Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons.

INTRODUCTION: Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. METHODS: In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. RESULTS: Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. CONCLUSIONS: Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. LEVEL OF EVIDENCE: Level IV.

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children. METHODS: Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade. RESULTS: ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004). CONCLUSIONS: Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons. LEVEL OF EVIDENCE: Level III.

Pediatric Sports Medicine, A New Subspeciality in Orthopedics: An Analysis of the Surgical Volume of Candidates for the American Board of Orthopaedic Surgery Part II Certification Exam Over the Past Decade.

BACKGROUND: Pediatric orthopaedic surgery has become increasingly subspecialized over the past decade. The purpose of this study was to analyze the volume of pediatric sports medicine cases performed by surgeons applying for the American Board of Orthopaedic Surgeons (ABOS) Part II certification exam over the past decade, comparing caseloads according to the type(s) of fellowship completed. METHODS: The ABOS database was reviewed for all surgeons applying for the ABOS Part II certification exam from 2004 to 2014. Fellowship training of the candidates was recorded as Pediatrics, Sports, and Dual-Fellowship (fellowship in both Pediatrics and Sports). All other candidates were categorized as "Other". A total of 102,424 pediatric cases (patients below 18 years) were reviewed to identify sports medicine cases performed by CPT code. Multiple linear regression and Mann-Whitney U tests were used to determine trends in case volume overall and according to fellowship training for all patients, patients ≥13 and patients <13. One-way ANOVA testing was used to compare multiple means followed by multiple post hoc comparisons using a Tukey all pairwise approach using SPSS. RESULTS: A total of 14,636 pediatric sports medicine cases were performed. There was an increase in the number of sports medicine cases performed in patients <13 (117.5±31.8 from 2004-2009 to 212.4±70.1 from 2010-2014, P=0.035; r=0.743, P=0.0007). The number of Pediatrics (r=0.601, P=0.005), Sports (r=0.741, P=0.0007) and Dual-Fellowship candidates increased (r=0.600, P=0.005) from 2004-2014. Dual-Fellowship surgeons performed 21.4% of pediatric sports medicine cases in 2014 when compared to 2.1% in 2004 (919% increase). As a group, the number of pediatric sports cases performed by Dual-Fellowship (r=0.630, P=0.004) and Sports (r=0.567, P=0.007) candidates has increased, while the number performed by "Other" candidates has decreased (r=0.758, P=0.0005). Per surgeon, Dual-Fellowship candidates performed a greater number of pediatric sports cases per collection period (36.5±9.18) than Pediatrics (6.71±0.94), Sports (5.99±0.46), and "Other" (1.21±0.15, P<0.0001 for each) candidates from 2004 to 2014. CONCLUSIONS: Over the past decade operative sports injuries have increased in children with a similar increase in the number of orthopedic surgeons specializing in pediatric sports medicine. On a per surgeon basis, these dual fellowship-trained candidates have performed on average five times the number of pediatric sports medicine cases compared to all other ABOS Part II candidates. These trends may point towards the development of a new subspecialty of pediatric sports medicine among orthopedic surgeons. LEVEL OF EVIDENCE: Level IV-Retrospective Database Review.

Subspecialty Training Among Graduates of Pediatric Orthopaedic Fellowships: An 11-Year Analysis of the Database of American Board of Orthopaedic Surgery.

BACKGROUND: The field of pediatric orthopaedic surgery is evolving with a reported increase in the number of pediatric orthopaedic fellows being trained as well as an increase in the number of fellows completing additional fellowship training in another subspecialty. The purpose of this study was to examine the historic trends of trainees seeking multiple fellowships within pediatric orthopaedics over an 11-year period using the database of the American Board of Orthopaedic Surgery (ABOS). METHODS: We queried the ABOS database for fellowship choice of applicants for the ABOS part II oral examination with the self-declared subspecialty of pediatric orthopaedics during the years of 2005 to 2015. Descriptive analysis was performed to determine the percentage of applicants who completed >1 fellowship, and the type of subspecialty fellowship completed. χ analysis was used to compare the proportion of multiple fellowship trainees between years. RESULTS: From 2005 to 2015, 310 applicants for ABOS part II pediatric subspecialty examination had completed a fellowship in pediatric orthopaedic surgery, with that number increasing from 14 to 43/y over that span. Forty-five trainees (15%) completed 48 additional fellowships over that decade, with 2 recent trainees completing multiple additional fellowships. The most common additional fellowships were sports (n=22, 46%), hand (n=8, 17%), and spine (n=7, 15%). The rate of additional fellowship training increased over 5-fold from 5% in the first 3 years of the study to 28% in the last 2 years of the study (P=0.001). CONCLUSIONS: The proportion of trainees completing additional subspecialty fellowships in addition to pediatric orthopaedics has risen over the past decade. The precise cause and effect of such change is uncertain and likely multifactorial. Reexamination of our classic training paradigms may be warranted in light of these trends. LEVEL OF EVIDENCE: Level III.

Changes in the Practice of Pediatric Orthopaedic Surgeons Over the Past Decade: Analysis of the Database of the American Board of Orthopaedic Surgery.

BACKGROUND: There has been an increase in the number of the graduates of pediatric orthopaedic fellowship programs over the past decade creating the potential for increased competition in the field. The purpose of this study was to analyze the effect of increased number of pediatric orthopaedic fellowship graduates on case volume as well as the type of procedures performed by recent graduates of pediatric orthopaedic fellowship programs from 2004 to 2014. METHODS: Case logs submitted for the American Board of Orthopaedic Surgery Part II examination by applicants with the self-declared subspecialty of pediatric orthopaedics from 2004 to 2014 were analyzed. Cases were categorized as trauma (upper and lower extremity), spine, sports medicine, hip, deformity correction, foot and ankle, hardware removal, soft tissue procedures, and other. The period was divided into 3 sections: 2004-2007, 2008-2011, 2012-2014. Descriptive analysis was used to report the change in the volume and pattern of practices over the study period. RESULTS: Although the number of pediatric orthopaedic subspecialty applicants increased from 15 to 44 from 2004 to 2014, the average cases per year increased from 2142 in 2004-2007 to 2960 in 2007-2011, and to 4160 in 2012-2014. The number of cases performed per applicant remained stable over the study period. Upper extremity trauma cases were the largest category of cases reported and increased in case volume by 141% from 2004 to 2014. Sports medicine cases increased in volume by 175%. CONCLUSIONS: Despite a large increase in the number of pediatric orthopaedic surgeons over the past decade, there is a concomitant increased in case volume across almost all subspecialties within pediatric orthopaedics. As such, pediatric orthopaedic surgeons who start a new practice can expect to develop a robust practice with a diverse group of pathologies. LEVEL OF EVIDENCE: Level III.

Chronic C1-C2 Rotatory Subluxation Reduced by C1 Lateral Mass Screws and C2 Translaminar Screws: A Case Report.

BACKGROUND: C1-C2 rotatory subluxation can result from a variety or etiologies. Pediatric patients are particularly susceptible to C1-C2 rotatory subluxation. If left untreated the condition is termed an atlantoaxial rotatory fixation (AARF) and chronic neck pain and deformity can result. Patients failing conservative treatment or those with recurrent or chronic rotatory subluxation may require halo treatment or surgical intervention. This illustrative case report is about a patient with chronic C1-C2 AARF who was treated with C1 lateral mass screws and C2 translaminar screws, a treatment that has not been addressed by this technique in a pediatric population. METHODS: This is a retrospective case review. RESULTS: After an unsuccessful attempt at reduction, an 11-year-old girl underwent surgery to treat her C1-C2 AARF. Through an all posterior approach, screws were placed bilaterally into the C1 lateral masses followed by the placement of C2 translaminar screws bilaterally. A small amount of distraction was applied through the screw construct to open up the C1-C2 articulation and the AARF was open reduced and fused. A detailed postoperative computed tomographic scan focused on the occiput C1-C2 joint confirmed the anatomical reduction of the joint complex. CONCLUSIONS: The patient had cosmetically pleasing relief of her torticollis and was doing well at 60 months after surgery. LEVEL OF EVIDENCE: Level IV.

Patient satisfaction surveys: an evaluation of POSNA members' knowledge and experience.

BACKGROUND: Patient satisfaction surveys (PSS) were originally designed to identify areas in need of improvement in patient interactions for individuals, practices, and institutions. As a result of the Affordable Care Act, the Centers for Medicare and Medicaid Services incorporated PSS into a formula designed to determine the quality of medical care delivered to hospital inpatients; the resultant score and rank will determine subsequent hospital payments. This survey was developed to evaluate POSNA members' knowledge of and experience with PSS. METHODS: The POSNA Practice Management Committee developed a 14-question survey that was sent to all active and candidate members (850). A total of 229 members responded; and results were tabulated by answer and simple percentages were calculated for each question. Comments were reviewed and grouped by similarity to identify frequency. RESULTS: A total of 82% of respondents were aware of PSS with 67% stating they were utilized in their setting. Utilization of PSS rarely alters clinical decision making. However, PSS do affect decisions regarding the patient experience; and 45% of respondents believe that PSS have utility with respect to business decisions. Fifty-nine percent of respondents feel that scores can be predictably improved. Less than half the respondents stated that they had a good or excellent understanding of PSS and only 48% believe that PSS are a valid measure of health care quality. CONCLUSIONS: POSNA members' knowledge of and experience with PSS are not universal or uniform. Although most agree that patient satisfaction does not drive clinical decision making, it does appear to impact business and clinic-flow decisions with the idea that it can be predictably improved. Despite this, members' self-assessed that knowledge is average and it is not clear to the members that patient satisfaction reflects medical quality. On the basis of these findings and as the impacts of PSS become more prominent, efforts to educate the members of POSNA about PSS should be enhanced. Furthermore, research to identify and develop best practices that enhance patient satisfaction and well-being while minimizing costs should be supported. LEVEL OF EVIDENCE: Level IV.

Orthopedic Surgery Matched Applicants Are Publishing More: A Bibliometric Analysis of Research Output.

Introduction This study analyzed the number of peer-reviewed publications submitted by matriculants prior to applying for the orthopedic surgery residency. The graduating residency classes of 2023 and 2027 were included in the study to understand the trend of publications, to inform aspiring orthopedic surgeons. Methods The top, middle, and bottom 10 orthopedic surgery residency programs were identified on the Doximity online website. Matriculants were searched on PubMed and Google Scholar for publication contributions. Variables including number of publications, orthopedic publications, first-author authorship, and H-index were analyzed. A logistic regression model was created, and a t-test was conducted to statistically compare the 2027 and 2023 graduating classes. Results Matriculants of the 2023 match had higher numbers of publications, orthopedic surgery-specific publications, first authorships, and h-indices than the matriculants of the 2018 match. Conclusion The average number of publications has been observed to increase over four years, indicating an increase in competition to match into orthopedic surgery residency. Publishing in higher numbers may be a good indicator of an applicant's success in not only matching but also matching into a higher-tier program.

Prescribing braces after forearm fractures does not decrease refracture rate.

Refracture is one of the most common complications of pediatric forearm fractures. One way to decrease this risk is to extend immobilization with a brace after the cast has been removed to allow for a range of motion exercises. The purpose of this study was to examine whether prescribing a brace after casting was discontinued decreased the risk of refracture. A retrospective, cohort study was performed at one level I trauma center. Girls under 10 years and boys under 12 years who sustained a forearm fracture from January 2013 to December 2018 were included. Patients with open fractures, fractures that required operative intervention, fractures involving the physis, fracture-dislocations, floating elbows, fractures in children with endocrine abnormalities, and fractures in patients lost to follow-up were excluded. The primary endpoint was a refracture within 6 months of the original injury that extended through the original fracture site. In total 2093 patients met the inclusion criteria. There were 19 refractures (0.9%). There was no statistically significant difference in the refracture rate between the braced (11/1091) and unbraced (8/1002) cohorts (Fisher exact value 0.65 at P < 0.05). The most common fracture type that went on to refracture was greenstick fractures. This large, retrospective study aimed to examine whether prescribing a brace had any significant effect on the refracture rate. Bracing after the cast is removed may help ease family anxiety and extend the period of immobilization while allowing for hygiene and range of motion, but it does not significantly decrease the rate of refracture.

The effectiveness of pre-contoured titanium alloy rods in inducing thoracic kyphosis after sequential spinal releases in an in vitro biomechanical model.

Purpose: Evaluate the ability of pre-contoured rods to induce thoracic kyphosis (TK) in human cadaveric spines and determine the effectiveness of sequential surgical adolescent idiopathic scoliosis (AIS) release procedures. Methods: Six thoracolumbar (T3-L2) spine specimens were instrumented with pedicle screws bilaterally (T4-T12). Over correction using pre-contoured rods was performed for intact condition and Cobb angle was measured. Rod radius of curvature (RoC) was measured pre- and post-reduction. The process was repeated following sequential release procedures of (1) interspinous and supraspinous ligaments (ISL); (2) ligamentum flavum; (3) Ponte osteotomy; (4) posterior longitudinal ligament (PLL); and (5) transforaminal discectomy. Cobb measurements determined the effective contribution of release on TK and RoC data displayed effects of reduction to the rods. Results: The intact TK (T4-12) was 38.0° and increased to 51.7° with rod reduction and over correction. Each release resulted in 5°-7°of additional kyphosis; the largest releases were ISL and PLL. All releases resulted in significant increases in kyphosis compared to intact with rod reduction and over correction. Regionally, kyphosis increased ∼2° for each region following successive releases. Comparing RoC before and after reduction showed significant 6° loss in rod curvature independent of release type. Conclusion: Kyphosis increased in the thoracic spine using pre-contoured and over corrected rods. Subsequent posterior releases provided a substantial, meaningful clinical change in the ability to induce additional kyphosis. Regardless of the number of releases, the ability of the rods to induce and over correct kyphosis was reduced following reduction.

A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results.

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

Evaluation of shoulder balance in early onset scoliosis after definitive fusion and comparison with adolescent idiopathic scoliosis shoulder balance.

STUDY DESIGN: The Children Spine Study Group registry was queried for early onset scoliosis (EOS) patients who had final definitive spinal fusion after their scoliosis was managed with either growing rods or VEPTR. The Harms Study Group registry was queried for adolescent idiopathic scoliosis (AIS) patients who had definitive fusion OBJECTIVE: The goal is to assess shoulder alignment in EOS patients after a definitive fusion and how these radiographic outcomes relate to the more familiar situation of post-definitive fusions shoulder alignment in AIS patients. BACKGROUND: EOS is a challenging pathology to manage. Numerous components are important in the success of spinal surgery for this population. Shoulder balance is a one of the components that is easily seen by the patient. Recently, the importance of its relationship to patient satisfaction has received greater attention. METHODS: Sample size: n = 145 (EOS (n = 34) and AIS (n = 111)). Shoulder balance parameters (SBP) of clavicular angle (CA), coracoid height difference (CHD), clavicular tilt angle difference (CTAD), and clavicle-rib cage intersection difference (CRID) measurements were measured from the reviewed radiographs and documented pre-definitive, post-definitive and 2-year follow-up measures. Shoulder balance parameters were compared between EOS and AIS cohorts at documented intervals. RESULTS: EOS mean pre-definitive fusion SBPs (CA, CTAD, CRID, CHD) were significantly higher compared to AIS, p = 0.004, 0.003, < 0.001, < 0.001, respectively. Significant post-definitive fusion corrections were noticed for CTAD (0.01), CHD (0.01), nearly significant CA (0.07), non-significant CRID in EOS patients. In AIS patients, no significant corrections were noticed for CA, CTAD, CHD and but significant for CRID (0.02). At post-definitive and 2-year follow-up, CA, CRID, CHD were not significant between cohorts, but CTAD (< 0.01) was significantly higher in EOS cohort at final follow-up. CONCLUSION: Post-definitive and 2-year follow-up shoulder balance for EOS patients was not significantly different from AIS patients. LEVEL OF EVIDENCE: III.

Pediatric disk herniation.

Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty-eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short-term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long-term data suggest that 20% to 30% of patients will require additional surgery later in life.

Changes in Pediatric Spine Surgery Patterns Over the Last 10 Years Among ABOS Part II Candidates.

STUDY DESIGN: A retrospective review of prospectively collected data. OBJECTIVE: Our purpose was to evaluate the volume of pediatric spine cases being done by surgeons applying for American Board of Orthopaedic Surgeons (ABOS) certification. SUMMARY OF BACKGROUND DATA: Pediatric orthopedic surgery has become increasingly subspecialized over the past decade. METHODS: Data were reviewed from the ABOS for surgeons undergoing part II of ABOS certification between 2004 and 2014. Applicants were divided into pediatric orthopedic surgeons and spine surgeons based on their self-declared subspecialty for the ABOS Part II examination. A total of 102,424 cases were reviewed to identify spine cases performed on patients <18 years old. RESULTS: Between 2004 and 2014, the total number of ABOS part II pediatric candidates increased significantly, from a low of 15 to a high of 44 (r = 0.68, P = 0.001). During this time frame, there has been no significant increase in the total number of pediatric spine cases reported (r = 0.09, P = 0.19). In 2004, 46.5% (33/71) of the pediatric spine cases were done by spine surgeons, which decreased to 17.3% (28/162) in 2014. Conversely in 2004, 53.5% (38/71) of pediatric spine cases were done by pediatric orthopedists, which increased to 82.7% (134/162) in 2014. The number of pediatric candidates performing pediatric spine cases decreased 35% from 2004 to 2014, but the percentage performing >20 spine cases during their candidate year has increased from 0% to 7% (r = 0.31, P = 0.04). CONCLUSION: The share of pediatric spine surgeries performed by pediatric candidates has increased from 54% in 2004 to 83%, with a corresponding fall in the share surgeries performed by spine candidates (47% to >17%). The percentage of pediatric candidates performing more than 20 spine cases/year increased from 0% to 7%, reflecting a trend of spine subspecialization within pediatric surgery. LEVEL OF EVIDENCE: 3.

Effect of Pedicle Fill on Axial Pullout Strength in Spinal Fixation After Rod Reduction.

Rod reduction to pedicle screws is used for a variety of spinal fixation procedures; however, it can alter the integrity of the screw-bone interface. The authors investigated the effect of pedicle fill (ratio of pedicle screw diameter to pedicle diameter) on the strength of the screw-bone interface after simulated rod reduction on 17 vertebrae (3 thoracolumbar spine specimens). Pedicle diameter was measured with standard clinical computed tomography scan protocols. The authors determined the minimum pedicle diameter for each level. Polyaxial pedicle screws were surgically placed bilaterally with a freehand technique with standard clinical anatomic landmarks. The pedicle pairs were instrumented with pedicle screws of predetermined diameter, 1 with greater than 80% fill and 1 with less than 80% fill. A simulated reduction maneuver was performed with a 5-mm gap followed by an axial pullout test to assess screw interface strength. Comparison of insertion torque between less than 80% fill and greater than 80% fill did not show significant increases. A significant difference in pullout load (P=.043) occurred with greater than 80% fill (791±637 N) compared with less than 80% fill (636±492 N). No significant difference in stiffness was noted (P=.154) with pedicle fill of greater than 80% (427±134 N/mm) compared with less than 80% (376±178 N/mm). The current findings support the use of greater than 80% pedicle fill for optimal screw anchoring in pedicle screw-based constructs involving rod reduction. Surgeons should consider placing screws that can safely fill vertebral pedicles, especially at the apex of the curve and the proximal and distal levels of constructs, where excessive forces are imparted to the screws. [Orthopedics. 2017; 40(6):e990-e995.].

Magnetically controlled growing rods for scoliosis surgery.

INTRODUCTION: Early onset scoliosis can be both a disfiguring as well as a life threatening condition. When more conservative treatments fail, pediatric spinal surgeons are forced to consider operative interventions. Traditionally, these interventions have involved the insertion of a variety of implants into the patient with a limited number of anchor points controlling the spine. In the past, these pediatric patients have had multiple surgeries for elective lengthening of these devices to facilitate their growth while attempting to control the scoliosis. These patients often experience a physical and emotional toll from their multiple repeated surgeries. Growing spine techniques have also had a noted high complication rate due to implant dislodgement and infections. Recently, the development of non-invasively, self-lengthening growing rods has occurred. These devices have the potential to allow for the devices to be lengthened magnetically in a conscious patient in the surgeon's office. Areas covered: This review summarized previously published articles in the English literature using a key word search in PubMed for: 'magnetically controlled growing rods', 'Magec rods', 'magnetic growing rods' and 'growing rods'. Expert commentary: Magnetically controlled growing rods have an advantage over growing rods in lengthening the growing spine in the absence of repetitive surgeries.

The Pursuit of Scholarship: Why We Should Care About Resident Research.

Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroup's task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroup's conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests.

Are Traditional Radiographic Methods Accurate Predictors of Pedicle Morphology?

STUDY DESIGN: Cadaveric in vitro computed tomography (CT) imaging study. OBJECTIVE: To examine minimum pedicle diameter from transverse and coronal CT reconstructions of thoracolumbar spine specimens and compare their degree of disparity, if any. Pedicle angulation in coronal and transverse planes was measured and their contribution to the disparity in minimum pedicle diameter was assessed. SUMMARY OF BACKGROUND DATA: Spinal minimum pedicle diameter can be obtained from both transverse and coronal CT reconstructions; however, the degree of disparity in these measurements has not been described previously. Angulation of the pedicle in transverse and coronal planes may contribute to a disparity in minimum pedicle diameter acquired from reconstructions. This also has not been described previously. This study examined whether the disparity could be predicted by spinal level, as pedicle angulations vary in both coronal and transverse planes. METHODS: Five thoracolumbar specimens (T1-L5, age 48-59 yrs, male) were CT scanned utilizing clinical protocols. Minimum pedicle diameters and pedicle angulations were acquired in transverse and coronal reconstructions. Disparities between minimum pedicle diameters were measured and the correlation between this disparity and spinal level was characterized. RESULTS: A significant difference (P < 0.001) in minimum pedicle diameter existed between measures from coronal and transverse reconstructions. There was a significant correlation (P < 0.001) between the difference in minimal pedicle diameter and the transverse pedicle angle as well as the coronal pedicle angle. CONCLUSION: An overestimation of minimum pedicle diameter in the transverse reconstruction occurs when the coronal pedicle angulation increases, and in the coronal reconstruction when the transverse pedicle angulation increases. Therefore, pedicle angle should be determined using both coronal and transverse reconstructions and utilized to reduce the risk of overestimation of the true pedicle diameter. LEVEL OF EVIDENCE: NA.