"Reverse roussouly": cervicothoracic curvature ratios define characteristic shapes in adult cervical deformity.

PURPOSE: To investigate normal curvature ratios of the cervicothoracic spine and to establish radiographic thresholds for severe myelopathy and disability, within the context of shape. METHODS: Adult cervical deformity (CD) patients undergoing cervical fusion were included. C2-C7 Cobb angle (CL) and thoracic kyphosis (TK), using T2-T12 Cobb angle, were used as a ratio, ranging from -1 to + 1. Pearson bivariate r and univariate analyses analyzed radiographic correlations and differences in myelopathy(mJOA > 14) or disability(NDI > 40) across ratio groups. RESULTS: Sixty-three CD patients included. Regarding CL:TK ratio, 37 patients had a negative ratio and 26 patients had a positive ratio. A more positive CL:TK correlated with increased TS-CL(r = 0.655, p = < 0.001)and mJOA(r = 0.530, p = 0.001), but did not correlate with cSVA/SVA or NDI scores. A positive CL:TK ratio was associated with moderate disability(NDI > 40)(OR: 7.97[1.22-52.1], p = 0.030). Regression controlling for CL:TK ratio revealed cSVA > 25 mm increased the odds of moderate to severe myelopathy and cSVA > 30 mm increased the odds of significant neck disability. Lastly, TS-CL > 29 degrees increased the odds of neck disability by 4.1 × with no cutoffs for severe mJOA(p > 0.05). CONCLUSIONS: Cervical deformity patients with an increased CL:TK ratio had higher rates of moderate neck disability at baseline, while patients with a negative ratio had higher rates of moderate myelopathy clinically. Specific thresholds for cSVA and TS-CL predicted severe myelopathy or neck disability scores, regardless of baseline neck shape. A thorough evaluation of the cervical spine should include exploration of relationships with the thoracic spine and may better allow spine surgeons to characterize shapes and curves in cervical deformity patients.

Health-related quality of life measures in adult spinal deformity: can we replace the SRS-22 with PROMIS?

PURPOSE: To determine the validity and responsiveness of PROMIS metrics versus the SRS-22r questionnaire in adult spinal deformity (ASD). METHODS: Surgical ASD patients undergoing ≥ 4 levels fused with complete baseline PROMIS and SRS-22r data were included. Internal consistency (Cronbach's alpha) and test-retest reliability [intraclass correlation coefficient (ICC)] were compared. Cronbach's alpha and ICC values ≥ 0.70 were predefined as satisfactory. Convergent validity was evaluated via Spearman's correlations. Responsiveness was assessed via paired samples t tests with Cohen's d to assess measure of effect (baseline to 3 months). RESULTS: One hundred and ten pts are included. Mean baseline SRS-22r score was 2.62 ± 0.67 (domains = Function: 2.6, Pain: 2.5, Self-image: 2.2, Mental Health: 3.0). Mean PROMIS domains = Physical Function (PF): 12.4, Pain Intensity (PI): 91.7, Pain Interference (Int): 55.9. Cronbach's alpha, and ICC were not satisfactory for any SRS-22 and PROMIS domains. PROMIS-Int reliability was low for all SRS-22 domains (0.037-0.225). Convergent validity demonstrated strong correlation via Spearman's rho between PROMIS-PI and overall SRS-22r (- 0.61), SRS-22 Function (- 0.781), and SRS-22 Pain (- 0.735). PROMIS-PF had strong correlation with SRS-22 Function (0.643), while PROMIS-Int had moderate correlation with SRS-22 Pain (- 0.507). Effect size via Cohen's d showed that PROMIS had superior responsiveness across all domains except for self-image. CONCLUSIONS: PROMIS is a valid measure compared to SRS-22r in terms of convergent validity, and has greater measure of effect in terms of responsiveness, but failed in reliability and internal consistency. Surgeons should consider the lack of reliability and internal consistency (despite validity and responsiveness) of the PROMIS to SRS-22r before replacing the traditional questionnaire with the computer-adaptive testing.

Adult cervical spine deformity: a state-of-the-art review.

Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.

Compensation from mild and severe cases of early proximal junctional kyphosis may manifest as progressive cervical deformity at two year follow-up.

BACKGROUND: Postoperative reciprocal changes (RC) in the cervical spine associated with varying factors of proximal junctional kyphosis (PJK) following fusions of the thoracopelvic spine are poorly understood. PURPOSE: Explore reciprocal changes in the cervical spine associated with varying factors (severity, progression, patient age) of PJK in patients undergoing adult spinal deformity (ASD) correction. PATIENTS AND METHODS: Retrospective review of a multicenter ASD database. INCLUSION: ASD patients > 18 y/o, undergoing fusions from the thoracic spine (UIV: T6-T12) to the pelvis with two-year radiographic data. ASD was defined as: Coronal Cobb angle ≥ 20°, Sagittal Vertical Axis ≥ 5 cm, Pelvic Tilt ≥ 25°, and/or Thoracic Kyphosis ≥ 60°. PJK was defined as a ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Patients were grouped by mild (M; 10°-20°) and severe (S; > 20°) PJK at one year. Propensity Score Matching (PSM) controlled for CCI, age, PI and UIV. Unpaired and paired t test analyses determined difference between RC parameters and change between time points. Pearson bi-variate correlations analyzed associations between RC parameters (T4-T12, TS-CL, cSVA, C2-Slope, and T1-Slope) and PJK descriptors. RESULTS: 284 ASD patients (UIV: T6: 1.1%; T7: 0.7%; T8: 4.6%; T9: 9.9%; T10: 58.8%; T11: 19.4%; T12: 5.6%) were studied. PJK analysis consisted of 182 patients (Mild = 91 and Severe = 91). Significant difference between M and S groups were observed in T4-T12 Δ1Y(- 16.8 v - 22.8, P = 0.001), TS-CLΔ1Y(- 0.6 v 2.8, P = 0.037), cSVAΔ1Y(- 1.8 v 1.9, P = 0.032), and C2 slopeΔ1Y(- 1.6 v 2.3, P = 0.022). By two years post-op, all changes in cervical alignment parameters were similar between mild and severe groups. Correlation between age and cSVAΔ1Y(R = 0.153, P = 0.034) was found. Incidence of severe PJK was found to correlate with TS-CLΔ1Y(R = 0.142, P = 0.049), cSVAΔ1Y(R = 0.171, P = 0.018), C2SΔ1Y(R = 0.148, P = 0.040), and T1SΔ2Y(R = 0.256, P = 0.003). CONCLUSIONS: Compensation within the cervical spine differed between individuals with mild and severe PJK at one year postoperatively. However, similar levels of pathologic change in cervical alignment parameters were seen by two years, highlighting the progression of cervical compensation due to mild PJK over time. These findings provide greater evidence for the development of cervical deformity in individuals presenting with proximal junctional kyphosis.

Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.

Background: With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. Purpose: The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. Study Design/Setting: This was a retrospective cohort study of the PearlDiver database. Patient Sample: We enrolled 670,526 patients undergoing spine fusion surgery. Outcome Measures: Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. Methods: Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05. Results: Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013). Conclusions: When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes.

Background: There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed. Results: Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P trend < .0001). Conclusion: Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.

Concurrent Presence of Thoracolumbar Scoliosis and Chiari Malformation: Is Operative Risk Magnified?

STUDY DESIGN: Retrospective review of Kids' Inpatient Database (KID). PURPOSE: Identify the risks and complications associated with surgery in adolescents diagnosed with Chiari and scoliosis. OVERVIEW OF LITERATURE: Scoliosis is frequently associated with Chiari malformation (CM). More specifically, reports have been made about this association with CM type I in the absence of syrinx status. METHODS: The KID was used to identify all pediatric inpatients with CM and scoliosis. The patients were stratified into three groups: those with concomitant CM and scoliosis (CMS group), those with only CM (CM group), and those with only scoliosis (Sc group). Multivariate logistic regressions were used to assess association between surgical characteristics and diagnosis with complication rate. RESULTS: A total of 90,707 spine patients were identified (61.8% Sc, 37% CM, 1.2% CMS). Sc patients were older, had a higher invasiveness score, and higher Charlson comorbidity index (all p<0.001). CMS patients had significantly higher rates of surgical decompression (36.7%). Sc patients had significantly higher rates of fusions (35.3%) and osteotomies (1.2%, all p<0.001). Controlling for age and invasiveness, postoperative complications were significantly associated with spine fusion surgery for Sc patients (odds ratio [OR], 1.8; p<0.05). Specifically, posterior spinal fusion in the thoracolumbar region had a greater risk of complications (OR, 4.9) than an anterior approach (OR, 3.6; all p<0.001). CM patients had a significant risk of complications when an osteotomy was performed as part of their surgery (OR, 2.9) and if a spinal fusion was concurrently performed (OR, 1.8; all p<0.05). Patients in the CMS cohort were significantly likely to develop postoperative complications if they underwent a spinal fusion from both anterior (OR, 2.5) and posterior approach (OR, 2.7; all p<0.001). CONCLUSIONS: Having concurrent scoliosis and CM increases operative risk for fusion surgeries despite approach. Being independently inflicted with scoliosis or Chiari leads to increased complication rate when paired with thoracolumbar fusion and osteotomies; respectively.

Trends in usage of navigation and robotic assistance in elective spine surgeries: a study of 105,212 cases from 2007 to 2015.

OBJECTIVE: Identify trends of navigation and robotic-assisted elective spine surgeries. METHODS: Elective spine surgery patients between 2007 and 2015 in the Nationwide Inpatient Sample (NIS) were isolated by ICD-9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified via chi-squared and t tests. Each system was analyzed from 2007 to 2015 for trends in usage. RESULTS: Included 3,759,751 patients: 100,488 Nav; 4724 Rob. Nav were younger (56.7 vs 62.7 years), had lower comorbidity index (1.8 vs 6.2, all p < 0.05), more decompressions (79.5 vs 42.6%) and more fusions (60.3 vs 52.6%) than Rob. From 2007 to 2015, incidence of complication increased for Nav (from 5.8 to 21.7%) and Rob (from 3.3 to 18.4%) as well as 2-3 level fusions (from 50.4 to 52.5%) and (from 1.3 to 3.2%); respectively. Invasiveness increased for both (Rob: from 1.7 to 2.2; Nav: from 3.7 to 4.6). Posterior approaches (from 27.4 to 41.3%), osteotomies (from 4 to 7%), and fusions (from 40.9 to 54.2%) increased in Rob. Anterior approach for Rob decreased from 14.9 to 14.4%. Nav increased posterior (from 51.5% to 63.9%) and anterior approaches (from 16.4 to 19.2%) with an increase in osteotomies (from 2.1 to 2.7%) and decreased decompressions (from 73.6 to 63.2%). CONCLUSIONS: From 2007 to 2015, robotic and navigation systems have been performed on increasingly invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches, whereas navigation computer-assisted procedures have decreased in rates of usage for decompression procedures.

Establishment of an Individualized Distal Junctional Kyphosis Risk Index following the Surgical Treatment of Adult Cervical Deformities.

STUDY DESIGN: A retrospective review of a multicenter comprehensive cervical deformity (CD) database. OBJECTIVE: To develop a novel risk index specific to each patient to aid in patient counseling and surgical planning to minimize postop distal junctional kyphosis (DJK) occurrence. BACKGROUND: DJK is a radiographic finding identified after patients undergo instrumented spinal fusions which can result in sagittal spinal deformity, pain and disability, and potentially neurological compromise. DJK is considered multifactorial in nature and there is a lack of consensus on the true etiology of DJK. MATERIALS AND METHODS: CD patients with baseline (BL) and at least one-year postoperative radiographic follow-up were included. A patient-specific DJK score was created through use of unstandardized Beta weights of a multivariate regression model predicting DJK (end of fusion construct to the second distal vertebra change in this angle by <-10° from BL to postop). RESULTS: A total of 110 CD patients included (61 yr, 66.4% females, 28.8 kg/m 2 ). In all, 31.8% of these patients developed DJK (16.1% three males, 11.4% six males, 62.9% one-year). At BL, DJK patients were more frail and underwent combined approach more (both P <0.05). Multivariate model regression analysis identified individualized scores through creation of a DJK equation: -0.55+0.009 (BL inclination)-0.078 (preinflection)+5.9×10 -5 (BL lowest instrumented vertebra angle) + 0.43 (combine approach)-0.002 (BL TS-CL)-0.002 (BL pelvic tilt)-0.031 (BL C2 - C7) + 0.02 (∆T4-T12)+ 0.63 (osteoporosis)-0.03 (anterior approach)-0.036 (frail)-0.032 (3 column osteotomy). This equation has a 77.8% accuracy of predicting DJK. A score ≥81 predicted DJK with an accuracy of 89.3%. The BL reference equation correlated with two year outcomes of Numeric Rating Scales of Back percentage ( P =0.003), reoperation ( P =0.04), and minimal clinically importance differences for 5-dimension EuroQol questionnaire ( P =0.04). CONCLUSIONS: This study proposes a novel risk index of DJK development that focuses on potentially modifiable surgical factors as well as established patient-related and radiographic determinants. The reference model created demonstrated strong correlations with relevant two-year outcome measures, including axial pain-related symptoms, occurrence of related reoperations, and the achievement of minimal clinically importance differences for 5-dimension EuroQol questionnaire.

Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression.

Background: Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods: This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results: One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions: Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.

External Validation of the National Surgical Quality Improvement Program Calculator Utilizing a Single Institutional Experience for Adult Spinal Deformity Corrective Surgery.

BACKGROUND: Identify the external applicability of the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk calculator in the setting of adult spinal deformity (ASD) and subsets of patients based on deformity and frailty status. METHODS: ASD patients were isolated in our single-center database and analyzed for the shared predictive variables displayed in the NSQIP calculator. Patients were stratified by frailty (not frail <0.03, frail 0.3-0.5, severely frail >0.5), deformity [T1 pelvic angle (TPA) > 30, pelvic incidence minus lumbar lordosis (PI-LL) > 20], and reoperation status. Brier scores were calculated for each variable to validate the calculator's predictability in a single center's database (Quality). External validity of the calculator in our ASD patients was assessed via Hosmer-Lemeshow test, which identified whether the differences between observed and expected proportions are significant. RESULTS: A total of 1606 ASD patients were isolated from the Quality database (48.7 years, 63.8% women, 25.8 kg/m2); 33.4% received decompressions, and 100% received a fusion. For each subset of ASD patients, the calculator predicted lower outcome rates than what was identified in the Quality database. The calculator showed poor predictability for frail, deformed, and reoperation patients for the category "any complication" because they had Brier scores closer to 1. External validity of the calculator in each stratified patient group identified that the calculator was not valid, displaying P values >0.05. CONCLUSION: The NSQIP calculator was not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to operating room, surgical site infection, urinary tract infection, and cardiac complications that are typically associated with poor patient outcomes. Physicians should not base their surgical plan solely on the NSQIP calculator but should consider multiple preoperative risk assessment tools.

Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: A Comprehensive 5-Phase Patient-Guided Program.

BACKGROUND: Many of the current rehabilitation programs for patients undergoing hip arthroscopy fail to consider the progression of soft tissue healing and inflammation that can be heightened due to aggressive therapy to the operative hip in the immediate postoperative period. HYPOTHESIS: It was hypothesized that introducing conservative physical therapy (PT) preoperatively along with a slow progression to return to activity using a structured, patient-guided postoperative program would improve patient outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors conducted a retrospective review of patients who received a hip arthroscopy, were at least 18 years old, and who had completed the following patient-reported outcomes (PROs) at 1-year follow-up: modified Harris Hip Score (mHHS), Hip Outcome Score, Nonarthritic Hip Score, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. Patients who underwent previous surgery on the ipsilateral hip and those with cartilage erosion down to exposed subchondral bone (Outerbridge grade 4) were excluded. Paired-samples t tests were used to compare the change in PRO scores at 3-month, 6-month, and 1-year follow-up, and the percentage of patients who achieved minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds on the mHHS were stratified according to their Outerbridge grade (0-3). RESULTS: Overall, 202 patients (53% female, 47% male) were included in the analysis. Significant improvement was seen from 3 to 6 months on all PRO measures and from 6 months to 1 year on all but the mHHS (P < .05 for all except the mHHS). A significantly smaller percentage of patients with Outerbridge grade 3 cartilage damage achieved the MCID and SCB on the mHHS compared with those with grade 0, both at 6 months (grade 3 vs 0: 20% vs 63.2% [MCID]; 18.0% vs 52.6% [SCB]; both P = .03) and 1 year (grade 3 vs 0: 22.0% vs 57.9% [MCID]; 14.0% vs 52.6% [SCB]; both P < .05). CONCLUSION: A structured, patient-guided PT protocol after arthroscopic acetabular labral repair can significantly improve postoperative outcomes.

Return to Full Function in Patient with Nonoperative Management of a Comminuted, Displaced Clavicle Fracture: A Case Report.

Case: Clavicle fractures are common skeletal injuries that account for 2%-10% of adult fractures. Surgical indications include presence of an open fracture, severe angulation, comminution, displacement, skin tenting with a threat of skin perforation, neurovascular compromise, symptomatic nonunion, or fracture shortening >1.5-2cm. In this case, the patient had a comminuted, displaced fracture - thus meeting criteria for operative treatment. However, the patient opted for nonoperative management. Conclusion: After 3 months, the patient regained full strength and range-of-motion. This case highlights the current heterogenous mixture of studies in the literature surrounding the best management for midshaft clavicle fractures. The patient was informed that data concerning the case would be submitted for publication and provided consent.

Comparison of perioperative complications following surgical treatment of shoulder instability.

Background: Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow. Methods: This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time. Results: This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P trend < .001). Conclusion: In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score-matched analysis of 20,035 procedures.

BACKGROUND: As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care. METHODS: Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score-matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time. RESULTS: A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31). CONCLUSION: When compared with a propensity score-matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.

Calf Strain in Athletes.

¼: Calf strain is a common condition. In high-performance athletes, calf strain contributes to a substantial absence from competition. ¼: Player age and history of a calf strain or other leg injury are the strongest risk factors for calf strain injury and reinjury. ¼: Although the diagnosis is often clinical, magnetic resonance imaging and ultrasound are valuable to confirm the location of the strain and the grade of injury. ¼: Nonoperative treatment is effective for most calf strain injuries. Operative management, although rarely indicated, may be appropriate for severe cases with grade-III rupture or complications. ¼: Further investigation is necessary to elucidate the benefits of blood flow restriction therapy, deep water running, lower-body positive pressure therapy, platelet-rich plasma, and stem cell therapy for calf strain rehabilitation.

Do the newly proposed realignment targets bridge the gap between radiographic and clinical success in adult cervical deformity corrective surgery.

Hypothesis: The myelopathy-based cervical deformity (CD) thresholds will associate with patient-reported outcomes and complications. Materials and Methods: This study include CD patients (C2-C7 Cobb > 10°, CL > 10°, cervical sagittal vertical axis > 4 cm, or CBVA > 25°) with BL and 1-year (1Y) data. Modifiers assessed low (L), moderate (M), and severe (S) deformity: CL (L: >3°; M:-21° to 3°; S: <‒21°), TS-CL (L: <26°; M: 26° to 45°; S: >45°), C2-T3 angle (L: >‒25°; M:-35° to-25°; S: <‒35°), C2 slope (L: <33°; M: 33° to 49°; S: >49°), MGS (L: >‒9° and < 0°; M: ‒12° to ‒9° or 0° to 19°; S: < ‒12° or > 19°), and frailty (L: <0.18; M: 0.18-0.27, S: >0.27). Means comparison and ANOVA assessed outcomes in the severity groups at BL at 1Y. Correlations found between modifiers assessed the internal relationship. Results: One hundred and four patients were included in the study (57.1 years, 50%, 29.3 kg/m2). Baseline S TS-CL, C2-T3, and C2S modifiers were associated with increased reoperations (P < 0.01), while S MGS, CL, and C2-T3 had increased estimated blood lost (>1000ccs, P < 0.001). S MGS and C2-T3 had more postop DJK (60%, P = 0.018). Improvement in TS-CL, C2S, C2-T3, and CL patients had better numeric rating scale (NRS) back (<5) and EuroQOL 5-Dimension questionnaire (EQ5D) at 1 year (P < 0.05). Improving the modifiers correlated strongly with each other (0.213-0.785, P < 0.001). Worsened TS-CL had increased NRS back scores at 1 year (9, P = 0.042). Worsened CL had increased 1-year modified Japanese Orthopedic Association (mJOA) (7, P = 0.001). Worsened C2-T3 had worse NRS neck scores at 1 year (P = 0.048). Improvement in all six modifiers (8.7%) had significantly better health-related quality of life (HRQL) scores at follow-up (EQ5D, NRS, and Neck Disability Index). Conclusions: Newly proposed CD modifiers based on mJOA were closely associated with outcomes. Improvement and deterioration in the modifiers significantly impacted the HRQL.

Sex differences in utilization and perioperative outcomes of arthroscopic rotator cuff repair.

Background: As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes. Methods: Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex. Results: Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable. Conclusion: Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

External Validation of the European Spine Study Group-International Spine Study Group Calculator Utilizing a Single Institutional Experience for Adult Spinal Deformity Corrective Surgery.

BACKGROUND: The International Spine Study Group (ISSG) and the European Spine Study Group (ESSG) developed an adult spinal deformity (ASD) risk calculator based on one of the most granular, prospective ASD databases. The calculator utilizes preoperative radiographic, surgical, and patient-specific variables to predict patient-reported outcomes and complication rates at 2 years. Our aim was to assess the ISSG-ESSG risk calculator's usability in a single-institution ASD population. METHODS: Frail ([F], 0.3 > 0.5) ASD patients were isolated in a single-center ASD database. Basic demographics were assessed via χ 2 and t tests. Each F patient was inputted into the ESSG risk calculator to identify individual predictive rates for postoperative 2-year health-related quality of life questions (HRQL) outcomes and major complications. These calculated predicted outcomes were analyzed against those identified from the ASD database in order to validate the calculator's predictability via Brier scores. A score closer to 1 meant the ISSG-ESSG calculator was not predictive of that specific outcome. A score closer to 0 meant the ISSG-ESSG calculator was a predictive tool for that factor. RESULTS: A total of 631 ASD patients were isolated (55.8 ± 16.8 years, 26.68 kg/m2, 0.95 ± 1.3 Charlson Comorbidity Index). Of those patients, 7.8% were frail. Fifty percent of frail patients received an interbody fusion, 58.3% received a decompression, and 79.2% underwent osteotomy. Surgical details were as follows: mean operative time was 342.9 ± 94.3 minutes, mean estimated blood loss was 2131.82 ± 1011 mL, and average length of stay was 7.12 ± 2.5 days. The ISSG-ESSG calculator predicted the likelihood of improvement for the following HRQL's: Oswestry Disability Index (ODI) (86%), Scoliosis Research Society (SRS)-22 mental health (71.1%), SRS-22 total (87.6%), and major complication (53.4%). The single institution had lower percentages of improvement in ODI (24.6%), SRS-22 mental health (21.3%), SRS-22 total (25.1%), and lower presence of major complication (34.8%). The calculated Brier scores identified the calculator's predictability for each factor was as follows: ODI (0.24), SRS-22 mental health (0.21), SRS-22 total (0.25), and major complication (0.28). CONCLUSIONS: All of the variables had low Brier scores, indicating that the ISSG-ESSG calculator can be used as a predictive tool for ASD frail patients.

Defining age-adjusted spinopelvic alignment thresholds: should we integrate BMI?

PURPOSE: To develop age- and BMI-adjusted alignment targets to improve patient-specific management and operative treatment outcomes. METHODS: Retrospective review of a single-center stereographic database. ASD patients receiving operative or non-operative treatment, ≥ 18y/o with complete baseline (BL) ODI scores and radiographic parameters (PT, SVA, PILL, TPA) were included. Patients were stratified by age consistent with US-Normative values (norms) of SF-36(< 35, 35-55, 45-54, 55-64, 65-74, ≥ 75y/o), and dichotomized by BMI (Non-Obese < 30; Obese ≥ 30). Linear regression analysis established normative age- and BMI-specific radiographic thresholds, utilizing previously published age-specific US-Normative ODI values converted from SF-36 PCS (Lafage et al.), in conjunction with BL age and BMI means. RESULTS: 486 patients were included (Age: 52.5, Gender: 68.7%F, mean BMI: 26.2, mean ODI: 32.7), 135 of which were obese. Linear regression analysis developed age- and BMI-specific alignment thresholds, indicating PT, SVA, PILL, and TPA to increase with both increased age and increased BMI (all R > 0.5, p < 0.001). For non-obese patients, PT, SVA, PILL, and TPA ranged from 10.0, - 25.8, - 9.0, 3.1 in patients < 35y/o to 27.8, 53.4, 17.7, 25.8 in patients ≥ 75 y/o. Obese patients' PT, SVA, PILL, and TPA ranged from 10.5, - 7.6, - 7.1, 5.8 in patients < 35 y/o to 28.3, 67.0, 19.15, 27.7 in patients ≥ 75y/o. Normative SVA values in obese patients were consistently ≥ 10 mm greater compared to non-obese values, at all ages. CONCLUSION: Significant associations exist between age, BMI, and sagittal alignment. While BMI influenced age-adjusted alignment norms for PT, SVA, PILL, and TPA at all ages, obesity most greatly influenced SVA, with normative values similar to non-obese patients who were 10 years older. Age-adjusted alignment thresholds should take BMI into account, calling for less rigorous alignment objectives in older and obese patients.