Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded, placebo-controlled trial. OBJECTIVE: To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA: Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS: Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS: A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS: By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.

A Comparative Analysis of Online Reporting of Possible Complications for Minimally Invasive Cosmetic Procedures.

Background: The rise in Botox, fillers, and chemical peel procedures demands transparent online information that discloses all relevant risks and complications. This study assesses the quality of complication disclosure on the most popular cosmetic sites. Methods: The top 50 Google search results for "Botox," "fillers," and "chemical peel" were analyzed for their reporting on relevant complications. Websites were categorized based on their origin. An overall complication, prevention, management, prevalence, and disclaimer score were assigned to each site. Results: A total of 136 websites were analyzed. Of these websites, 31 (22.7%) did not mention any complications or risks associated with the treatment. The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels. The least-reported serious complications were toxin spread effects (31.0%) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%). Reports of serious and rare side effects were significantly lower than those of common side effects (Botox, P = .001; fillers, P = .004; chemical peels, P < .001). The overall mean (standard deviation) complication score across all websites was 2.81/5 (1.31). Online health reference and academic/hospital sites disclosed complications better than sources in most other categories (P < .001). Conclusions: The reporting of online complications for the top 3 cosmetic procedures performed in the US is highly variable, biased, and at times, completely absent. Patients pursuing cosmetic surgery are heavily influenced by the internet and vulnerable to misinformation. Cosmetic procedure websites are in need of drastic improvement to ensure the health and safety of all patients.

Tommy John: Elbow Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace.

Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.

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

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

Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF): A Video Technique Guide.

Background: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been established as an excellent alternative to the traditional open approach for the treatment of degenerative conditions of the lumbar spine1-3. Description: The procedure is performed with the patient under general anesthesia and on a radiolucent table in order to allow for intraoperative fluoroscopy. The procedure is performed through small incisions made over the vertebral levels of interest, typically utilizing either a fixed or expandable type of tubular dilator, which is eventually seated against the facet joint complex4. A laminectomy and/or facetectomy is performed in order to expose the disc space, and the ipsilateral neural elements are visualized5. The end plates are prepared, and an interbody device is placed after the disc is removed. Pedicle screws and rods are then placed for posterior fixation. Alternatives: Nonoperative alternatives include physical therapy and corticosteroid injections. Other operative techniques include open TLIF or other types of lumbar fusion approaches, such as posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion, lateral or extreme lateral interbody fusion, or oblique lumbar interbody fusion. Rationale: Open TLIF was developed in order to obtain a more lateral approach to the lumbar disc space than was previously possible with PLIF. The goal of this was to minimize the amount of thecal-sac and nerve-root retraction required during PLIF4. Additionally, as the number of patients who required revision after PLIF increased, the need arose for an approach to the lumbar spine that circumvented the posterior midline scarring from previous PLIF surgical sites6. MI-TLIF was introduced to reduce the approach-related paraspinal muscle damage of open TLIF5. Indications for MI-TLIF include most degenerative pathology of the lumbar spine, including disc herniation, low-grade spondylolisthesis, and spinal and foraminal stenosis7. However, MI-TLIF allows for less robust correction of deformity than other minimally invasive approaches; therefore, MI-TLIF may not be as effective in cases of substantial spinal deformity or high-grade spondylolisthesis8. Expected Outcomes: MI-TLIF results in significantly less blood loss, postoperative pain, and hospital length of stay compared with open TLIF1-3. Although some studies have suggested increased operative time for MI-TLIF9,10, meta-analyses have shown comparable operative times between the 2 techniques1-3. It is thought that the discrepancy in reported operative times is the result of a learning curve and that, once that is overcome, the difference in operative time between the 2 techniques becomes minimal11,12. One disadvantage of MI-TLIF that has remained constant in the literature is its increased intraoperative fluoroscopy time compared with open TLIF3,13. The complication rate has largely been found to be equivalent between open and MI-TLIF1-3 or slightly lower with MI-TLIF14, especially in the hands of an experienced surgeon15. Finally, the fusion rate and improvement in patient outcome scores have also been found to be largely equivalent1-3. Important Tips: We suggest placing the ipsilateral pedicle screw after the interbody cage has been inserted.Fully visualize the Kambin triangle16 prior to performing the facetectomy. Protect the exiting and traversing nerve roots by placing small cottonoids around them and retracting delicately.Bone removed during facetectomy can be utilized as autograft for the interbody cage.Avoid removing pedicle bone during decompression.If central stenosis is present, the neural decompression should be extended medial to the epidural fat so that the dura mater can be visualized all of the way to the contralateral pedicle.Perform an adequate end plate preparation prior to interbody insertion while being mindful to avoid injuring the end plate, to minimize the risk of future cage subsidence.Confirm correct placement of the interbody device on intraoperative fluoroscopy.If bone morphogenic protein is utilized, be careful not to pack too much posteriorly as this may cause nerve irritation. Acronyms and Abbreviations: TLIF = transforaminal lumbar interbody fusionMI-TLIF = minimally invasive TLIFPLIF = posterior lumbar interbody fusionALIF = anterior lumbar interbody fusionLLIF = lateral lumbar interbody fusionXLIF = extreme lateral interbody fusionOLIF = oblique lumbar interbody fusionDLIF = direct lateral interbody fusionMRI = magnetic resonance imagingA/P = anteroposteriorEMG = electromyographicBMP = bone morphogenic proteinXR = x-ray (radiograph)OTC = over the counterDVT = deep vein thrombosisPE = pulmonary embolismMI = myocardial infarctionMIS = minimally invasive surgeryOR = operating roomLOS = length of stayVAS = visual analog scaleODI = Oswestry Disability IndexM-H = Mantel-HaenszelRR = risk ratioCI = confidence intervalNSAIDs = nonsteroidal anti-inflammatory drugs.

Patient-reported Outcomes of Scar Impact: Comparing of Abdominoplasty, Breast Surgery, and Facial Surgery Patients.

Scarring negatively impacts patient mental health, causing worsened self-confidence, body image, and social interactions, as well as anxiety and depression. The objective of this study is to evaluate the scarring impact after facial surgery, breast surgery, and full abdominoplasty for symptoms, appearance, psychosocial health, career, and sexual well-being using validated patient-reported outcome measures. Method: A total of 901 patients from five providers completed the SCAR-Q (covering symptoms, appearance, and psychosocial) and Career/Sexual Well-being assessments via phone or email where a higher score indicated a more positive scar perception. Results: Of the 901 patients, 38.1% had abdominoplasty surgery, 38.1% breast reduction, 15.3% facial surgery, 4.7% breast lift, and 3.9% breast augmentation. The differences in SCAR-Q, appearance, and symptom scores between the five procedures were statistically significant. Breast augmentation SCAR-Q scores (median = 256) and facial surgery (median = 242) were significantly higher than those of abdominoplasty patients (median = 219; P = 0.003 and P = 0.001, respectively). Duration after surgery was positively correlated with improved symptom scale scores for abdominoplasty (r = 0.24, P < 0.001), breast augmentation (r = 0.71, P = 0.015), and facial surgery patients (r = 0.28, P = 0.001), but not for other procedures. Conclusions: This study is the first to show that breast augmentation and facial surgery patients have a more positive perception of their scars in terms of appearance, symptoms, psychosocial, career, and sexual well-being impact than abdominoplasty patients. Furthermore, the data suggest that symptoms may improve over time for abdominoplasty, breast augmentation, and facial surgery patients. This study highlights the need for further follow-up, counseling, or other improvements to postoperative scar care.

Scar Perception: A Comparison of African American and White Self-identified Patients.

Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools. Method: A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception. Results: Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232 ± 79 versus 203 ± 116), appearance (66 ± 26 versus 55 ± 29), and Career/Sexual Well-Being (16 ± 2 versus 15 ± 5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores. Conclusions: African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.

Do Websites Serve Our Patients Well? A Comparative Analysis of Online Information on Cosmetic Injectables.

BACKGROUND: Patients access online cosmetic health information to help with decision making. This information is unregulated, variable in quality, and may be biased. This study compared the most popular cosmetic injectables websites to assess their readability, quality, and technical performance. METHODS: A Google search for "Botox" (botulinum toxin type A) and "fillers" was performed in July of 2020, identifying the most popular health information websites. Sites were analyzed for their readability and quality of health information using the validated DISCERN criteria and the Health on the Net Foundation Code of Conduct principles. Technical qualities were evaluated using two website performance algorithms, WooRank and WebsiteGrader. RESULTS: Eighty-five websites were analyzed (13 academic/hospital websites, seven commercial websites, 25 private practice board-certified websites, seven private practice not-board-certified websites, 16 online health reference websites, and 17 other websites). The mean readability consensus score was 11 (eleventh grade reading level). The mean DISCERN quality scores were higher for online health reference websites compared to academic/hospital websites (p = 0.045), commercial websites (p = 0.045), private practice board-certified websites (p < 0.001), and private practice not-board-certified websites (p = .002). No correlation between a website's rank and its DISCERN score was found (ρ = -0.07; p = 0.49). CONCLUSIONS: Cosmetic injectable websites are too difficult to read by the sixth grade standard recommended by the National Institutes of Health and the American Medical Association. Online health reference sites are higher in quality than physician sites. This has implications for the ability of many patients to be fully informed consumers. The readability, quality, and technical aspects of websites may affect the overall accessibility of patient health information.

Preoperative portal vein recanalization-transjugular intrahepatic portosystemic shunt for chronic obliterative portal vein thrombosis: Outcomes following liver transplantation.

High-grade portal vein thrombosis (PVT) is often considered to be a technically challenging scenario for liver transplantation (LT) and in some centers a relative contraindication. This study compares patients with chronic obliterative PVT who underwent portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) and subsequent LT to those with partial nonocclusive PVT who underwent LT without an intervention. This institutional review board-approved study analyzed 49 patients with cirrhosis with PVT from 2000 to 2020 at our institution. Patients were divided into two groups, those that received PVR-TIPS due to anticipated surgical challenges from chronic obliterative PVT and those who did not because of partial PVT. Demographic data and long-term outcomes were compared. A total of 35 patients received PVR-TIPS while 14 did not, with all receiving LT. Patients with PVR-TIPS had a higher Yerdel score and frequency of cavernoma than those that did not. PVR-TIPS was effective in decreasing portosystemic gradient (16 down to 8 mm HG; p < 0.05). Both groups allowed for end-to-end anastomoses in >90% of cases. However, veno-veno bypass was used significantly more in patients who did not receive PVR-TIPS. Additionally, patients without PVR-TIPS required significantly more intraoperative red blood cells. Overall survival was not different between groups. PVR-TIPS demonstrated efficacy in resolving PVT and allowed for end-to-end portal vein anastomoses. PVR-TIPS is a viable treatment option for chronic obliterative PVT with or without cavernoma that simplifies the surgical aspects of LT.

When successful, anterior vertebral body tethering (VBT) induces differential segmental growth of vertebrae: an in vivo study of 51 patients and 764 vertebrae.

PURPOSE: This study aimed to determine (1) does vertebral body tethering (VBT) produce differential growth modulation in individual vertebrae in patients with idiopathic scoliosis, (2) does VBT change disc shape, and (3) does VBT affect total spine length? METHODS: Patients with idiopathic scoliosis treated with VBT of the main thoracic curve and minimum 2-year follow-up were included. Vertebrae and discs were categorized as uninstrumented proximal thoracic, instrumented main thoracic, or uninstrumented thoracolumbar-lumbar. The left- and right-sided heights of each vertebra and disc were measured on subsequent radiographs to assess for differential growth. T1-T12 thoracic and T1-S1 thoracolumbar growth velocities were compared with standardized reference data. RESULTS: Fifty-one patients (764 vertebrae and 807 discs) were analyzed. The average major curve magnitude improved from 46° ± 11° to 17° ± 11° at 2-year follow-up. Differential growth was observed in MT vertebrae, in which the left/concave side grew 2.0 ± 2.2 mm compared with 1.5 ± 2.3 mm on the right/convex (tethered) side (p < 0.001). Differential height changes were observed for all discs, but were most pronounced in instrumented MT discs, in which the right/convex sides decreased by an average of 1.2 mm each, compared with no significant height change on the left/concave side. Total spinal growth velocities were not significantly different from standard reference data. CONCLUSION: Vertebral body tethering limits convex spinal growth as designed while permitting concave growth. Curve correction results from differential vertebral growth and decreased convex disc height. Overall spinal growth continues at the expected rate. LEVEL OF EVIDENCE: Level IV case series.

Which Resources Are Better: Sales or Scholarly? An Assessment on the Readability, Quality, and Technical Features of Online Chemical Peel Websites.

BACKGROUND: Chemical peels are an exceedingly popular cosmetic treatment with a wide variety of suppliers, each with its own online health resource describing the procedure. With increasing reliance on the internet for medical information, it is crucial that these resources provide reliable information for patients to make informed decisions. OBJECTIVES: The aim of this study was to examine popular chemical peel resources and determine if those that offered chemical peel treatments (Sales) had lower readability, quality of information, and technical features compared with those that did not (Scholarly). METHODS: The term "chemical peel" was searched in July 2020 and the top 50 websites were retrieved for analysis. Each resource's readability, quality, and technical features were measured through 8 readability formulas, the DISCERN and Health on the Net Code (HONcode), and 2 website performance monitors. RESULTS: The 50 websites were analyzed with an average Fry readability score of 13th grade. Scholarly websites displayed higher readability than Sales (Flesch Reading Ease 54.4 > 47.4, P = 0.047 and Coleman-Liau Index 10.6 < 11.7, P = 0.04). Scholarly resources surpassed Sales both in quality (DISCERN 56.4 > 39.7, P < 0.001 and HONcode 11.8 > 9.5, P = 0.032) and technical features (WooRank 76.9 > 68.6, P = 0.0082). CONCLUSIONS: The average readability of chemical peel resources is too difficult, and their quality must be improved. Scholarly resources exhibited higher readability, quality, and technical features than Sales websites.

The top 100 classic papers on adolescent idiopathic scoliosis in the past 25 years: a bibliometric analysis of the orthopaedic literature.

STUDY DESIGN: Bibliometric analysis. OBJECTIVES: To identify the 100 most cited orthopedic papers in adolescent idiopathic scoliosis (AIS) over the past 25 years and characterize them by study type, topic, and country and assess study quality (design, level of evidence, and impact factor) to provide an updated account of the most impactful AIS evidence. AIS represents a three-dimensional deformity that drives a significant number of investigations. Although available evidence continues to grow, recent impactful studies pertaining to AIS have not been identified; their quality has not been thoroughly assessed. METHODS: Web of Science was reviewed to identify the top 1000 cited AIS studies published from 1992 to 2017. Articles were organized by number of citations. Titles and abstracts were screened for inclusion/relevance, and the top 100 articles by citation count were identified, and study and publication characteristics were extracted. RESULTS: Among the top 100 articles, 42 were cited ≥ 100 times. Mean number of authors and citations of these studies was 5.6 and 118.3, respectively. Study types were predominantly retrospective (n = 53), followed by prospective (n = 18), cross-sectional (n = 13), and systematic review/meta-analysis (n = 7). Topics covered in these studies included clinical/patient outcomes (n = 47), methodology/validation (n = 22), basic science (n = 15), radiographic analyses (n = 12), and gait/biomechanics (n = 4). Most studies originated in the United States of America (n = 65) and were published in Spine (n = 76), with 8266 total citations. Most studies were of Level III (n = 55) or Level II (n = 23) evidence. Mean impact factor was 3.47. CONCLUSIONS: Despite recent studies' shorter time frames for impact, citations of AIS research have progressively increased during the past 25 years. The top 100 cited orthopedic studies were predominantly Level III, retrospective, nonrandomized studies, and therefore, were subject to biases. The low proportion of prospective studies (18%) reflects an area of future improvement, underscoring the need for higher-quality studies to support our practice. LEVEL OF EVIDENCE: N/A.

After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up.

BACKGROUND: In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO. OBJECTIVE: To investigate if performance of 3CO surgeries improves with years of practice. METHODS: Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis. RESULTS: Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001). CONCLUSION: Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.

Lumbosacral stress and age may contribute to increased pelvic incidence: an analysis of 1625 adults.

PURPOSE: While there is a consensus that pelvic incidence (PI) remains constant after skeletal maturity, recent reports argue that PI increases after 60 years. This study aims to investigate whether PI increases with age and to determine potential associated factors. METHODS: 1510 patients with various spinal degenerative and deformity pathologies were enrolled, along with an additional 115 asymptomatic volunteers. Subjects were divided into six age subgroups with 10-year intervals. RESULTS: PI averaged 54.1° in all patients. PI was significantly higher in the 45-54-year age group than 35-44-year age group (55.8° vs. 49.7°). There were significant PI differences between genders after age 45. Linear regression revealed age, gender and malalignment as associated factors for increased PI with R 2 of 0.22 (p < 0.001). CONCLUSIONS: PI is higher in female patients and in older patients, especially those over 45 years old. Spinal malalignment also may have a role in increased PI due to increased L5-S1 bending moment.

Bone substitutes in adolescent idiopathic scoliosis surgery using sublaminar bands: is it useful? A case-control study.

INTRODUCTION: In order to avoid pseudarthrosis in adolescent idiopathic (AIS) patients, it is recommended to bring additional bone graft or substitute. Modern rigid instrumentations have been shown to provide less pseudarthroses even without bone substitutes. The aim of our study was to determine the impact of using bones substitutes on fusion rates in adolescent idiopathic scoliosis patients undergoing PSF with sublaminar bands. METHOD: AIS patients scheduled to undergo PSF with sublaminar bands were prospectively enrolled into this study and not given any bone substitutes (no-substitute group). Data were collected and analyzed in patients with at least two years of follow-up. Pseudarthrosis was diagnosed if at least one of the following was present: persistent back pain, hardware failure, loss of correction greater than 10°. The results were compared to a control group who received bone substitutes for the same surgical procedure. RESULTS: Eighty-eight patients were included. For the whole cohort, the mean age was 14.8 years old and the mean follow-up was 30.9 months. For the 'no-substitute' group (n = 44), the mean Cobb angle was 56° pre-operatively, 20.1° post-operatively, and 22° at final follow-up. The fusion rate was not statistically different between the two groups (97.7% vs 95.5%, p = 0.56). At last follow-up, one pseudarthrosis occurred in the 'no substitute' group and two in the control group. DISCUSSION: This is the first study to determine the impact of bone substitutes in AIS fusion using sublaminar bands. In our study, the use of local autologous bone graft alone resulted in a fusion rate of 97.7% despite the use of more flexible instrumentation. The high rate of fusion in AIS patients is more probably due to the healing potential of these young patients rather than to the type of instrumentation. CONCLUSION: The use of additional bone graft or bone substitutes may not be mandatory when managing AIS. LEVEL OF EVIDENCE: 4.