Roussouly classification of adult spinal deformity.

With an estimated prevalence of 68% among healthy adults without a previous diagnosis of scoliosis, adult spinal deformities are a growing concern as the population ages. Our understanding of this growing concern has been historically guided by previous studies performed on the pediatric population. Over time, different classifications have been developed with their own respective limitations. The Roussouly classification was the first classification to describe the shapes of an asymptomatic spine. It considers lumbar lordosis, pelvic incidence, and the inflection point from lumbar lordosis to thoracic kyphosis to attempt to stratify the shapes of an asymptomatic spine. This classification aims to guide treatment, provide information regarding prognosis, allow stratification for research, and be highly reproducible. Overall, the Roussouly classification is a novel way to think about sagittal malalignment, considering the patient's individual anatomy, while allowing for communication between surgeons. Additionally, it has proven to be a reliable system that provides prognostic value for clinicians and may minimize complications when a patient's sagittal alignment is optimized using this classification system.

Posterior Capsule Reconstruction with Polypropylene Mesh After Total Hip Arthroplasty.

Instability remains a challenge after total hip arthroplasty (THA). We have previously utilized a monofilament polypropylene mesh to reconstruct the posterior capsule for unstable THA. This study identified 24 hips that underwent mesh reconstruction of the posterior capsule for instability. Survivorship was 70.8% at mean 6.5 years (range 6 weeks-20.1 years). Six patients underwent re-operation, and one patient had the mesh removed. Of eight hips, five (62.5%) with a history of prior revision re-dislocated, while only 2/16 hips (12.5%) with no previous revision history re-dislocated (p = 0.02). Posterior capsule reconstruction with polypropylene mesh has reasonable mid-term survivorship in this challenging population. (Journal of Surgical Orthopaedic Advances 32(2):092-096, 2023).

Instagram and Spine Fusion: An Analysis of Social Media and Its Relationship to Patient Perception of Surgery.

STUDY DESIGN: Cross sectional study. OBJECTIVES: To analyze posts shared on Instagram referencing spinal fusion for tone, gender, activities of daily living (ADLs), rehabilitation, incision, pain, neurological injury, and content of post. METHODS: Public instragram posts, which were isolated and evaluated using the hashtags "#spinefusion" and "#spinalfusion." All posts were analyzed by the authors for the variables previously listed. In total, 264 posts were included for investigation and analysis of patient perception of spine fusion through social media. RESULTS: Of all included posts, approximately 86% of posts had a positive tone. There was statistical significance between positive tone and activities of daily living (ADLs) (P = 0.047), as well as negative tone and persistent pain (P = 0.008). Adequate return to activities of daily living is perceived by patients as a positive outcome after surgery: odds ratio (OR) (95% CI) of 2.11 (1.01-4.39). Persistent post operative pain results negatively on perceived outcomes after surgery OR = 0.38 (0.18-0.78). CONCLUSIONS: Reported outcomes after spine fusion has not been evaluated through social media avenues. This analysis of patients sharing their experience on social media after spinal fusion demonstrates that returning to activities of daily living is of the utmost importance to patients. Additionally, post-operative pain is a strong metric utilized by patients with their satisfaction after surgery.

Treatment for sacral insufficiency fractures: A systematic review.

Intro: Sacral insufficiency fractures after lumbosacral fusion continue to establish themselves as a rare complication after surgery. The diagnosis can often be missed due to inconclusive imaging and non-specific symptoms. In the literature, the treatment of sacral insufficiency fractures varies from non-operative and conservative management to surgical intervention with lumbopelvic fixation. Methods: We performed a systematic review searching the PubMed database using sacral insufficiency fracture treatment after lumbosacral fusion and sacral insufficiency fracture after posterior spinal instrumentation as keywords. Results: This search strategy identified 32 publications from the PubMed database for literature review. After evaluating the inclusion and exclusion criteria, a total of 17 articles were included in the review. 65% of sacral insufficiency fractures were managed surgically with 35% of patients proceeding with non-operative, conservative management only. Revision surgery always involved sacropelvic fixation which typically led to immediate resolution or reduction of symptoms, with the exception of 2 cases that did not receive adequate reduction of symptoms. Five cases reported failed non-operative management that subsequently responded to revision surgery. Conclusion: Outcomes after non-operative management usually leads to symptom resolution; however has a slower symptom relief time as well as a higher chance of failed treatment. Operative outcomes, generally with a variation of sacropelvic fixation lead to immediate symptom resolution and very rarely failed treatment. Clinicians must always maintain a high index of suspicion of new onset lower back or sacral pain after lumbosacral surgery and order a CT scan to rule out a potential insufficiency fracture. Objectives: The objective of this study was to review the literature to examine treatment options for sacral insufficiency fractures after lumbosacral fusion in order to improve clinical practice and management. This systematic review of the literature regarding treatment of sacral insufficiency fractures will assist clinicians in making the accurate diagnosis and devise a strategic treatment plan for patients with sacral insufficiency fractures after spinal instrumentation.

Patient perception of medial patellofemoral ligament reconstruction on Instagram.

To date, there is limited social media evaluation of patients after medial patellofemoral ligament (MPFL) reconstruction and analysis of their perceived surgical outcome. The purpose of this study was to examine patient perceived outcomes after MPFL reconstruction via social media analysis on Instagram. A total of 486 posts containing "#MPFL" were included in the assessment. The tone of the post was examined in relation to demographic variables and the content of the post. When comparing posts containing positive vs. negative tone, those referencing rehabilitation (P < 0.0001) and activities of daily living (ADLs) (P = 0.0002) were more likely to be positive. Posts referencing surgical incision or scar (P = 0.02) or postoperative instability/dislocation (P < 0.0001) were more likely to have a negative tone. Multivariable logistic regression identified references to incision/scar (odds ratio [OR]: 0.446, P = 0.0264) and instability/dislocation (OR: 0.071, P < 0.0001) as strong negative predictors of positive tone. However, referencing rehabilitation (OR: 2.464, P = 0.0091) or ADLs (OR: 2.251, P = 0.0187) substantially increased the likelihood of a positive post tone. In conclusion, positive tone was associated with improved rehabilitation and ability to perform ADLs postoperatively. In contrast, negative tone was associated with dissatisfaction with the scar/incision, as well as postoperative patellar instability.

Sacral insufficiency fracture after lumbosacral decompression and fusion.

Sacral insufficiency fracture is becoming increasingly recognized as a complication of lumbosacral fusion, due to alteration of spinal biomechanics. Recognition of patient presentation is important because plain films may initially be negative with this complication. This case series of seven sacral insufficiency fractures following lumbosacral fusion characterizes key characteristics of presentation and management for sacral insufficiency fracture following lumbosacral fusion, which does not have a clearly defined algorithm for treatment. These seven fractures presented with initial complaints of back pain, lower extremity radicular symptoms, or a combination of the two. All identified fractures in this series were located below the inferior-most level of the fusion construct. Cross-sectional imaging such as computed tomography or magnetic resonance imaging was utilized in each case to make the diagnosis of sacral insufficiency fracture. Management depends on the patient's presentation, symptoms, and fracture pattern, but treatment options include operative revision surgery and nonoperative modalities such as a standard rehabilitation protocol, lumbar bracing, and bone stimulators with close follow-up.

Relation of tranexamic acid therapy to length of stay in the hip fracture population.

Tranexamic acid (TXA) is a medication that is routinely used to minimize blood loss during surgery. There is minimal literature evaluating the effects of TXA in hip fractures in regards to length of stay, readmission rates, and location of discharge. This study included adult patients who were admitted for hip fracture that required surgery over a 22-month period (May 2017-February 2019). A total of 525 hip fractures were operated on during this time period. Retrospective analysis was performed on patients treated with TXA (n = 27) vs those who were not (n = 498). Primary outcomes were length of stay, disposition after discharge, need for transfusion, mobilization with therapy, and readmission rates. TXA during hip fractures reduced median length of stay in the hip fracture cohort to 3 vs 5 days (P < 0.01). Patients were more likely to be discharged home as opposed to a nursing facility. Patients who received TXA during their hip fracture surgery were less likely to need transfusions while admitted (P < 0.01). No increased readmission rates were seen within 30 days after discharge (P = 0.59). In conclusion, when indicated, TXA appears to be safe for utilization in hip fracture surgery, resulting in decreased length of stay, less transfusions, and no increase in readmission rates.

Relation of mobilization after hip fractures on day of surgery to length of stay.

This study examined whether evaluation by physical therapy on the day of surgery impacts length of stay in patients with hip fractures. A total of 528 adult patients with hip fracture requiring surgery were prospectively included in the study over a 22-month period. The median length of stay of mobilized patients was 4.0 days, vs 5.0 days in nonmobilized patients (P = 0.0158). Of the 259 mobilized patients, 64 were discharged home (24.71%) vs 47 (17.84%) in the nonmobilized cohort (P = 0.0434), with no increase in readmission rates. In conclusion, mobilization on the day of surgery reduced length of stay by 1 day, with a higher percentage of patients being discharged home.

William Beall Carrell, MD (1883-1944).

This article commemorates Dr. William Beall Carrell, who made many contributions to the field of orthopedic surgery. His legacy continues through the Carrell Clinic and Scottish Rite for Children in Dallas.

Brandon Carrell, MD (1911-1981).

This biographical sketch on Dr. Brandon Carrell commemorates the life of an influential surgeon in the Dallas community. His contributions to pediatric orthopedic surgery helped form the field it is today.

Spinal Brucellosis: A Case Report and Review of the Literature.

INTRODUCTION: The most common location of infection of brucellosis is the musculoskeletal system. It is estimated that the spine is involved in 2-54% of brucellosis infections, with the lumbar spine most commonly affected. We report an uncommon case of brucellar spondylodiscitis, in addition to the pathology, common presentation, and management of spinal brucellosis through additional literature review. CASE REPORT: A 65-year-old Hispanic male presented to an orthopedic spine surgeon with signs and symptoms concerning for metastatic disease to the spine. Investigation revealed that the patient had the rare diagnosis of brucellar spondylodiscitis. This only became apparent after detailed questioning of the patient's history revealed his employment within a Mexican meat slaughterhouse and a regular consumer of unpasteurized Mexican cheeses. CONCLUSION: Although uncommon, brucellosis spondylodiscitis should remain as a differential diagnosis in any patient who presents with back pain and fever. Detailed history taking and thorough physical examination remain vital in the work-up of brucellar spondylodiscitis. Understanding the pathology, radiographic findings, and necessary work-up are essential to properly treat this infection.

Leon L. Wiltse, MD (1913-2005).

This biographical sketch draws on articles written by and about one of the most influential orthopedic spine surgeons of our time, Dr. Leon L. Wiltse. Our aim is to commemorate his life and contributions to the fields of orthopedic and spine surgery, while also highlighting his early connections to the Dallas area.

The erector spinae plane block for analgesia after lumbar spine surgery: A systematic review.

OBJECTIVE: To evaluate the available evidence for the utility of Erector Spinae Plane blocks (ESPB) after Lumbar surgery. METHODS: Databases were searched until December 20, 2020. ESPB was utilized as a MesH term and terms such as: lumbar spinal stenosis, spondylolisthesis, decompression and lumbar spine surgery. RESULTS: Studies demonstrate that ESPB are consistently found to be a safe and effective method of analgesia after lumbar surgery, with limited adverse effects. CONCLUSION: ESPB appear to be an effective method to relieve pain after lumbar surgery. More RCTs will be needed to further investigate the clinical effectiveness of this intervention.

Triaging Spine Surgery and Treatment during the COVID-19 Pandemic.

OBJECTIVE: To utilize evidence-based medicine to help determine guidelines for spinal surgery during the Covid-19 era. METHODS: A literature review was performed of peer-reviewed articles focused on indications for common procedures in spine surgery. Based on these indications, we sub-categorized these procedures into elective, urgent and emergent categories. Case examples provided. RESULTS: Indications for spinal surgery were reviewed based on current literature and categorized. This manuscript presents a decision-making algorithm to help provide a guideline for determining the appropriateness of proceeding with spinal surgery during this COVID-19 time period. CONCLUSIONS: Spinal surgery during the COVID-19 pandemic is an intricate challenging decision-making process, involving clinical, sociologic and economic factors.

Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.

PURPOSE OF REVIEW: The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic. RECENT FINDINGS: SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting "elective" surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely "elective" procedure, versus an "urgent" procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into "elective" versus "urgent" categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one's peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

Surgical automation reduces operating time while maintaining accuracy for direct anterior total hip arthroplasty.

OBJECTIVE: Investigate the efficiency/accuracy of surgical automation versus manual component implantation in DA THA. METHODS: Retrospective review of 111 hips: 51 hips via automation and 60 hips via manual technique for DA THA. RESULTS: OR time averaged 8 min faster in the Automated group, compared to Manual group (p = 0.0009). Average femoral size was one size larger in the Automated group compared to Manual group (p = 0.007). No clinically significant differences were found between Manual and Automated groups for cup position or limb-length discrepancy. One calcar fracture occurred in the Automated group. CONCLUSION: Surgical automation is efficient and accurate for DA THA.

James Pat Evans, MD, 1930-2019.

This biographical sketch of Dr. J. Pat Evans commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, drawing on articles written in remembrance of him and his contributions to orthopedic surgery and sports medicine.

Robert Wilson Jackson, MD (1932-2010).

This article commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, Dr. Robert Jackson.

Financial impact of removal of total knee arthroplasty from the inpatient-only list for a physician-owned BPCI program.

OBJECTIVE: Assessing financial effects of removal of TKA from CMS inpatient-only list on physician-owned bundles. METHODS: We determined whether Medicare TKAs remained inpatient, versus changed to observational. We used CMS data to determine savings. Direct costs associated with BPCI were calculated. RESULTS: 7/28 TKAs (25.0%) had inpatient status changed to observational, excluding them from BPCI. Estimated savings losses were $24,332. Direct costs for administrating BPCI were $51,250. Had the rate of patients changed to observational been 50%, bundle savings from remaining patients would be less than direct costs. CONCLUSION: Removing TKA from CMS inpatient-only list may have negative financial implications.