Local FK506 delivery induces osteogenesis in rat bone defect and rabbit spine fusion models.

Bone grafting procedures are commonly used for the repair, regeneration, and fusion of bones in a wide range of orthopaedic surgeries, including large bone defects and spine fusion procedures. Autografts are the clinical gold standard, though recombinant human bone morphogenetic proteins (rhBMPs) are often used, particularly in difficult clinical situations. However, treatment with rhBMPs can have off-target effects and increase surgical costs, adding to patients' already high economic and mental burden. Recent studies have identified that FDA-approved immunosuppressant drug, FK506 (Tacrolimus), can also activate the BMP pathway by binding to its inhibitors. This study tested the hypothesis that FK506, as a standalone treatment, could induce osteogenic differentiation of human mesenchymal stromal cells (hMSCs), as well as functional bone formation in a rat segmental bone defect model and rabbit spinal fusion model. FK506 enhanced osteogenic differentiation and mineralization of hMSCs in vitro. Standalone treatment with FK506 delivered on a collagen sponge produced consistent bone bridging of a critically sized rat femoral defect with functional mechanical properties comparable to naïve bone. In a rabbit single level posterolateral spine fusion model, treatment with FK506 delivered on a collagen sponge successfully fused the L5-L6 vertebrae at rates comparable to rhBMP-2 treatment. These data demonstrate the ability of FK506 to induce bone formation in human cells and two challenging in vivo models, and indicate FK506 can be utilized to treat a variety of spine disorders.

Sclerostin small-molecule inhibitors promote osteogenesis by activating canonical Wnt and BMP pathways.

Background: The clinical healing environment after a posterior spinal arthrodesis surgery is one of the most clinically challenging bone-healing environments across all orthopedic interventions due to the absence of a contained space and the need to form de novo bone. Our group has previously reported that sclerostin in expressed locally at high levels throughout a developing spinal fusion. However, the role of sclerostin in controlling bone fusion remains to be established. Methods: We computationally identified two FDA-approved drugs, as well as a single novel small-molecule drug, for their ability to disrupt the interaction between sclerostin and its receptor, LRP5/6. The drugs were tested in several in vitro biochemical assays using murine MC3T3 and MSCs, assessing their ability to (1) enhance canonical Wnt signaling, (2) promote the accumulation of the active (non-phosphorylated) form of ß-catenin, and (3) enhance the intensity and signaling duration of BMP signaling. These drugs were then tested subcutaneously in rats as standalone osteoinductive agents on plain collagen sponges. Finally, the top drug candidates (called VA1 and C07) were tested in a rabbit posterolateral spine fusion model for their ability to achieve a successful fusion at 6 wk. Results: We show that by controlling GSK3b phosphorylation our three small-molecule inhibitors (SMIs) simultaneously enhance canonical Wnt signaling and potentiate canonical BMP signaling intensity and duration. We also demonstrate that the SMIs produce dose-dependent ectopic mineralization in vivo in rats as well as significantly increase posterolateral spine fusion rates in rabbits in vivo, both as standalone osteogenic drugs and in combination with autologous iliac crest bone graft. Conclusions: Few if any osteogenic small molecules possess the osteoinductive potency of BMP itself - that is, the ability to form de novo ectopic bone as a standalone agent. Herein, we describe two such SMIs that have this unique ability and were shown to induce de novo bone in a stringent in vivo environment. These SMIs may have the potential to be used in novel, cost-effective bone graft substitutes for either achieving spinal fusion or in the healing of critical-sized fracture defects. Funding: This work was supported by a Veteran Affairs Career Development Award (IK2-BX003845).

Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction.

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

The temporal and spatial expression of sclerostin and Wnt signaling factors during the maturation of posterolateral lumbar spine fusions.

The bone healing environment in the posterolateral spine following arthrodesis surgery is one of the most challenging in all of orthopedics and our understanding of the molecular signaling pathways mediating osteogenesis during spinal fusion is limited. In this study, the spatial and temporal expression pattern of Wnt signaling factors and inhibitors during spinal fusion was assessed for the first time. Bilateral posterolateral spine arthrodesis with autologous iliac crest bone graft was performed on 21 New Zealand White rabbits. At 1-, 2-, 3-, 4-, and 6-weeks, the expression of sclerostin and a variety of canonical and noncanonical Wnts signaling factors was measured by qRT-PCR from tissue separately collected from the transverse processes, the Outer and Inner Zones of the fusion mass, and the adjancent paraspinal muscle. Immunohistochemistry for sclerostin protein was also performed. Sclerostin and many Wnt factors, especially Wnt3a and Wnt5a, were found to have distinct spatial and temporal expression patterns. For example, harvesting ICBG caused a significant increase in sclerostin expression. Furthermore, the paraspinal muscle immediately adjacent to the transplanted ICBG also had significant increases in sclerostin expression at 3 weeks, suggesting new potential mechanisms for pseudarthroses following spinal arthrodesis. The presented work is the first description of the spatial and temporal expression of sclerostin and Wnt signaling factors in the developing spine fusion, filling an important knowledge gap in the basic biology of spinal fusion and potentially aiding in the development of novel biologics to increase spinal fusion rates.

Current Procedural Terminology-based Procedure Categorization Enhances Cost Prediction of Medicare Severity Diagnosis Related Group in Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to analyze how a Current Procedural Terminology (CPT)-based categorization method can predict cost variation in surgical spine procedures. SUMMARY OF BACKGROUND DATA: Neck and back disorders affect a majority of the adult population and account for tens of billions of dollars in health care spending each year. In the era of bundled payments and value-based reimbursement, it is imperative for surgeons to identify sources of cost variability across surgical spine procedures. Historically, this has been accomplished using Medicare Severity Diagnosis Related Group (MS-DRG) codes, but they utilize an overly simplistic categorization of surgical procedures. The specificity and familiarity of the CPT coding structure makes it a better option for categorizing differences in surgical decision making and technique. METHODS: Hospital billing data for patients undergoing a surgical spine procedure requiring an overnight, in-patient stay was retrospectively collected over 4 fiscal years (2012-2016) from a single health care system. Linear regression analysis was performed to assess the correlation between cost variation and: spine-specific MS-DRG codes; a novel CPT-based categorization method; and the combination of MS-DRG codes and CPT-based categorization. RESULTS: There were 5020 surgical procedures were analyzed with respect to 16 different MS-DRG codes and 30 distinct CPT-based surgical categories (CSCs). Linear regression results were: MS-DRG R2 = 0.6545 (P < 0.001); CSC R2 = 0.5709 (P < 0.001); and R2 = 0.744 for the combined MS-DRG and CSC methods (P < 0.05). Median difference between the actual and predicted cost for the combined model was -$261.00, compared with -$727.50 for the CSC model and -$478.70 for the MS-DRG model. CONCLUSION: Addition of the CPT-based categorization method to MS-DRG coding provides an enhanced method to evaluate the association between predicted and actual cost when using linear regression analysis to assess cost variation in spine surgery.Level of Evidence: 3.

A scalable tool for adjudication of time sensitive cases during COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, prioritization of care and utilization of scarce resources are daily considerations in healthcare systems that have never experienced these issues before. Elective surgical cases have been largely postponed, and surgery departments are struggling to correctly and equitably determine which cases need to proceed. A resource to objectively prioritize and track time sensitive cases would be useful as an adjunct to clinical decision-making. METHODS: A multidisciplinary working group at Emory Healthcare developed and implemented an adjudication tool for the prioritization of time sensitive surgeries. The variables identified by the team to form the construct focused on the patient's survivability according to actuarial data, potential impact on function with delay in care, and high-level biology of disease. Implementation of the prioritization was accomplished with a database design to streamline needed communication between surgeons and surgical adjudicators. All patients who underwent time sensitive surgery between 4/10/20 and 6/15/20 across 5 campuses were included. RESULTS: The primary outcomes of interest were calculated patient prioritization score and number of days until operation. 1767 cases were adjudicated during the specified time period. The distribution of prioritization scores was normal, such that real-time adjustment of the empiric algorithm was not required. On retrospective review, as the patient prioritization score increased, the number of days to the operating room decreased. This confirmed the functionality of the tool and provided a framework for organization across multiple campuses. CONCLUSIONS: We developed an in-house adjudication tool to aid in the prioritization of a large cohort of canceled and time sensitive surgeries. The tool is relatively simple in its design, reproducible, and data driven which allows for an objective adjunct to clinical decision-making. The database design was instrumental in communication optimization during this chaotic period for patients and surgeons.

Managing Resident Workforce and Education During the COVID-19 Pandemic: Evolving Strategies and Lessons Learned.

BACKGROUND: The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs. METHODS: In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures. RESULTS: Our 5 tenants support a 2-team system, whereby the residents are divided into cycling "active-duty" and "working remotely" factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department. CONCLUSIONS: The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.

Examination of the Role of Cells in Commercially Available Cellular Allografts in Spine Fusion: An in Vivo Animal Study.

BACKGROUND: Despite the extensive use of cellular bone matrices (CBMs) in spine surgery, there is little evidence to support the contribution of cells within CBMs to bone formation. The objective of this study was to determine the contribution of cells to spinal fusion by direct comparisons among viable CBMs, devitalized CBMs, and cell-free demineralized bone matrix (DBM). METHODS: Three commercially available grafts were tested: a CBM containing particulate DBM (CBM-particulate), a CBM containing DBM fibers (CBM-fiber), and a cell-free product with DBM fibers only (DBM-fiber). CBMs were used in viable states (CBM-particulatev and CBM-fiberv) and devitalized (lyophilized) states (CBM-particulated and CBM-fiberd), resulting in 5 groups. Viable cell counts and bone morphogenetic protein-2 (BMP-2) content on enzyme-linked immunosorbent assay (ELISA) within each graft material were measured. A single-level posterolateral lumbar fusion was performed on 45 athymic rats with 3 lots of each product implanted into 9 animals per group. After 6 weeks, fusion was assessed using manual palpation, micro-computed tomography (µ-CT), and histological analysis. RESULTS: The 2 groups with viable cells were comparable with respect to cell counts, and pairwise comparisons showed no significant differences in BMP-2 content across the 5 groups. Manual palpation demonstrated fusion rates of 9 of 9 in the DBM-fiber specimens, 9 of 9 in the CBM-fiberd specimens, 8 of 9 in the CBM-fiberv specimens, and 0 of 9 in both CBM-particulate groups. The µ-CT maturity grade was significantly higher in the DBM-fiber group (2.78 ± 0.55) compared with the other groups (p < 0.0001), while none of the CBM-particulate samples demonstrated intertransverse fusion in qualitative assessments. The viable and devitalized samples in each CBM group were comparable with regard to fusion rates, bone volume fraction, µ-CT maturity grade, and histological features. CONCLUSIONS: The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. Meanwhile, the groups with a fiber-based DBM demonstrated significantly higher fusion outcomes compared with the CBM groups with particulate DBM, indicating that the DBM component is probably the key determinant of fusion. CLINICAL RELEVANCE: Data from the current study demonstrate that cells yielded no additional benefit in spinal fusion and emphasize the need for well-designed clinical studies on cellular graft materials.

Rational Selection of Patient-Reported Outcomes Measures in Lumbar Spine Surgery Patients.

BACKGROUND: The Short Form-12 (SF-12) was developed as a shorter version of the SF-36, yet there has been limited validation of its reliability at measuring postoperative changes. The purpose of this study was to determine if the SF-12 could safely substitute for the SF-36 in measuring postoperative change in lumbar spine surgery patients and if the condition specific (Oswestry Disability Index [ODI]) or pain (visual analog scale [VAS]) instruments, provided additional utility. METHODS: A total of 972 patients from a single center who underwent lumbar spine surgery for a predominant symptom of radiating leg pain with (n = 237) or without (n = 735) fusion and prospectively completed both SF-36 and ODI instruments before and after surgery were included. The SF-12 score was calculated from the appropriate subset of SF-36 responses. The absolute sensitivity and the intraclass correlation coefficient were calculated. Reliability of each instrument to measure preoperative to postoperative change was calculated as the standardized response mean. RESULTS: The SF-12 and SF-36 demonstrated a strong correlation with each other ([0.97, P < .001] and [0.93, P < .001], respectively) preoperatively and postoperatively. The SF-12 and SF-36 scores were moderately to strongly inversely correlated with the ODI. The ODI showed greater reliability at measuring change than the SF-12 for both fusion (0.94 versus 0.72) and nonfusion (0.81 versus 0.33) lumbar surgery patients. CONCLUSIONS: The SF-12 was as effective as the SF-36 to measure general health status in lumbar spine surgery patients, and both were moderate to strong predictors of ODI preoperatively and postoperatively, but lack the reliability to detect change seen with the ODI or VAS after surgical intervention. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: These data suggest that the SF-12 is a valid substitute for the SF-36 to measure postoperative outcomes changes, but that the ODI should continue to be used to measure condition specific changes in function.

Spine Infections Reduced at Dedicated Orthopaedics and Spine Hospital.

BACKGROUND: Previous studies stratified postoperative infection risk by patient comorbidities. However, it is unclear whether the incidence varies by surgical approach in a specialized orthopaedic setting. This study aims to compare infection rates and microbiologic characteristics of postoperative spine infections requiring return to the operating room for debridement by hospital setting: a dedicated orthopaedic and spine hospital versus a general hospital serving multiple surgical specialties. METHODS: The study is a retrospective review of prospectively collected data. Procedures performed between March 2006 and August 2008 at the multispecialty university hospital were compared with cases at an orthopaedic specialty hospital from September 2008 through August 2016. The surgeons, residents, and patients were similar, but the operative venue changed in 2008. RESULTS: The overall general university hospital infection rate was 2.03%, higher than the overall infection rate at the dedicated orthopaedic and spine hospital of 1.31% (P < .0104). The general university infection rate was 2.27% in the final years of practice, compared with 0.91% at the dedicated orthopaedic and spine hospital (P < .0001) during a recent 2-year time frame. Demographic variables did not significantly differ between the 2 settings. The overall proportion of Gram-negative infection rates was not statistically different (21.7% vs 18.6%), despite an increased proportion of Gram-negative infections at the general university hospital following surgery from an anterior approach. Most of the organisms isolated in both facilities were Staphylococcus species. There was no difference in the seasonality of postoperative spine infections in either setting. CONCLUSIONS: In transitioning from a multispecialty university hospital to a dedicated orthopaedic hospital, the incidence of postoperative spine infections was significantly reduced to 0.91%. Despite the change in venue, the proportion of Gram-negative infections (∼20%) following spine surgery did not significantly change. These results suggest improved infection rates during the course of the last 10 years with consistent proportions of Gram-negative infections. LEVEL OF EVIDENCE: 3.

Noggin regulates foregut progenitor cell programming, and misexpression leads to esophageal atresia.

Esophageal atresia (EA/TEF) is a common congenital abnormality present in 1 of 4000 births. Here we show that atretic esophagi lack Noggin (NOG) expression, resulting in immature esophagus that contains respiratory glands. Moreover, when using mouse esophageal organoid units (EOUs) or tracheal organoid units (TOUs) as a model of foregut development and differentiation in vitro, NOG determines whether foregut progenitors differentiate toward esophageal or tracheal epithelium. These results indicate that NOG is a critical regulator of cell fate decisions between esophageal and pulmonary morphogenesis, and its lack of expression results in EA/TEF.

The impact of insurance coverage on access to orthopedic spine care.

BACKGROUND: Poor socioeconomic status is a significant barrier to health care in the United States. Policy changes have attempted to expand insurance coverage in hopes of improving access to care. These policies have prioritized primary care and preventative medicine. Access to specialty care, particularly orthopaedic care, has not received the same attention. This study examines access to orthopaedic spine surgery practices based on type of insurance coverage. METHODS: Five offices with board certified orthopaedic spine surgeons were randomly contacted from each state. A fictitious patient provided a scripted surgical indication for their appointment. They provided their insurance coverage as either Medicare, Medicaid or a private plan. Timing of the provided appointment was recorded. Any appointment was subsequently canceled so as not to interfere with the practice's scheduling. RESULTS: Two hundred and thirty-four orthopaedic spine surgery practices were contacted between January and June of 2016. Eighty-six percent of practices accepted a private plan without primary care provider (PCP) referral. Greater than 99% of practices accepted privately insured patients if a PCP referral were included. Those with Medicare were able to obtain an appointment from 81% of practices. No practices contacted in this study offered an appointment to the caller with Medicaid. CONCLUSIONS: Policy changes have expanded insurance coverage in order to improve access to care for patients of low socioeconomic status. There was a significant barrier to accessing spine care for patients with Medicaid insurance. Access was greatest for those with private insurance followed by those with Medicare. This study demonstrates that there is a significant disparity in ability to access spine specialists despite having insurance coverage.

The in vivo response to a novel Ti coating compared with polyether ether ketone: evaluation of the periphery and inner surfaces of an implant.

BACKGROUND CONTEXT: Increasing bone ongrowth and ingrowth of polyether ether ketone (PEEK) interbody fusion devices has the potential to improve clinical outcomes. PURPOSE: This study evaluated the in vivo response of promoting new bone growth and bone apposition with NanoMetalene (NM) compared with PEEK alone in a cancellous implantation site with an empty aperture. STUDY DESIGN: This is a randomized control animal study. METHODS: Implants and funding for this study were provided by SeaSpine (60,000 USD). Cylindrical dowels with two apertures were prepared as PEEK with a sub-micron layer of the titanium (NM). The titanium coating was applied over the entire implant (Group 1) or just the apertures (Group 2). Polyether ether ketone implants with no coating served as controls (Group 3). Implants were placed in the cancellous bone of the distal femur or proximal tibia with no graft material placed in the apertures in eight adult sheep. Bone ongrowth to the surface of the implant and ingrowth into the apertures was assessed at 4 and 8 weeks after surgery with micro-computed tomography (CT) and undecalcified histology. RESULTS: The apertures in the implants were notably empty in the PEEK group at 4 and 8 weeks. In contrast, new bone formation into the apertures was found in samples coated with NM even though no graft material was placed into the defect. The bone growing into the aperture tracked along the titanium layer. Apertures with the titanium coating demonstrated significantly more bone by micro-CT qualitative grading compared with PEEK with average bone coverage scores of Group 1 (NM) 1.62±0.89, Group 2 (NM apertures only) 1.62±0.77, and Group 3 (PEEK) 0.43±0.51, respectively, at 4 weeks (p<.01) and Group 1 (NM) 1.79±1.19, Group 2 (NM apertures only) 1.98±1.18, and Group 3 (PEEK) 0.69±0.87, respectively, at 8 weeks (p<.05). The amount of bone in the apertures (ingrowth) quantified using the volumetric data from the micro-CT supported an overall increase in bone volume inside the apertures with the titanium coating compared with PEEK. Histology showed newly formed woven bone tracked along the surface of the titanium in the apertures. The PEEK interface presented the typical nonreactive fibrous tissue inside the apertures at 4 weeks and some focal contact with bone on the outside at 4 weeks and 8 weeks. CONCLUSIONS: Micro-CT and histology demonstrated bone ongrowth to the surfaces coated with NM where the newly formed bone tracked along the thin titanium-coated surfaces. Polyether ether ketone surfaces presented the nonreactive fibrous tissue at the interface as previously reported in preclinical scenarios.

Red Flags for Low Back Pain Are Not Always Really Red: A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain.

BACKGROUND: Low back pain has a high prevalence and morbidity, and is a source of substantial health-care spending. Numerous published guidelines support the use of so-called red flag questions to screen for serious pathology in patients with low back pain. This paper examines the effectiveness of red flag questions as a screening tool for patients presenting with low back pain to a multidisciplinary academic spine center. METHODS: We conducted a retrospective review of the cases of 9,940 patients with a chief complaint of low back pain. The patients completed a questionnaire that included several red flag questions during their first physician visit. Diagnostic data for the same clinical episode were collected from medical records and were corroborated with imaging reports. Patients who were diagnosed as having a vertebral fracture, malignancy, infection, or cauda equina syndrome were classified as having a red flag diagnosis. RESULTS: Specific individual red flags and combinations of red flags were associated with an increased probability of underlying serious spinal pathology, e.g., recent trauma and an age of >50 years were associated with vertebral fracture. The presence or absence of other red flags, such as night pain, was unrelated to any particular diagnosis. For instance, for patients with no recent history of infection and no fever, chills, or sweating, the presence of night pain was a false-positive finding for infection >96% of the time. In general, the absence of red flag responses did not meaningfully decrease the likelihood of a red flag diagnosis; 64% of patients with spinal malignancy had no associated red flags. CONCLUSIONS: While a positive response to a red flag question may indicate the presence of serious disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis. Clinicians should use caution when utilizing red flag questions as screening tools.

Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms: A Simple Mathematical Model Based on More Than 8,000 Patients.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within 1 year of presentation. SUMMARY OF BACKGROUND DATA: Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type. METHODS: We analyzed patient-reported data from 8006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%. RESULTS: The baseline 1-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in nontriaged patients and a 29% improvement from our institution's existing triage system. CONCLUSION: The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood-11), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within 1 year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or nonoperative spine specialists. LEVEL OF EVIDENCE: 4.

Population Health Management: Is There Any Role for Orthopaedics?: An AOA Critical Issues Symposium.

The next phase of health-care reform will accelerate the formation of integrated delivery systems and the creation of value and savings through population health management. Accomplishing this goal requires 3 key factors, including (1) enabling groups of physicians and hospitals to legally work together to cover a broad geographic area, (2) the formation of integrated delivery systems that cover the low to high-acuity and post-acute care spectrums, and (3) identifying mechanisms through which a subspecialty can impact the health of a population of patients.At first glance, it would be easy to assume that this is largely a primary care initiative and that orthopaedic surgeons cannot influence population health since they often just repair things after they have broken or worn out. This symposium will challenge that assumption and demonstrate the potential for orthopaedic surgeons to play a major role in population health management. Some of the mechanisms include implementing shared decision-making for elective procedures, reducing premature/unnecessary imaging and subspecialty referrals, improving bone health (osteoporosis prevention and fall risk assessment), and developing payment methodologies to reward population-based, rather than individual-based, positive musculoskeletal outcomes.

Musculoskeletal Workforce Needs: Are Physician Assistants and Nurse Practitioners the Solution? AOA Critical Issues.

Growth estimates and demographic shifts of the population of the United States foreshadow a future heightened demand for musculoskeletal care. Although many articles have discussed this growing demand on the musculoskeletal workforce, few address the inevitable need for more musculoskeletal care providers. As we are unable to increase the number of orthopaedic surgeons because of restrictions on graduate medical education slots, physician assistants (PAs) and nurse practitioners (NPs) represent one potential solution to the impending musculoskeletal care supply shortage. This American Orthopaedic Association (AOA) symposium report investigates models for advanced practice provider integration, considers key issues affecting PAs and NPs, and proposes guidelines to help to assess the logistical and educational possibilities of further incorporating NPs and PAs into the orthopaedic workforce in order to address future musculoskeletal care needs.

Posterolateral Lumbar Arthrodesis With and Without Interbody Arthrodesis for L4-L5 Degenerative Spondylolisthesis: A Comparative Value Analysis.

STUDY DESIGN: Independent retrospective review of prospectively collected data, comparative cohort study. OBJECTIVE: The objective of this study was to compare the clinical, radiographical, and cost/value of the addition of an interbody arthrodesis (IBA) to a posterolateral arthrodesis (PLA) in the surgical treatment of L4-L5 degenerative spondylolisthesis (DS). The authors hypothesized that the addition of IBA to PLA would produce added value while incurring minimal additional costs. SUMMARY OF BACKGROUND DATA: Many lumbar surgical advances have been made during the past several decades, yet there is a paucity of strong evidence-based validation, let alone comparative value analyses. The addition of an IBA to a PLA has become increasingly popular during the past 2 decades, yet the potential added value for the patient has not been carefully defined. METHODS: Patients undergoing single-level arthrodesis for L4-L5 DS performed at our institution from 2004 to 2012 were identified. Exclusion criteria included multilevel arthrodesis, spinal stenosis requiring decompression at or above L2-L3, previous L4-L5 spinal fusion, spondylolisthesis of greater than 33% of the vertebral body, and use of minimally invasive surgery. Radiographical fusion status, epidemiological, surgical, and functional outcomes, and cost/value data were recorded or calculated. RESULTS: A total of 179 patients with follow-up meeting inclusion criteria were identified: 68 with PLA alone and 111 with PLA + IBA. No statistical differences were noted in Oswestry Disability Index, 36-item Short-Form Health Survey scores, fusion rates, or cost/value at 6 months and at more than 3 years despite the PLA cohort being significantly older with more medical comorbidities. When length of stay was normalized across cohorts, the addition of an IBA increased hospital costs ranging from $577 to $5276, but this did not reach statistical significance. CONCLUSION: This single-center review of open surgical treatment of L4-L5 DS demonstrated that the addition of IBA to PLA added cost while producing equivalent results in fusion rates, Oswestry Disability Index, and 36-item Short-Form Health Survey scores when compared with PLA alone. LEVEL OF EVIDENCE: 3.