-0.943). When the Diméglio stage was paired with age and sex in a multivariable linear regression model predicting the percent of final height, the adjusted R2 was 78.7% (model P value <0.001), suggesting a strong relationship between the Diméglio stage (plus age and sex) and percent of final height. CONCLUSION: This unique approach to maturity assessment demonstrates that the Diméglio staging system can be used effectively in a modern, diverse patient population. LEVEL OF EVIDENCE: Level II; retrospective cohort study.

Measuring Proximal Tibial Metaphyseal Width and Lateral Epiphyseal Height Improves Determination of Remaining Growth in Children.

BACKGROUND: Accurate assessments of skeletal maturity is of critical importance to guide type and timing of orthopaedic surgical interventions. Several quantitative markers of the proximal tibia were recently developed using historical knee radiographs. The purpose of the present study was to determine which marker would be most effective in assessment of full-length radiographs in a modern pediatric patient population. METHODS: All full-length radiographs at our institutions between 2013 and 2018 were reviewed. Inclusion criteria for our study required that the child reached final height as defined by 2 consecutive unchanged heights, at least 6 months apart, after age 16 for boys and 14 for girls. Patients with metabolic bone disease, prior surgery such as epiphysiodesis, or previous infections around the knee were excluded. Summary statistics for each of the 3 proximal tibial ratios were calculated and multiple linear regression was performed with percent of growth remaining as a dependent variable. A recommended regression model is presented and evaluated. RESULTS: A total of 692 full-length radiographs met inclusion criteria. Proximal tibial ratios were calculated and averaged values for each percent of growth remaining was presented. Multiple linear regression demonstrated that using all 3 variables led to overfitting of the model so tibial metaphyseal width/lateral tibial epiphyseal height was selected as the optimal ratio for use by clinicians. The optimal model for determining growth was found to have R2=0.723 in the developmental set and R2=0.762 in an excluded validation set. CONCLUSIONS: This study demonstrates that the proximal tibial metaphyseal width/lateral tibial epiphyseal height is the ideal measurement for clinicians seeking to determine growth remaining in children. It presents average values between 0% and 25% of growth remaining. This study also develops and validates a multivariable regression model for determining percentage of growth remaining in children that will allow for quantitative determination of growth using full-length radiographs. LEVEL OF EVIDENCE: Level III.

Predicting Growth Quantitatively Through Proximal Tibia Radiograph Markers.

BACKGROUND: The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity. METHODS: From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged. RESULTS: Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996). CONCLUSIONS: We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia. CLINICAL RELEVANCE: This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.

Changes in Proximal Femoral Shape During Fetal Development.

BACKGROUND: Walker and Goldsmith's classic article on fetal hip joint development reported that neck/shaft angle did not change from 12 weeks of gestational age through term while version increased from 0 to 40 degrees. This suggests no change in coronal alignment during development, a conclusion we dispute. By re-examining their data, we found that the true neck/shaft angle (tNSA) decreased by 7.5 degrees as version increased by 40 degrees from 12 weeks of gestational age to term. METHODS: Four investigators measured both femoral version and neck-shaft angle from photographs published by the authors of femurs at multiple stages of maturation from 12 weeks of gestational age to term. The tNSAs and inclination angles were calculated for each femur illustrated using previously validated formula. Changes in the morphology of the femur over time were analyzed using a Student t test. Interobserver and intraobserver reliability were also determined by the Pearson R coefficient. RESULTS: As reported by Walker and Goldsmith, apparent neck/shaft angle (aNSA) did not significantly change during maturation, whereas version increased by 40 degrees. However, tNSA decreased by 7.5 degrees during maturation, while the inclination increased by 32 degrees over the same period. This paper demonstrates angular changes in both the coronal and transverse planes with a 4:1 ratio of angular change in the transverse and coronal planes respectively. Interobserver Pearson coefficient R=0.98 and an intraobserver Pearson coefficient R=0.99. CONCLUSIONS: Although Walker and Goldsmith reported angular changes only in the transverse plane, we conclude that they identified angular changes in both the coronal and transverse planes. Here we show it is mathematically necessary for tNSA to decrease, if aNSA remains constant as version increases. CLINICAL RELEVANCE: A reader who is not well versed in the difference between aNSA and tNSA or version and inclination cannot appreciate what Walker and Goldsmith presented. Surgeons operating on the proximal femur also benefit from understanding these distinctions.

The Rothman Index Is Associated With Postdischarge Adverse Events After Hip Fracture Surgery in Geriatric Patients.

BACKGROUND: The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population. QUESTIONS/PURPOSES: (1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes? METHODS: One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes. RESULTS: We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05). CONCLUSIONS: The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care. LEVEL OF EVIDENCE: Level II, diagnostic study.

Discriminative Ability of Elixhauser's Comorbidity Measure is Superior to Other Comorbidity Scores for Inpatient Adverse Outcomes After Total Hip Arthroplasty.

BACKGROUND: Identifying patients at highest risk for a complex perioperative course following total hip arthroplasty (THA) is more important than ever in order to educate patients, optimize outcomes, and to minimize cost and length of stay. There are no known studies comparing the clinically relevant discriminative ability of 3 commonly used comorbidity indices for adverse outcomes following THA: Elixhauser Comorbidity Measure (ECM), the Charlson Comorbidity Index (CCI), and the modified Frailty Index (mFI). METHODS: Patients undergoing THA were extracted from the 2013 National Inpatient Sample. The discriminative ability of ECM, CCI, and mFI, as well as the demographic factors age, body mass index, and gender for the occurrence of index admission Centers for Medicare & Medicaid Services procedure-specific complication measures, extended length of hospital stay, and discharge to a facility were assessed using the area under the curve analysis from receiver operating characteristic curves. RESULTS: ECM outperformed CCI and mFI for the occurrence of all 5 adverse outcomes. Age outperformed gender and obesity for the occurrence of all 5 adverse outcomes. ECM (the best performing comorbidity index) outperformed age (the best performing demographic factor) in discriminative ability for the occurrence of 3 of 5 adverse outcomes. CONCLUSION: The less commonly used ECM outperformed the more often utilized CCI and newer mFI as well as demographic factors in correctly preoperatively identifying patients' probabilities of experiencing an adverse outcome suggesting that wider adoption of ECM should be considered in both identifying likelihoods of adverse patient outcomes and for research purposes in future studies.

Humeral Head Ossification Predicts Peak Height Velocity Timing and Percentage of Growth Remaining in Children.

BACKGROUND: Understanding skeletal maturity is important in the management of idiopathic scoliosis. Iliac apophysis, triradiate cartilage, hand, and calcaneal ossification patterns have previously been described to assess both peak height velocity (PHV) and percent growth remaining; however, these markers may not be present on standard spine radiographs. The purpose of this study was to describe a novel maturity assessment method based on proximal humeral epiphyseal ossification patterns. METHODS: Ninety-four children were followed at least annually throughout growth with serial radiographs and physical examinations. The PHV of each child was determined by measuring the change in height observed at each visit and adjusting for the interval between visits. Percent growth remaining was determined by comparing current to final standing height. The humeral head periphyseal ossification was grouped into stages by 8 investigators ranging from medical student to attending surgeon. RESULTS: The morphologic changes involving the proximal humeral physis were categorized into 5 stages based on development of the humeral head epiphysis and fusion of the lateral margin of the physis. Our novel classification scheme was well distributed around the PHV and reliably correlated with age of peak growth and percent growth remaining with >70% nonoverlapping interquartile ranges. Furthermore, the scheme was extremely reliable with intraclass correlation coefficients of 0.96 and 0.95 for intraobserver and interobserver comparisons, respectively. CONCLUSIONS: The humeral head classification system described here was strongly correlated with age of PHV as well as percentage growth remaining. Furthermore, the staging system was extremely reliable in both interobserver and intraobserver correlations suggesting that it can be easily generalized. CLINICAL RELEVANCE: As a view of the humeral head is almost always present on standard scoliosis spine x-ray at our institution, our classification can be easily adapted by surgeons to gain additional insight into skeletal maturity of patients with scoliosis. We believe that our method will significantly improve the evaluation of the child with scoliosis without increasing radiation exposure, time, or cost.

Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

BACKGROUND: There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are "observed" for one or more nights. Current regulations in the United States allow these "observed" patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, "outpatient" means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data. QUESTIONS/PURPOSES: The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of "inpatient" and "outpatient" (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions. METHODS: Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed "outpatient" by the hospital. The actual hospital LOS of "outpatients" was characterized. "Outpatients" were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors. RESULTS: Of 72,651 patients undergoing THA, 529 were identified as "outpatients" but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as "outpatients" but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found "inpatient" THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with "outpatient" THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort. CONCLUSIONS: Future THA, TKA, or other investigations on this topic should consistently quantify the term "outpatient" because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison of Outpatient vs Inpatient Total Knee Arthroplasty: An ACS-NSQIP Analysis.

BACKGROUND: There has been a recent surge of interest in performing primary total knee arthroplasty (TKA) in the outpatient setting to reduce cost and increase patient satisfaction. Detailed information on the safety of outpatient TKA in large sample sizes is scarce. METHODS: Patients who underwent primary, elective TKA were identified in the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days, whereas inpatient procedure was defined as having a length of stay ≥1 days. To reduce the effect of confounding factors and nonrandom assignment of treatment, propensity score matching was used. Multivariate analyses on the matched samples were used to compare the rates of adverse events that happened any time during the 30-day postoperative period, postdischarge adverse events, and readmissions between the outpatient and inpatient cohorts. RESULTS: A total of 112,922 TKA patients met the inclusion criteria. Of these, only 642 (0.57%) were outpatient procedures. Outpatients tended to be men, slightly younger, and have less comorbidity. After propensity matching, multivariate analysis revealed a higher rate of postdischarge blood transfusions (P < .001) in the outpatient cohort. There were no other significant differences in 30-day postoperative individual adverse events or readmissions. CONCLUSION: Based on the perioperative outcome measures studied here, outpatient TKA can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients postdischarge may be warranted.

Synthesis and characterization of a hydrogel with controllable electroosmosis: a potential brain tissue surrogate for electrokinetic transport.

Electroosmosis is the bulk fluid flow initiated by application of an electric field to an electrolyte solution in contact with immobile objects with a nonzero ζ-potential such as the surface of a porous medium. Electroosmosis may be used to assist analytical separations. Several gel-based systems with varying electroosmotic mobilities have been made in this context. A method was recently developed to determine the ζ-potential of organotypic hippocampal slice cultures (OHSC) as a representative model for normal brain tissue. The ζ-potential of the tissue is significant. However, determining the role of the ζ-potential in solute transport in tissue in an electric field is difficult because the tissue's ζ-potential cannot be altered. We hypothesized that mass transport properties, namely the ζ-potential and tortuosity, could be modulated by controlling the composition of a set of hydrogels. Thus, poly(acrylamide-co-acrylic acid) gels were prepared with three compositions (by monomer weight percent): acrylamide/acrylic acid 100/0, 90/10, and 75/25. The ζ-potentials of these gels at pH 7.4 are distinctly different, and in fact vary approximately linearly with the weight percent of acrylic acid. We discovered that the 25% acrylic acid gel is a respectable model for brain tissue, as its ζ-potential is comparable to the OHSC. This series of gels permits the experimental determination of the importance of electrokinetic properties in a particular experiment or protocol. Additionally, tortuosities were measured electrokinetically and by evaluating diffusion coefficients. Hydrogels with well-defined ζ-potential and tortuosity may find utility in biomaterials and analytical separations, and as a surrogate model for OHSC and living biological tissues.

Whole brain segmentation with full volume neural network.

Whole brain segmentation is an important neuroimaging task that segments the whole brain volume into anatomically labeled regions-of-interest. Convolutional neural networks have demonstrated good performance in this task. Existing solutions, usually segment the brain image by classifying the voxels, or labeling the slices or the sub-volumes separately. Their representation learning is based on parts of the whole volume whereas their labeling result is produced by aggregation of partial segmentation. Learning and inference with incomplete information could lead to sub-optimal final segmentation result. To address these issues, we propose to adopt a full volume framework, which feeds the full volume brain image into the segmentation network and directly outputs the segmentation result for the whole brain volume. The framework makes use of complete information in each volume and can be implemented easily. An effective instance in this framework is given subsequently. We adopt the 3D high-resolution network (HRNet) for learning spatially fine-grained representations and the mixed precision training scheme for memory-efficient training. Extensive experiment results on a publicly available 3D MRI brain dataset show that our proposed model advances the state-of-the-art methods in terms of segmentation performance.

Modification and application of the proximal humerus ossification system to adolescent idiopathic scoliosis patients.

PURPOSE: We have previously demonstrated that proximal humeral ossification patterns are reliable for assessing peak height velocity in growing patients. Here, we sought to modify the system by including medial physeal closure and evaluate whether this system combined with the Cobb angle correlates with progression to surgery in patients with adolescent idiopathic scoliosis. METHODS: We reviewed 616 radiographs from 79 children in a historical collection to integrate closure of the medial physis into novel stages 3A and 3B. We then analyzed radiographs from the initial presentation of 202 patients with adolescent idiopathic scoliosis who had either undergone surgery or completed monitoring at skeletal maturity. Summary statistics for the percentage of patients who progressed to the surgical range were calculated for each category of humerus and Cobb angle. RESULTS: The intra-observer and inter-observer ICC for assessment of the medial physis was 0.6 and 0.8, respectively. Only 3.4% of radiographs were unable to be assessed for medial humerus closure. The medial humerus physis begins to close about 1 year prior to the lateral physis and patients with a closing medial physis, but an open lateral physis were found to be the closest to PHV (0.7 years). Stratifying patients by Cobb angle and modified humerus stage yield categories with low and high risks of progression to the surgical range. CONCLUSION: The medial humerus can be accurately evaluated and integrated into a new modified proximal humerus ossification system. Patients with humerus stage 3A or below have a higher rate of progression to the surgical range than those with humerus stage 3B or above.

Incidence and considerations of 90-day readmissions following posterior lumbar fusion.

BACKGROUND CONTEXT: Posterior lumbar fusion (PLF) is a commonly performed procedure. The evolution of bundled payment plans is beginning to require physicians to more closely consider patient outcomes up to 90 days after an operation. Current quality metrics and other databases often consider only 30 postoperative days. The relatively new Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD) tracks patient-linked hospital admissions data for up to one calendar year. PURPOSE: To identify readmission rates within 90 days of discharge following PLF and to put this in context of 30 day readmission and baseline readmission rates. STUDY DESIGN: Retrospective study of patients in the HCUP-NRD. PATIENT SAMPLE: Any patient undergoing PLF performed in the first 9 months of 2013 were identified in the HCUP-NRD. OUTCOME MEASURES: Readmission patterns up to a full calendar year after discharge. METHODS: PLFs performed in the first 9 months of 2013 were identified in the HCUP-NRD. Patient demographics and readmissions were tracked for 90 days after discharge. To estimate the average admission rate in an untreated population, the average daily admission rate in the last quarter of the year was calculated for a subset of PLF patients who had their operation in the first quarter of the year. This study was deemed exempt by the institution's Human Investigation Committee. RESULTS: Of 26,727 PLFs, 1,580 patients (5.91%) were readmitted within 30 days of discharge and 2,603 patients (9.74%) were readmitted within 90 days of discharge. Of all readmissions within 90 days, 54.56% occurred in the first 30 days. However, if only counting readmissions above the baseline admission rate of a matched population from the 4th quarter of the year (0.08% of population/day), 89.78% of 90 day readmissions occurred within the first 30 days. CONCLUSIONS: The current study delineates readmission rates after PLF and puts this in the context of 30-day readmission rates and baseline readmission rates for those undergoing PLF. These results are important for patient counseling, planning, and preparing for potential bundled payments in spine surgery.

Management of Degenerative Spondylolisthesis: Analysis of a Questionnaire Study, Correlation With a National Sample, and Perioperative Outcomes of Treatment Options.

BACKGROUND: Surgical treatment for lumbar degenerative spondylolisthesis has been shown to provide better long-term outcomes than conservative treatment. However, there is variation in surgical approaches employed by surgeons. This study investigates current surgical practice patterns and compares perioperative outcomes of 3 common surgical treatments for this pathology. METHODS: A survey was administered to surgeons who attended the Lumbar Spine Research Society (LSRS) meeting in 2014. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2014 to characterize the same responses. The 2 data sets were compared. Perioperative outcomes of those in the ACS-NSQIP posterior fusion subcohorts were characterized and compared. RESULTS: Posterior surgical approaches utilized by surgeons who responded to the LSRS survey were similar to those captured by ACS-NSQIP where 72% of those with degenerative spondylolisthesis were fused. Of those that were fused, 8% had an uninstrumented posterior fusion, 33% had an instrumented posterior fusion, and 59% had an instrumented posterior fusion with interbody. On multivariate analysis, there was no difference in risk of postoperative adverse events, readmission, or length of stay between these 3 common types of fusion. CONCLUSIONS: Practice patterns for the posterior management of lumbar degenerative spondylolisthesis were similar between LSRS survey responses and ACS-NSQIP data. The ACS-NSQIP perioperative outcome measures assessed were similar regardless of surgical technique. These findings highlight that cost-benefit considerations and longer-term outcomes have to be the measures by which surgical technique is chosen for degenerative spondylolisthesis.

The Proximal Humeral Ossification System Improves Assessment of Maturity in Patients with Scoliosis.

BACKGROUND: We recently developed a classification system to assess skeletal maturity by scoring proximal humeral ossification in a similar way to the canonical Risser sign. The purpose of the present study was to determine whether our system can be used to reliably assess radiographs of the spine for modern patients with idiopathic scoliosis, whether it can be used in combination with the Sanders hand system, and whether the consideration of patient factors such as age, sex, and standing height improves the accuracy of predictions. METHODS: We retrospectively reviewed 414 randomized radiographs from 216 modern patients with scoliosis and measured reliability with use of the intraclass correlation coefficient (ICC). We then analyzed 606 proximal humeral radiographs for 70 children from a historical collection to determine the value of integrating multiple classification systems. The age of peak height velocity (PHV) was predicted with use of linear regression models, and performance was evaluated with use of tenfold cross-validation. RESULTS: The proximal humeral ossification system demonstrated excellent reliability in modern patients with scoliosis, with an ICC of 0.97 and 0.92 for intraobserver and interobserver comparisons, respectively. The use of our system in combination with the Sanders hand system yielded 7 categories prior to PHV and demonstrated better results compared with either system alone. Linear regression algorithms showed that integration of the proximal part of the humerus, patient factors, and other classification systems outperformed models based on canonical Risser and triradiate-closure methods. CONCLUSIONS: Humeral head ossification can be reliably assessed in modern patients with scoliosis. Furthermore, the system described here can be used in combination with other parameters such as the Sanders hand system, age, sex, and height to predict PHV and percent growth remaining with high accuracy. CLINICAL RELEVANCE: The proximal humeral ossification system can improve the prediction of PHV in patients with scoliosis on the basis of a standard spine radiograph without a hand radiograph for the determination of bone age. This increased accuracy for predicting maturity will allow physicians to better assess patient maturity relative to PHV and therefore can help to guide treatment decision-making without increasing radiation exposure, time, or cost. The present study demonstrates that assessment of the proximal humeral physis is a viable and valuable aid in the determination of skeletal maturity as obtained from radiographs of the spine that happen to include the shoulder in adolescent patients with idiopathic scoliosis.

Longer Operative Time Is Associated With Increased Adverse Events After Anterior Cervical Diskectomy and Fusion: 15-Minute Intervals Matter.

Little is known about the impact of operative time, as an independent and interval variable, on general health perioperative outcomes following anterior cervical diskectomy and fusion. Therefore, patients undergoing a 1-level anterior cervical diskectomy and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as an interval variable) was tested for association with perioperative outcomes using a multivariate regression that was adjusted for differences in baseline characteristics. A total of 15,241 patients were included. Increased surgical duration was consistently correlated with a rise in any adverse event postoperatively, with each additional 15 minutes of operating time raising the risk for having any adverse event by an average of 10% (99.64% confidence interval, 3%-17%, P<.001). In fact, 15-minute increases in surgical duration were associated with incremental increases in the rates of venous thromboembolism, sepsis, unplanned intubation, extended length of hospital stay, and hospital readmission. Greater operative time, despite controlling for other patient variables, increases the risk for overall postoperative adverse events and multiple individual adverse outcomes. This increased risk may be attributed to anesthetic effects, physiologic stresses, and surgical site issues. Although it is difficult to fully isolate operative time as an independent variable because it may be closely related to the complexity of the surgical pathology being addressed, the current study suggests that surgeons should maximize operative efficiency as possible (potentially using strategies that have been shown to improve operative time in the 15-minute magnitude), without compromising the technical components of the procedure. [Orthopedics. 2018; 41(4):e483-e488.].

Adverse Events Following Posterior Lumbar Fusion: A Comparison of Spine Surgeons Perceptions and Reported Data for Rates and Risk Factors.

BACKGROUND: Postoperative complications and risks factors for adverse events play an important role in both decision making and patient expectation setting. The present study serves to contrast surgeons' perceived and reported rates of postoperative adverse events following posterior lumbar fusion (PLF) and to assess the accuracy of predicting the impact of patient factors on such outcomes. METHODS: A survey investigating perceived rates of adverse events and the impact of patient risk factors on them following PLF for degenerative conditions was distributed to spine surgeons at the Lumbar Spine Research Society (LSRS) 2016 annual meeting. For comparison, the corresponding rates and patient risk factors were assessed in patients undergoing elective PLF from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data years 2011-2014. RESULTS: From the survey, there were 53 responses (response rate of 79%) from attending physicians at LSRS. From NSQIP, there were 16,589 patients who met the inclusion criteria. Adverse event rates estimated by the surgeons at LSRS were close to those determined by NSQIP data (no greater than 2.81% different). The largest differences were for deep vein thrombosis (overestimation of 2.81%, P < .001), anemia requiring transfusion (overestimation of 2.47%, P = .018), and urinary tract infection (overestimation of 2.29%, P < .001). Similarly, the estimated impact of patient factors was similar to the data (within relative risk of 2.02). The largest differences were for current smoking (overestimation of 2.02 relative risk, P < .001), insulin dependent diabetes (overestimation of 1.36, P < .001), and obesity (overestimation of 1.35, P < .001). CONCLUSIONS: The current study noted that surgeon estimates were relatively close to national numbers for estimating the adverse events and impact of patient factors on such outcomes after PLF for degenerative conditions. The estimates are roughly appropriate with a bias toward overestimation for planning and expectation setting.

Predicting Adverse Outcomes After Total Hip Arthroplasty: A Comparison of Demographics, the American Society of Anesthesiologists class, the Modified Charlson Comorbidity Index, and the Modified Frailty Index.

INTRODUCTION: No known study has compared the predictive power of the American Society of Anesthesiologists (ASA) class, modified Charlson Comorbidity Index, modified Frailty Index, and demographic characteristics for general health complications after total hip arthroplasty (THA). METHODS: Comorbidity indices and demographics from National Surgical Quality Improvement Program THA patients were evaluated for discriminative ability in predicting adverse outcomes using the area under the curve analysis from the receiver operating characteristic curves. Perioperative outcomes included any adverse event, severe adverse events, minor adverse events, extended hospital stay, and discharge to higher-level care. RESULTS: In total, 64,792 THA patients were identified. The most predictive comorbidity index was ASA, and demographic factor was age. Of these, age had the greatest discriminative ability for four of the five adverse outcomes. CONCLUSION: For THA, easily obtained patient ASA and age are more predictive of perioperative adverse outcomes than the more complex and numerically tabulated modified Charlson Comorbidity Index and modified Frailty Index.

General Health Adverse Events Within 30 Days Following Anterior Cervical Discectomy and Fusion in US Patients: A Comparison of Spine Surgeons' Perceptions and Reported Data for Rates and Risk Factors.

STUDY DESIGN: Survey study and retrospective review of prospective data. OBJECTIVES: To contrast surgeons' perceptions and reported national data regarding the rates of postoperative adverse events following anterior cervical discectomy and fusion (ACDF) and to assess the accuracy of surgeons in predicting the impact of patient factors on such outcomes. METHODS: A survey investigating perceived rates of perioperative complications and the perceived effect of patient risk factors on the occurrence of complications following ACDF was distributed to spine surgeons at the Cervical Spine Research Society (CSRS) 2015 Annual Meeting. The equivalent reported rates of adverse events and impacts of patient risk factors on such complications were assessed in patients undergoing elective ACDF from the National Surgical Quality Improvement Program (NSQIP). RESULTS: There were 110 completed surveys from attending physicians at CSRS (response rate = 44%). There were 18 019 patients who met inclusion criteria in NSQIP years 2011 to 2014. The rates of 11 out of 17 (65%) postoperative adverse events were mildly overestimated by surgeons responding to the CSRS questionnaire in comparison to reported NSQIP data (overestimates ranged from 0.24% to 1.50%). The rates of 2 out of 17 (12%) postoperative adverse events were mildly underestimated by surgeons (range = 0.08% to 1.2%). The impacts of 5 out of 10 (50%) patient factors were overestimated by surgeons (range relative risk = 0.56 to 1.48). CONCLUSIONS: Surgeon estimates of risk factors for and rates of adverse events following ACDF procedures were reasonably nearer to national data. Despite an overall tendency toward overestimation, surgeons' assessments are roughly appropriate for surgical planning, expectation setting, and quality improvement initiatives.

High Publication Rate of Abstracts Presented at Lumbar Spine Research Society Meetings.

BACKGROUND: Although publication rates from multiple orthopedic research conferences have been published in the literature, the publication rates of abstracts presented at the Lumbar Spine Research Society (LSRS) meetings have never been reported. The purpose of this study is to evaluate the publication rates from the LSRS annual meeting years 2008-2012 and then to compare those rates with that of other spine research society meetings. METHODS: Podium presentations from 2008 to 2012 and poster presentations from 2010 to 2012 were reviewed. For each presentation, a PubMed search was performed to determine if a full-text publication existed. χ2 tests were used to compare LSRS publication rates to those of other spine meetings. In addition, impact of published articles was evaluated by average citation count and average journal impact factor. RESULTS: From 2008 to 2012, a total of 332 podium and poster presentations were identified. The overall publication rate was 55.1% (183/332). For podium presentations, this was greatest in 2012 (66.0%) and lowest in 2008 (51.5%). For poster presentations, this was greatest in 2012 (53.6%) and lowest in 2010 (25.0%). The publication rate of presentations is statistically greater than the publication rates of Eurospine (37.8%, P < .001), North American Spine Society (40.0%, P < .001), The International Society for the Study of the Lumbar Spine (45.0%, P = .012), and the Scoliosis Research Society (47.0%, P = .042) but not statistically different than that of Cervical Spine Research Society (65.7%, P = .059). In addition, the average citation count per published article categorized by year ranged from 13 to 31. The average journal impact factor of published articles categorized by year ranged from 2.31 to 2.55. CONCLUSIONS: While LSRS is a relatively young society, these findings point to the high quality of presentations at this scientific meeting. These findings speak to the scientific rigor of presentations at LSRS. CLINICAL RELEVANCE: This study helps clinicians and scientists gauge the quality of a research meeting and make informed choices on which gatherings to attend.