Should pelvic incidence influence realignment strategy? A detailed analysis in adult spinal deformity.

OBJECTIVE: The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery. METHODS: Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups. RESULTS: A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9). CONCLUSIONS: There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.

Subsidence in Nonexpandable, Single-Plane Expandable, and Dual-Plane Expandable TLIFs A Propensity-Matched Cohort Study.

BACKGROUND: Transforaminal lumbar interbody fusion (TLIF) has become a common tool to achieve interbody fusion in lumbar spine surgery while avoiding the time, expense, and morbidity associated with an anterior approach. Nonexpandable (NE) devices have excellent fusion results but are limited to implant size by spinal anatomy; conversely, expandable implants have been associated with increased intraoperative subsidence. Dual-plane expandable (DPE) devices are theorized to have reduced subsidence risk, but DPE cages have not been directly compared to NE and single plane expandable (SPE) implants in vivo. STUDY DESIGN: A retrospective review of patients who underwent TLIF at a single metropolitan academic medical center from 2018 through 2021 was conducted to compare intraoperative subsidence between NE versus SPE or DPE devices. Patients were propensity score matched (PSM) by age and bone density according to implant type. A second PSM cohort comparing DPE with SPE devices was performed. RESULTS: A total of 402 patients underwent PSM with 46 NE and 49 DPE cases matched, and 103 SPE patients were matched with 24 DPE cases. The average age was 59 years with 52.5% female patients. Mean body mass index was 29. Nonexpandable TLIF was the most common device implanted 62%, followed by SPE (26%) and DPE (12.2%). Dual-plane expandable devices had a significantly greater intraoperative subsidence than NE devices (12% vs. 0%). Nonexpandable and SPE devices had significantly larger implant lordosis when compared to DPE (10.93 SPE vs. 6. 17 NE vs. 3.83 DPE). Single plane expandable devices had a significantly greater discrepancy between implant lordosis and interbody level lordosis compared to DPE. CONCLUSIONS: Dual-plane expandable cages are associated with increased intraoperative subsidence compared to NE and SPE implants. Additionally, SPE devices have greater discrepancy between stated implant lordosis and interbody level lordosis compared with DPE devices.

Durability of substantial clinical benefit leading to optimal outcomes in adult spinal deformity corrective surgery: a minimum 5-year analysis.

OBJECTIVE: The objective was to evaluate factors associated with the long-term durability of outcomes in adult spinal deformity (ASD) patients. METHODS: Operative ASD patients fused from at least L1 to the sacrum with baseline (BL) to 5-year (5Y) follow-up were included. Substantial clinical benefit (SCB) in Oswestry Disability Index (ODI), numeric rating scale (NRS)-back, NRS-leg, and Scoliosis Research Society (SRS)-22r scores and physical component score were assessed on the basis of previously published values. Factors were evaluated on the basis of meeting optimal outcomes (OO) at 2 years (2+) and 5 years (5+). Furthermore, 2+ patients were isolated and evaluated on the basis of meeting OO at 5 years (2+5+) or not at 5 years (2+5-). OO were defined as follows: no reoperation, major mechanical failure, proximal junctional failure, and meeting either 1) SCB in terms of ODI score (decrease > 18.8) or 2) ODI < 15 and SRS-22r total > 4.5. RESULTS: In total, 330 ASD patients met the inclusion criteria, with 45.5% meeting SCB for ODI at 2 years, while 46.0% met SCB at 5 years; 79% of those who achieved 2-year (2Y) SCB went on to achieve 5Y SCB. This rate was lower for OO, with 41% achieving 2Y OO (2+), while 37% met 5Y OO (5+) and 80% of 2+ patients had durable outcomes until 5+ (32% of the total cohort). Of the patient factors, frailty was significantly different among groups at 2 years, while comorbidity burden was significantly different at 5 years and the combination thereof differed in those with durable outcomes. Those who regained their level of activity postoperatively had 4 times higher odds of maintaining OO from 2 years to 5 years (p < 0.05). Osteoporosis rates, although equivocal at BL, were higher at the last follow-up in those who met 2Y OO but failed to meet 5Y OO. The odds of achieving OO at 5 years in 2+ patients decreased by 47% for each additional comorbidity and decreased by 74% in those who had lower-extremity paresthesias at BL (both p < 0.05). Controlling for patient factors and BL disability found fewer levels fused, decreased correction of sagittal vertical axis, and increased correction of pelvic incidence-lumbar lordosis mismatch to be predictive of maintaining 2Y OO until 5 years (p < 0.05). CONCLUSIONS: SCB was met in 46% of ASD patients at 5 years. The durability of OO was seen in a third of patients until 5 years postoperatively. Higher rates of medical complications were seen in those who failed to achieve and maintain OO until 5 years. Frailty and comorbidity burden were significant factors associated with the achievement and durability of OO until 5 years.

Needle Arthroscopy Versus Conventional Arthroscopy in the Evaluation of Carpal Pathology: A Comparative Study.

BACKGROUND: The needle scope is a less invasive intervention to evaluate carpal pathology. We hypothesize that there is no difference in the evaluation and diagnostic capability of the needle scope versus the conventional wrist arthroscope. METHODS: Twenty patients indicated for wrist arthroscopy were prospectively enrolled. Prior to insertion of the 2.7-mm arthroscope, the needle scope evaluated for synovitis; cartilage damage (location and modified Outerbridge classification); integrity of the volar, scapholunate (SL), and lunotriquetral ligaments; and the triangular fibrocartilage complex (TFCC). Following needle scope evaluation, the surgeon completed a survey regarding the visualization and diagnosis. The 2.7-mm arthroscope was then inserted, and the surgeon completed the second portion of the survey. Statistical analysis was then completed to determine statistical significance. RESULTS: Twelve patients were female (60%), and the mean age was 39.8 years (±11.8 years). Eleven patients underwent arthroscopy for TFCC pathology, 4 patients for SL tearing, and 5 patients for extensive synovitis. There was no difference between the needle scope and wrist arthroscopy diagnosis. There was no difference between radiocarpal and midcarpal visualization. Surgeon-rated ease of use and diagnostic confidence were the same between two groups. The needle scope was better able to visualize the scapho-trapezium-trapezoid and carpometacarpal joints; however, the image was of marginally decreased quality. CONCLUSION: In this study, there was no difference between radiocarpal or midcarpal visualization and surgeon-rated ease of use, while diagnostic confidence was the same between two groups. LEVEL OF EVIDENCE: II (prospective cohort study)-Diagnostic.

Is It Possible for Patients with Early Distal Junctional Kyphosis following Adult Cervical Deformity Corrective Surgery to Achieve Similar Outcomes to Their Unaffected Counterparts? An Analysis of Recovery Kinetics.

Background: Distal junctional kyphosis (DJK) is a concerning complication for surgeons performing cervical deformity (CD) surgery. Patients sustaining such complications may demonstrate worse recovery profiles compared to their unaffected peers. Methods: DJK was defined as a >10° change in kyphosis between LIV and LIV-2, and a >10° index angle. CD patients were grouped according to the development of DJK by 3M vs. no DJK development. Means comparison tests and regression analyses used to analyze differences between groups and arelevant associations. Results: A total of 113 patients were included (17 DJK, 96 non-DJK). DJK patients were more sagittally malaligned preop, and underwent more osteotomies and combined approaches. Postop, DJK patients experienced more dysphagia (17.7% vs. 4.2%; p = 0.034). DJK patients remained more malaligned in cSVA through the 2-year follow-up. DJK patients exhibited worse patient-reported outcomes from 3M to 1Y, but these differences subsided when following patients through to 2Y; they also exhibited worse NDI (65.3 vs. 35.3) and EQ5D (0.68 vs. 0.79) scores at 1Y (both p < 0.05), but these differences had subsided by 2Y. Conclusions: Despite patients exhibiting similar preoperative health-related quality of life metrics, patients who developed early DJK exhibited worse postoperative neck disability following the development of their DJK. These differences subsided by the 2-year follow-up, highlighting the prolonged but eventually successful course of many DJK patients after CD surgery.

Assessing the Impact of Radiographic Realignment on Adult Spinal Deformity Patients with Sacroiliac Joint Pain at Presentation.

Background: Adult spinal deformity (ASD) patients with concurrent sacroiliac joint (SIJ) pain are susceptible to worse postoperative outcomes. There is scarce literature on the impact of ASD realignment surgery on SIJ pain. Methods: Patients undergoing ASD realignment surgery were included and stratified by the presence of SIJ pain at the baseline (SIJP+) or SIJ pain absence (SIJP-). Mean comparison tests via ANOVA were used to assess baseline differences between both cohorts. Multivariable regression analyses analyzed factors associated with SIJ pain resolution/persistence, factoring in BMI, frailty, disability, and deformity. Results: A total of 464 patients were included, with 30.8% forming the SIJP+ cohort. At the baseline (BL), SIJP+ had worse disability scores, more severe deformity, higher BMI, higher frailty scores, and an increased magnitude of lower limb compensation. SIJP+ patients had higher mechanical complication (14.7 vs. 8.2%, p = 0.024) and reoperation rates (32.4 vs. 20.2%, p = 0.011) at 2 years. SIJP+ patients who subsequently underwent SI fusion achieved disability score outcomes similar to those of their SIJ- counterparts. Multivariable regression analysis revealed that SIJP+ patients who were aligned in the GAP lordosis distribution index were more likely to report symptom resolution at six weeks (OR 1.56, 95% CI: 1.02-2.37, p = 0.039), 1 year (OR 3.21, 2.49-5.33), and 2 years (OR 3.43, 2.41-7.12). SIJP- patients who did not report symptom resolution by 1 year and 2 years were more likely to demonstrate PI-LL > 5° (OR 1.36, 1.07-2.39, p = 0.045) and SVA > 20 mm (OR 1.62, 1.24-1.71 p = 0.017). Conclusions: SIJ pain in ASD patients may result in worsened pain and disability at presentation. Symptom resolution may be achieved in affected patients by adequate postoperative lumbar lordosis restoration.

The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery. METHODS: Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity. RESULTS: We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025). CONCLUSIONS: Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.

The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery. BACKGROUND: ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery. METHODS: Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis. RESULTS: A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034). CONCLUSIONS: The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.

Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?

OBJECTIVE: To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery. STUDY DESIGN: Retrospective review of prospective CD database. BACKGROUND: Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. METHODS: Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy. RESULTS: In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048]. CONCLUSIONS: Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.

Gender does not impact clinical outcomes following SLAP repair.

Background: The purpose of the current study was to investigate whether pain, function, satisfaction, return to play (RTP), or psychological readiness to RTP differ between sexes post-operatively following SLAP repair. Methods: A retrospective review of patients who underwent arthroscopic repair of a SLAP tear was performed. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. Clinical outcomes were compared between male and female patients. Results: Our study included 169 patients treated with SLAP repair, 133 of them male (78.7%) and 36 of them female (21.3%), with an average age of 32.3 ± 8.3 and 33.4 ± 6.8 respectively. The mean follow-up duration was 5.8 years. At final follow up, there was no difference between treatment groups in any of the functional outcome measures assessed (p > 0.05). Conclusion: There is no difference in clinical outcomes, function, satisfaction, or revision procedures in mid- to long-term follow-up after SLAP repair between male and female patients. This data is useful in the preoperative counselling of patients undergoing arthroscopic management of symptomatic superior labral pathology. Level of evidence: III.

Does the presence of cervical deformity in patients with baseline mild myelopathy increase operative urgency in adult cervical spinal surgery? A retrospective analysis.

OBJECTIVE: The objective of this study was to assess whether delaying surgical management of cervical deformity (CD) in patients with concomitant mild myelopathy increases the risk of suboptimal outcomes. METHODS: Patients aged ≥ 18 years who had a baseline diagnosis of mild myelopathy with baseline and up to 2 years of postoperative data were assessed. Patients were categorized as having CD (CD+) or not (CD-) at baseline. Patients with symptoms of myelopathy for more than 1 year after the initial visit prior to surgery were considered delayed. Clinical and radiographic data were assessed using means comparison analyses. Multivariate regression analysis assessed correlations between increasing time to surgery and peri- and postoperative outcomes adjusted for baseline age and frailty score. Backstep logistic regression analysis assessed the risk of complications or reoperation, while controlling for baseline T1 slope minus cervical lordosis (TS-CL). RESULTS: One hundred six patients were included (mean age 58.11 ± 11.97 years, 48% female, mean BMI 29.13 ± 6.89). Of the patients with baseline mild myelopathy, 22 (20.8%) were CD- while 84 (79.2%) were CD+. Overall, 9.5% of patients were considered to have delayed surgery. Linear regression revealed that both CD- and CD+ patients were more likely to require reoperation when there was more time between the initial visit and surgical admission (p < 0.001). Additionally, an adjusted logistic regression indicated that CD+ patients who had a greater length of time to surgery had a higher likelihood for major complications (p < 0.001). Conversely, CD+ patients who were operated on within 30 days of the initial visit had a significantly lower risk for a major complication (OR 0.901, 95% CI 0.889-1.105, p = 0.043), and a lower risk for reoperation (OR 0.954, 95% CI 0.877-1.090, p = 0.043), while controlling for the severity of deformity based on baseline TS-CL. CONCLUSIONS: The findings of this study demonstrate that a delay in surgery after the initial visit significantly increases the risk for major complications and reoperation in patients with CD with associated mild baseline myelopathy. Early operative treatment in this patient population may lower the risk of postoperative complications.

Post-Operative Physical Therapy Following Cervical Spine Surgery: Analysis of Patient-Reported Outcomes.

Introduction Post-operative physical therapy (PT) following anterior cervical discectomy and fusion (ACDF) surgery is often performed to improve a patient's functional ability and reduce neck pain. However, current literature evaluating the benefits of post-operative PT using patient-reported outcomes (PROs) is limited and remains inconclusive. Here we compare post-operative improvement between patients who did and did not undergo formal PT after ACDF using Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Methods A retrospective observational study examining patients who underwent one- or two-level primary ACDF or cervical disc replacement (CDR) at an academic orthopedic hospital and who had PROMIS scores recorded pre-operatively and through two-year follow-up. Patients were stratified according to whether or not they attended formal postoperative PT. PROMIS scores and patient demographics were compared using the Mann-Whitney U test, Fisher's exact test, chi-square test of independence, and Student's t-test within and between cohorts. Results Two hundred and twenty patients were identified. Demographic differences between PT and no PT groups include age (PT 54.1 vs. no PT 49.5, p=0.005) and BMI (PT 28.1 vs. no PT 29.8, p=0.028). The only significant difference in post-operative PROMIS scores was in physical health scores at three months post-operatively (no PT 43.9 vs. PT 39.1, p=0.008). Physical health scores improved from baseline to one-year follow-up in both cohorts (PT +3.5, p=0.025; no PT +6.6, p=0.008). There were no significant differences when comparing improvements in physical health scores between groups at six months and one year. Conclusion In conclusion, there was no significance to support the benefits of post-operative PT as measured by PROMIS scores. No significant differences in PROMIS were observed between groups from pre-operative baseline scores to six-month and one-year follow-ups.

Effects of Intraoperative Local Pain Cocktail Injections on Early Function and Patient-Reported Outcomes: A Randomized Controlled Trial.

OBJECTIVE: To determine whether a perioperative pain cocktail injection improves postoperative pain, ambulation distance, and long-term outcomes in patients with hip fracture. DESIGN: Prospective, single-blinded, randomized controlled trial. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty. INTERVENTION: Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI). MAIN OUTCOME MEASUREMENTS: Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, postoperative ambulation, Short Musculoskeletal Function Assessment. RESULTS: Seventy-five patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared with the control group on postoperative day (POD) 0 ( P < 0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 ( P < 0.01). Patient ambulation distance was greater on POD 2 ( P < 0.01) and POD 3 ( P < 0.05) in the HiFI group. The control group experienced more major complications ( P < 0.05). At 6-week postop, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The Short Musculoskeletal Function Assessment bothersome index was also significantly lower for patients in the HiFI group, P < 0.05. CONCLUSIONS: Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health-related quality of life after discharge. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Impact of time to revision total knee arthroplasty on outcomes following aseptic failure.

INTRODUCTION: Prior studies have demonstrated an association between time to revision total knee arthroplasty (rTKA) and indication; however, the impact of early versus late revision on post-operative outcomes has not been reported. MATERIALS AND METHODS: A retrospective, observational study examined patients who underwent unilateral, aseptic rTKA at an academic orthopedic hospital between 6/2011 and 4/2020 with > 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary TKA (pTKA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared. RESULTS: 470 rTKA were included (199 early, 271 late). Early rTKA patients were younger by 2.5 years (p = 0.002). The predominant indications for early rTKA were instability (28.6%) and arthrofibrosis/stiffness (26.6%), and the predominant indications for late rTKA were aseptic loosening (45.8%) and instability (26.2%; p < 0.001). Late rTKA had longer operative times (119.20 ± 51.94 vs. 103.93 ± 44.66 min; p < 0.001). There were no differences in rTKA type, disposition, hospital length of stay, all-cause 90-day emergency department visits and readmissions, reoperations, and number of re-revisions. CONCLUSIONS: Aseptic rTKA performed before 2 years had different indications but demonstrated similar outcomes to those performed later. Early revisions had shorter surgical times, which could be attributed to differences in rTKA indication. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Reoperation Rates Due to Adjacent Segment Disease Following Primary 1 to 2-Level Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To investigate the effect of the approach of the transforaminal lumbar interbody fusion [TLIF; open vs . minimally invasive (MIS)] on reoperation rates due to ASD at 2 to 4-year follow-up. SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration is a complication of lumbar fusion surgery, which may progress to adjacent segment disease (ASD) and cause debilitating postoperative pain potentially requiring additional operative management for relief. MIS TLIF surgery has been introduced to minimize this complication but the impact on ASD incidence is unclear. MATERIALS AND METHODS: For a cohort of patients undergoing 1 or 2-level primary TLIF between 2013 and 2019, patient demographics and follow-up outcomes were collected and compared among patients who underwent open versus MIS TLIF using the Mann-Whitney U test, Fischer exact test, and binary logistic regression. RESULTS: Two hundred thirty-eight patients met the inclusion criteria. There was a significant difference in revision rates due to ASD between MIS and open TLIFs at 2 (5.8% vs . 15.4%, P =0.021) and 3 (8% vs . 23.2%, P =0.03) year follow-up, with open TLIFs demonstrating significantly higher revision rates. The surgical approach was the only independent predictor of reoperation rates at both 2 and 3-year follow-ups (2 yr, P =0.009; 3 yr, P =0.011). CONCLUSIONS: Open TLIF was found to have a significantly higher rate of reoperation due to ASD compared with the MIS approach. In addition, the surgical approach (MIS vs . open) seems to be an independent predictor of reoperation rates.

"Bones and Joints" The Role of Cannabidiol (CBD) in Musculoskeletal Health.

Cannabis has a rich history as a therapeutic tool with wide ranging applications. The efficacy of cannabidiol (CBD), the non-psychoactive component of cannabis, has been well demonstrated for pain management. Further, recent orthopedic studies have demonstrated positive effects of CBD on wound healing, inflammation, bone marrow density, and fracture healing. Despite the growing interest in CBD, there is a paucity of research on its impact on fracture risk and bone density in human clinical trials and the existing literature has significant limitations. As the rate of cannabis consumption increases, further research is essential to delineate the therapeutic qualities of CBD and its long-term effects on fracture healing and bone metabolism in order to optimize patient outcomes.

Carpometacarpal Arthroplasty What's the Rule of Thumb?

Carpometacarpal (CMC) arthritis of the thumb is one of the most common pathologies encountered in clinical hand and orthopedic surgery practices. Anatomy of the CMC joint and its biomechanics are theorized to predispose the articulation to laxity and subsequent degenerative changes. Diagnosis of CMC arthritis is primarily based on history, physical examination, and imaging findings, all of which coalesce to guide treatment. There are a multitude of treatment options for CMC arthritis, each with its own set of pearls and pitfalls with treatment decision making shared by surgeon and patient. Continued research and longitudinal data on outcome measures will assist in determining the ultimate "rule of thumb" for the treatment of CMC arthritis.

Primary Biceps Tenodesis Is Superior to Revision Following Failed SLAP Repair.

Purpose: To compare satisfaction and return to play (RTP) rates between patients undergoing primary biceps tenodesis for a symptomatic SLAP tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair. Methods: A retrospective review of patients who underwent subpectoral mini-open biceps tenodesis following failed SLAP repair between January 2011 and October 2019 was performed. Inclusion criteria included age older than 16 years, skeletal maturity, and a minimum follow-up of 12 months. Both athletes and nonathletes were included across all types of sport. Patients who had anterior or posterior instability or rotator cuff tears were excluded; in addition, those requiring concomitant procedures were excluded. Case-control matching was performed using age, sex, indication, follow-up, and type of sport, to generate a 3:1 control group for the primary biceps tenodesis cohort. Primary outcome measurements were collected via telephone in 2020 and included the American Shoulder and Elbow Surgeons score, visual analog scale score, Subjective Shoulder Value score, patient satisfaction, willingness to undergo surgery again, and revisions. RTP and timing of RTP were evaluated as secondary outcomes. A P value of <.05 was considered to be statistically significant. Results: The current study included 76 patients in total; 57 patients with primary biceps tenodesis, and 19 patients with secondary biceps tenodesis. The mean age was 39 years (19-48 years), 100% were male, and the mean follow-up was 54 months (16-99 months). Patient reported outcomes were obtained postoperatively via telephone survey. Overall, we found that primary biceps tenodesis patients reported greater American Shoulder and Elbow Surgeons scores (89.9 vs 76.4, P = .0162), lower visual analog scale scores (1.0 vs 3.1, P = .0034), and greater Subjective Shoulder Value scores (86.7 vs 64.7, P = .0004). Overall, there was no significant difference in the total rate of RTP (84% vs 75%, P = .5025), or timing of RTP (8.2 months vs 8.1 months, P = .9529) between patient groups. Patients reported playing tennis, swimming, golf, rock climbing, and basketball. No patients required a further shoulder surgery after undergoing biceps tenodesis. Conclusions: In this study, patients undergoing primary biceps tenodesis had significantly better functional outcomes compared with secondary biceps tenodesis following a failed SLAP repair. Level of Evidence: III, retrospective comparative study.

No Difference in Outcomes After Arthroscopic Bankart Repair With Remplissage or Arthroscopic Latarjet Procedure for Anterior Shoulder Instability.

Purpose: To evaluate the outcomes of arthroscopic Bankart repair with remplissage (ABRR) compared with the arthroscopic Latarjet (AL) procedure for anterior shoulder instability in patients with a labral tear and a concomitant engaging Hill-Sachs lesion. Methods: A retrospective review of patients who underwent either ABRR or the AL procedure for a diagnosis of anterior shoulder instability with a concomitant engaging Hill-Sachs lesion between 2011 and 2019 was performed. Recurrent instability, the visual analog scale score, the Subjective Shoulder Value, the Western Ontario Shoulder Instability score, patient satisfaction, willingness to undergo surgery again, and return to work or sport were evaluated. Results: Our study included 41 patients treated with ABRR and 26 treated with the AL procedure. At final follow-up, there was no difference between patients who underwent ABRR and those who underwent the AL procedure in the reported Western Ontario Shoulder Instability score (21.8% vs 28.2%, P = .33) or any of its components, the visual analog scale score (0.9 vs 1.4, P = .32), the Subjective Shoulder Value (78.4 vs 74.5, P = .6062), the rate of satisfaction (81.6% vs 85.6%, P = .54), or whether patients would undergo surgery again (81.6% vs 96.1%, P = .16). Overall, 5 patients in the ABRR group and 2 patients in the AL group had recurrent instability events (12.2% vs 7.8%, P = .70), with no significant difference in the rate of recurrent dislocation (12.2% vs 3.8%, P = .39). Conclusions: In patients with anterior shoulder instability and a concomitant Hill-Sachs lesion, both ABRR and the AL procedure were shown to be reliable treatments, with a low rate of recurrent instability and excellent patient-reported outcomes in appropriately selected patients. However, our study could not determine whether there was critical glenoid bone loss in patients undergoing ABRR, and surgeons should still exercise caution in performing ABRR in patients with high-grade glenoid bone loss or in those with failed prior stabilizations. Level of Evidence: Level III, retrospective cohort study.

Revision Anterior Cruciate Ligaments and the Role of Osteotomies.

Anterior cruciate ligament (ACL) injuries are one of the most common and debilitating injuries experienced by athletes. While many patients successfully undergo ACL reconstructions, long-term failure rates have been reported between 2% to 27% resulting in the need for revisions. One of the main causes for the failure of ACL reconstruction is osseous malalignment (coronal versus sagittal). This review discusses the pathology behind osseous malalignment and provides insights into the origins that helped advance our understanding of our treatment, the high tibial osteotomy.