Factors Important to Patient Decision-Making After Ulnar Collateral Ligament Injury in Competitive High School and Collegiate Baseball Players.

Background: Patients are faced with several treatment decisions after an ulnar collateral ligament (UCL) injury: nonoperative versus operative treatment, repair versus reconstruction, and immediate versus delayed surgery. Purpose/Hypothesis: The aim of this study was to investigate the factors important to patients when deciding which treatment to pursue after a UCL injury. We hypothesized that (1) length of time away from sports and seasonal timing would be important to patients and (2) treatment decision-making would be heavily influenced by how many and which seasons of their baseball career would be missed. Study Design: Cross-sectional study. Methods: High school and collegiate baseball players with UCL tears treated at an academic institution were surveyed retrospectively on their sports participation at the time of injury and their UCL injury treatment decisions. Respondents rated the influence of various factors on a 5-point Likert scale, and they selected the top 3 factors and the single most important factor influencing their treatment decisions. Multiple logistic regression analysis was used to assess the relationship between player characteristics and factors important to their treatment decision. Results: A total of 83 athletes completed the survey; 40 were in high school and 43 were in college at the time of injury; 7 were treated nonoperatively and 76 underwent surgery (66 immediately and 10 in a delayed fashion), 10 with UCL repair and 66 with UCL reconstruction. The ability to play competitive baseball in the long term was very important or extremely important to 90% of players, while the ability to play in the short term was very important or extremely important to 17%. Length of recovery and seasonal timing were also important factors for 53% and 54% of players, respectively, and almost all (90%) highly valued advice from a surgeon. Possible failure of nonoperative treatment leading to increased time away and the possible loss of 2 consecutive baseball seasons heavily influenced decision-making in 41% of respondents. Conclusion: Survey respondents were driven by the desire to play baseball in the long term. Treatment decisions were influenced by the length of recovery and by the seasonal timing of their injury, both of which affect how many and which seasons of baseball a player may miss. Patients found advice from their surgeon to be extremely important to decision-making.

A Comparison of 2 Abbreviated Methods for Assessing Adolescent Bone Age: The Shorthand Bone Age Method and the SickKids/Columbia Method.

BACKGROUND: Radiographic assessment of bone age is critically important to decision-making on the type and timing of operative interventions in pediatric orthopaedics. The current widely accepted method for determining bone age is time and resource-intensive. This study sought to assess the reliability and accuracy of 2 abbreviated methods, the Shorthand Bone Age (SBA) and the SickKids/Columbia (SKC) methods, to the widely accepted Greulich and Pyle (GP) method. METHODS: Standard posteroanterior radiographs of the left hand of 125 adolescent males and 125 adolescent females were compiled, with bone ages determined by the GP method ranging from 9 to 16 years for males and 8 to 14 years for females. Blinded to the chronologic age and GP bone age of each child, the bone age for each radiograph was determined using the SBA and SKC methods by an orthopaedic surgery resident, 2 pediatric orthopaedic surgeons, and a musculoskeletal radiologist. Measurements were then repeated 2 weeks later after rerandomization of the radiographs. Intrarater and interrater reliability for the 2 abbreviated methods as well as the agreement between all 3 methods were calculated using weighted κ values. Mean absolute differences between methods were also calculated. RESULTS: Both bone age methods demonstrated substantial to almost perfect intrarater reliability, with a weighted κ ranging from 0.79 to 0.93 for the SBA method and from 0.82 to 0.96 for the SKC method. Interrater reliability was moderate to substantial (weighted κ: 0.55 to 0.84) for the SBA method and substantial to almost perfect (weighted κ: 0.67 to 0.92) for the SKC method. Agreement between the 3 methods was substantial for all raters and all comparisons. The mean absolute difference, been GP-derived and SBA-derived bone age, was 7.6±7.8 months, as compared with 8.8±7.4 months between GP-derived and SKC-derived bone ages. CONCLUSIONS: The SBA and SKC methods have comparable reliability, and both correlate well to the widely accepted GP methods and to each other. However, they have relatively large absolute differences when compared with the GP method. These methods offer simple, efficient, and affordable estimates for bone age determination, but at best provide an estimate to be used in the appropriate setting. LEVEL OF EVIDENCE: Diagnostic study-level III.

Instagram Use Among Orthopaedic Surgery Residency Programs.

INTRODUCTION: The COVID-19 pandemic created unprecedented challenges to residency recruitment. With in-person away rotations prohibited and interviews held virtually, orthopaedic residency programs turned to social media. Studies document the exponential growth of residency program Instagram accounts after March 2020, but few analyze the content of their posts. This study provides an updated assessment of such Instagram accounts including a detailed analysis of their content and a discussion of potentially concerning posts. METHODS: Orthopaedic surgery residency programs participating in the National Resident Matching Program and any Instagram accounts associated with these programs were identified. Instagram accounts were analyzed, and the 25 most recent posts and all highlighted stories for each account were coded for content based on a predetermined list of categories. Specific attention was given to content that may raise legal, ethical, or professionalism concerns. The primary outcome was the most common content code among posts. The secondary outcomes were the number of posts identified as potentially concerning and the types of concerns represented. RESULTS: Overall, 138 of 193 residency programs (72%) had an Instagram account at the time of cross-sectional analysis, 65% of which were created between April and December 2020. All accounts were public. Profiles had on average 1,156 ± 750 followers and 59 ± 75 posts. Of the 3,348 posts analyzed, the most common coded themes were resident introductions (33%), camaraderie (27%), and social life and hobbies (26%). There were 81 concerning posts from 52 separate accounts. Seventy-five of the concerning posts (93%) depicted residents scrubbed alone. CONCLUSION: Orthopaedic residency Instagram accounts are potential tools for residency recruitment and can depict a program's culture through posts over time. However, public accounts are open to scrutiny by other viewers, including patients and their families. Care must be taken to consider multiple perspectives of post content, so as to bolster, not damage, the residency program's reputation.

A Comprehensive Unit-based Safety Program to Improve Perioperative Efficiency in Adolescent Idiopathic Scoliosis.

BACKGROUND: Addressing operational inefficiencies in operating rooms (ORs) enhances patient access to care, reduces delays, and improves employee and patient satisfaction. The Comprehensive Unit-based Safety Program (CUSP) promotes patient safety through increased teamwork, empowerment of frontline staff, and utilization of science of safety principles. CUSP has demonstrated success in outpatient and inpatient settings to decrease complication rates and establish a culture of safety but has been used minimally in the perioperative setting. In this study, the CUSP methodology was utilized to improve perioperative efficiency in pediatric spine surgery, and preimplementation and postimplementation efficiency were compared, using the rate of first case on-time starts (FCOTS) as the primary metric. METHODS: A CUSP quality improvement workgroup including nurses, technicians, surgeons, anesthesiologists, and administrators sought feedback on opportunities for improvement and tracked key performance metrics in the OR from 2015 to 2020. Key interventions developed in response to feedback included standardizing and streamlining room setup and adjusting staffing models for greater efficiency. Univariate analysis was conducted to compare time periods pre-CUSP and post-CUSP implementation. RESULTS: First case on-time starts increased from 38% to a high of 81% after implementation. For more complex cases, the average patient in the room to anesthesia ready time improved by 31% with decreased variance over time, and average closure to patient out of room time improved by 45%. Improvements were sustained through Year 3, while CUSP remained a primary focus for the team. CONCLUSIONS: CUSP is effective in enhancing perioperative efficiency, demonstrating strong improvement in on-time starts over 5 years. The results indicate that process improvement in ORs requires consistent attention to sustain gains over time. Engaging frontline staff in quality improvement fosters collaboration and provides employee buy-in to promoting a culture of safety and improving value in patient care. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Current Status of Podcasts in Orthopaedic Surgery Practice and Education.

Within orthopaedic surgery, podcasts are a popular medium for sharing information. The purpose of this Training Room feature was to identify the number, type, longevity, popularity, and advantages and disadvantages of orthopaedic surgery podcasts and to better understand the role of podcasts in our field by interviewing key leaders in orthopaedic surgery who host their own podcast. We identified 102 unique orthopaedic podcasts. The number of active podcasts grew from 5 in 2016 to 67 in 2021, which represents an increase of 1,340%. Podcasts offer the advantages of easy access to knowledge and opportunity for multitasking. They come with the disadvantages of lack of visualization in a field that relies heavily on diagrams, photographs, videos, and radiographs and lack of peer review, which means false information may be propagated. We anticipate an increase in the number and popularity of orthopaedic surgery podcasts in the coming years.

All-Suture Anchors in Orthopaedic Surgery: Design, Rationale, Biomechanical Data, and Clinical Outcomes.

All-suture anchors (ASAs) are a relatively new alternative to traditional suture anchors, comprised of sutures, suture tapes, or ribbons woven through a soft sleeve. These novel anchors are typically smaller than traditional anchors, allowing for more anchors to be used in the same amount of space or for use when bone stock is limited, for example, in revision settings. They can be inserted through curved guides to reach more challenging locations, and they have thus far had similar loads to failure during biomechanical testing as traditional anchors. However, these benefits must be weighed against new challenges. When using ASAs, care must be taken to fully deploy and seat the anchor against cortical bone for optimal fixation and to prevent gap formation. Furthermore, decortication, often performed to enhance the biologic environment for soft-tissue healing, may weaken the cortical bone on which ASA fixation depends on. The purpose of this article is to provide insight on the designs, advantages, and potential disadvantages associated with ASAs, as well as review the available biomechanical and clinical data.

Resection of congenital hemivertebra in pediatric scoliosis: the experience of a two-specialty surgical team.

OBJECTIVE: Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population. METHODS: Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records. RESULTS: From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery. CONCLUSIONS: Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.

Complications in ambulatory pediatric patients with nonidiopathic spinal deformity undergoing fusion to the pelvis using the sacral-alar-iliac technique within 2 years of surgery.

OBJECTIVE: Significant investigation in the adult population has generated a body of research regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following long fusions to the sacrum and pelvis. However, much less is known regarding early complications, including PJK and PJF, in the ambulatory pediatric patient. As such, the objective of this study was to address the minimal literature on early complications after ambulatory pediatric patients underwent fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac (S2AI) instrumentation. METHODS: The authors performed a retrospective review of pediatric patients with nonidiopathic spinal deformity < 18 years of age with ambulatory capacity who underwent fusion to the pelvis at a multisurgeon pediatric academic spine practice from 2016 to 2018. All surgeries were posterior-only approaches with S2AI screws as the primary technique for sacropelvic fixation. Descriptive, outcome, and radiographic data were obtained. The definition of PJF included symptomatic PJK presenting as fracture, screw pullout, or disruption of the posterior osseoligamentous complex. RESULTS: Twenty-five patients were included in this study. Nine patients (36.0%) had 15 complications for an overall complication rate of 60.0%. Unplanned return to the operating room occurred 8 times in 6 patients (24.0%). Four patients (16.0%) had wound issues (3 with deep wound infection and 1 with wound breakdown) requiring reoperation. Three patients (12.0%) had PJF, all requiring reoperation. A 16-year-old female patient with syndromic scoliosis underwent extension of fusion due to posterior tension band failure at 6 months. A 17-year-old male patient with neuromuscular scoliosis underwent extension of fusion due to proximal screw pullout at 5 months. A 10-year-old female patient with congenital scoliosis underwent extension for PJF at 5 months following posterior tension band failure. One patient had pseudarthrosis requiring reoperation 20 months postoperatively. CONCLUSIONS: Fixation to the pelvis enables significant deformity correction, but with rather high rates of complications and unexpected returns to the operating room. Considerations of sagittal plane dynamics for PJK and PJF should be strongly analyzed when performing fixation to the pelvis in ambulatory pediatric patients.

Ambulatory capacity following fusion to the sacrum with pelvic fixations pediatric spinal deformity patients.

OBJECTIVE: To investigate outcomes of ambulatory pediatric patients fused to the sacrum with pelvic fixation. STUDY DESIGN: Retrospective cohort. BACKGROUND: Historically in the pediatric spinal deformity literature, long fusions to the sacrum with pelvic fixation have been limited to non-ambulatory patients with pelvic obliquity. This analysis assesses the impact of how long fusions that include pelvic fixation in ambulatory pediatric patients. METHODS: Consecutive pediatric patients undergoing fusion to the sacrum with pelvic fixation with any ambulatory capacity at a tertiary academic pediatric spine program from 2016 to 2018 were included in this review. Patient demographics, surgical details, and postoperative results were collected and analyzed to identify the impact on postoperative gait and ambulation function. Outcomes were determined from PROMIS, Parent Proxy Mobility questionnaires, as well as an institution specific pediatric gait questionnaire. RESULTS: 25 patients met inclusion criteria. 96.0% of patients had non-idiopathic scoliosis. 48% (12/25) of patients had previous spinal surgery. Median fusion levels were 17.0. 40% (10/25) had preoperative motor and gait deficits and only one patient with a documented decline at postoperative clinical examination. All 25 patients retained ambulatory capacity following their spinal fusion to the sacrum with pelvic fixation. 64% (16/25) of patients or family members completed the postoperative gait questionnaire. The mean PROMIS T-score was 43.4 (95% CI 36.5-50.0) for intact patients. The postoperative gait questionnaires revealed that 75% (6/8) of neurologically intact patients stated they would have the surgery again. 100% (8/8) of these patients noted an improved posture and 25% (2/8) reported a subjective decrease in ambulatory capacity status/post fusion to the sacrum. 100.0% (8/8) of limited ambulatory patients stated they would have the surgery again and noted improved posture with only 25% (2/8) noting a subjective decrease in ambulation postoperatively. CONCLUSION: In appropriately selected pediatric spinal deformity patients fusion to the sacrum using pelvic fixation can maintain ambulation with high overall surgical satisfaction. LEVEL OF EVIDENCE: III.

Trends in total shoulder arthroplasty from 2005 to 2018: lower complications rates and shorter lengths of stay despite patients with more comorbidities.

BACKGROUND: Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis. RESULTS: Bivariate analysis revealed significantly more comorbidities among patients in the 2015-2018 cohort compared with the 2005-2010 cohort, specifically American Society of Anesthesiologist class III or IV (57.0% vs. 44.3%, P < .001), morbid obesity (10.8% vs. 7.8%, P < .001), diabetes (17.8% vs. 12.1%, P < .001), and chronic obstructive pulmonary disease (6.7% vs. 4.1%, P = .003). The use of regional anesthesia has decreased (5.6% in 2005-2010 vs. 2.8% in 2015-2018, P < .001), as has operative time (▵: -16 minutes, P < .001) and length of stay (▵: -0.6 days, P < .001). There were also significant decreased rates of perioperative blood transfusion (OR [odds ratio], 0.46), non-home discharge (OR, 0.79), urinary tract infection (OR, 0.47), and sepsis (OR, 0.17), (P < .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts. CONCLUSIONS: Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.

Percutaneous Epiphysiodesis Using Transphyseal Screws: a Case Series Demonstrating High Efficacy.

BACKGROUND: Percutaneous epiphysiodesis using transphyseal screws (PETS) has been associated with implant failure, implant prominence, angular deformities, and delayed growth inhibition. QUESTIONS/PURPOSES: The aim of this study was to assess the complication rate and efficacy (defined as actual growth inhibition divided by expected growth inhibition) of PETS and to identify factors associated with improved efficacy. METHODS: Patients who underwent distal femoral and/or proximal tibial PETS between January 2007 and June 2014 were identified. Complications, efficacy, and final limb-length discrepancy (LLD) were calculated using multipliers and inhibition rates based on previous growth. Associations between efficacy and screw insertion angle (SIA), body mass index, and number of threads crossing the physis were calculated. RESULTS: Eight-two patients (126 treated physes) were included. The mean pre-operative LLD was 27.7 mm (SD = 7.5). Following epiphysiodesis, 15 had temporary pain (18%), five had temporary effusion (6.1%), four had broken implants (4.9%), four developed mild angulation (4.9%), and three had failed epiphysiodesis requiring revision (3.7%). Thirty-one underwent screw removal (n = 31, 38%). Mean LLD at maturity was 17.3 mm (SD = 5.8 mm). Mean efficacy at the distal femur was 97% (SD = 46%), at the proximal tibia was 108% (SD = 66%) and was 103% (SD = 57%) overall. Increased screw threads across the lateral proximal tibial physis (Spearman's correlation coefficient = 0.67; 95% CI = 0.40-0.94) and higher BMI (Spearman's correlation coefficient = 0.55; 95% CI = 0.34-0.77) were positively associated with increased efficacy. CONCLUSIONS: The efficacy of PETS may be more favorable than previously reported. Only 3.7% had serious complications requiring revision epiphysiodesis, lower than previous reports. Attention to sufficient screw threads across the physis may be important in optimizing PETS results.

Evaluating Length: The Use of Low-dose Biplanar Radiography (EOS) and Tantalum Bead Implantation.

BACKGROUND: Low-dose biplanar radiography (EOS) is an appealing imaging modality for use in children given its low radiation and ease of use. The goal of this study was to determine the accuracy and reliability of EOS compared with CT scanogram for measurement of leg length and to assess interrater and intrarater reliability of measured interbead distances for EOS and CT scanogram after insertion of tantalum beads into lamb femurs. METHODS: Tantalum beads (0.8 mm) were inserted into the cortex on both the medial and lateral sides of 10 skeletally immature lamb femurs. CT scanogram and EOS imaging were obtained. Measurements of total length and distance between bead pairs were recorded on anteroposterior and lateral views by 2 orthopaedic surgeons on 2 separate occasions. Pearson correlations were performed for statistical comparisons. RESULTS: EOS measurements showed near-perfect correlation to those of CT scanogram (r>0.96, P<0.001). Intrarater reliability was excellent for all measurements with EOS (r>0.98, P<0.001) and CT scanogram (r>0.99, P<0.001) as was interrater reliability for EOS (r>0.98, P<0.001) and CT scanogram (r>0.99, P<0.001). CONCLUSIONS: EOS is comparable with CT scanogram in the assessment of limb length and the distance between 2 radiopaque markers. Reliability was excellent for all measurements. The combination of EOS imaging and tantalum bead implantation may be an effective way to evaluate physeal growth following procedures such as epiphysiodesis and physeal bar resection. LEVEL OF EVIDENCE: Level II­diagnostic