Clinical Outcomes and Complication Rates for Noncontiguous Anterior Cervical Discectomy and Fusion, Cervical Disc Arthroplasty, and Hybrid Cervical Surgery: A Systematic Review.

OBJECTIVE: This study examined clinical outcomes associated with 3 types of noncontiguous cervical surgeries - anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), and hybrid cervical surgery (HCS) - to improve surgeon decision-making. METHODS: A systematic review was performed using PubMed, CINAHL, MEDLINE, and Web of Science from database inception until June 6th, 2023. Inclusion criteria were studies that reported any type of clinical outcome, examined noncontiguous ACDF, noncontiguous CDA, and/or noncontiguous HCS. RESULTS: Ten articles out of 523 articles initially retrieved were included. Patients (n = 388) had a mean age of 52 ± 5.1 years and a mean follow up time of 33 ± 6.0 months. Overall, 119 patients underwent non-contiguous HCS, 65 underwent non-contiguous CDA, and 204 underwent non-contiguous ACDF. There appears to be no clinically meaningful difference in Neck Disability Index (NDI) score, Japanese Orthopedic Association (JOA) score, and improvement in pain based on surgery type. There was a total of 83 complications (21% of cases) with non-contiguous ACDF having a higher absolute rate of dysphagia (20%) as compared to non-contiguous HCS (6.7%) or non-contiguous CDA (6.2%). Non-contiguous ACDF had a higher absolute rate of adjacent segment degeneration (ASD) as a reported complication (6.4%) as compared to non-contiguous HCS (1.7%) and non-contiguous CDA (0.0%). CONCLUSIONS: There may be no clinically meaningful difference in many clinical outcomes for different non-contiguous surgical interventions for non-contiguous cervical degenerative disc disease (CDDD). However, complication rates, such as dysphagia and ASD, appear higher for non-contiguous ACDF as compared to non-contiguous CDA or HCS.

Safety and efficacy of waterproof casting for early onset scoliosis.

PURPOSE: The efficacy of traditional Mehta casting in the treatment of early onset scoliosis (EOS) is well-established. However, waterproof casting has not been previously described. Inherent advantages of waterproof casting include clearance for bathing/swimming, avoiding cast holidays, and improved family satisfaction. The purpose of this study was to assess the safety and efficacy of waterproof serial casting at controlling curve progression in EOS. METHODS: The current study is an IRB-approved Level IV retrospective consecutive cohort of EOS patients who underwent a serial 75% body weight traction-elongation-flexion Mehta cast protocol with waterproof cast padding. The addition of 3-point apical translation with stockinettes was utilized during casting. Bracing was initiated after correction < 15° or 1 year of serial casting. RESULTS: Seventeen patients at mean age 21.6 months, with pre-cast Cobb angle 52.3° (R: 35°-82°), underwent serial waterproof casting. In-cast correction index was 64%; for post-cast, Cobb angle was 18.6°. At mean 5.6 years follow-up (R: 2.3-8.9 years), 82% successfully avoided surgical intervention, 53% maintained correction < 25°, and 29% are considered "cured". 3/17 (18%) underwent a 2nd round of casting, and a total of 3/17 (18%) ultimately required surgery at 6.2 years post-casting. No major cast-related complications, decubiti, or cast holidays were encountered. CONCLUSION: Serial waterproof casting is safe and efficacious in EOS when compared to published results of traditional Mehta casting. Of 17 patients with mean pre-cast Cobb 52.3°, 82% successfully avoided surgery and 53% maintained mild curves < 25° magnitude at 5.6 years follow-up. No major complications or skin decubiti occurred, and advantages include clearance for bathing and avoidance of need for cast holidays during treatment. LEVEL OF EVIDENCE: Level IV.

Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine.

INTRODUCTION: Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution. METHODS: This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest. RESULTS: Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables. DISCUSSION: In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI. LEVEL OF EVIDENCE: Retrospective case series, Level III evidence.

A Comparison of Prognostic Models to Facilitate Surgical Decision-Making for Patients With Spinal Metastatic Disease.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Compare the performance of and provide cutoff values for commonly used prognostic models for spinal metastases, including Revised Tokuhashi, Tomita, Modified Bauer, New England Spinal Metastases Score (NESMS), and Skeletal Oncology Research Group model, at three- and six-month postoperative time points. SUMMARY OF BACKGROUND DATA: Surgery may be recommended for patients with spinal metastases causing fracture, instability, pain, and/or neurological compromise. However, patients with less than three to six months of projected survival are less likely to benefit from surgery. Prognostic models have been developed to help determine prognosis and surgical candidacy. Yet, there is a lack of data directly comparing the performance of these models at clinically relevant time points or providing clinically applicable cutoff values for the models. MATERIALS AND METHODS: Sixty-four patients undergoing surgery from 2015 to 2022 for spinal metastatic disease were identified. Revised Tokuhashi, Tomita, Modified Bauer, NESMS, and Skeletal Oncology Research Group were calculated for each patient. Model calibration and discrimination for predicting survival at three months, six months, and final follow-up were evaluated using the Brier score and Uno's C, respectively. Hazard ratios for survival were calculated for the models. The Contral and O'Quigley method was utilized to identify cutoff values for the models discriminating between survival and nonsurvival at three months, six months, and final follow-up. RESULTS: Each of the models demonstrated similar performance in predicting survival at three months, six months, and final follow-up. Cutoff scores that best differentiated patients likely to survive beyond three months included the Revised Tokuhashi score=10, Tomita score=four, Modified Bauer score=three, and NESMS=one. CONCLUSION: We found comparable efficacy among the models in predicting survival at clinically relevant time points. Cutoff values provided herein may assist surgeons and patients when deciding whether to pursue surgery for spinal metastatic disease. LEVEL OF EVIDENCE: 4.

Influence of tibial tuberosity position and trochlear depth on patellar tracking in patellar instability: Variations with Patella Alta.

BACKGROUND: Patella alta reduces articular constraints acting on the patella from the trochlear groove with the knee extended. The current study was performed to address how patella alta alters the influence of tibial tuberosity position and trochlear depth on patellar tracking in patients being treated for patellar instability. METHODS: Fifteen subjects with recurrent patellar instability participated in knee extension within a dynamic CT scanner. Computational models were reconstructed from the motions to characterize patellar lateral shift, patellar tilt, patellar height, trochlear depth and lateral position of the tibial tuberosity at 0° and 30° of knee flexion. Linear regressions were used to correlate patellar tracking with anatomy for an alta group (7 knees, Caton-Deschamps index > 1.2) and a non-alta group. FINDINGS: For the alta group, lateral patellar shift and tilt increased with increasing lateral position of the tibial tuberosity at 0° (r2 > 0.8, P < 0.005). For the non-alta group, lateral patellar shift and tilt increased as depth of the groove decreased at 0° (r2 > 0.8, P = 0.001). Lateral patellar tilt also increased with increasing lateral position of the tibial tuberosity at 30° for the non-alta group (r2 = 0.55, P = 0.04). INTERPRETATION: For patients with patellar instability, lateral patellar maltracking with the knee extended can be largely attributed to either a shallow trochlear groove or a combination of patella alta and a lateral position of the tibial tuberosity. These relationships should be considered in both conservative and surgical treatment planning.

The Natural History of Benign Bone Tumors of the Extremities in Asymptomatic Children: A Longitudinal Radiographic Study.

BACKGROUND: Benign bone tumors are common incidental findings in the pediatric population during radiographic evaluation. Counseling these patients requires reassurance and raises questions about the natural history of these tumors over time. The purpose of this study was to estimate the prevalence and observe the behavior of benign childhood bone tumors in an asymptomatic population. METHODS: A historical, longitudinal radiographic collection of healthy children was reviewed, which included comprehensive left-sided radiographs of the extremities at yearly intervals. In this study, 262 subjects with 25,555 radiographs were screened for benign bone tumors at a median age of 8 years (range, 0 to 18 years). All potential tumors were reviewed by a multidisciplinary panel, which confirmed the radiographic diagnosis of each lesion, the age at which the lesion first appeared, and the age at which it had resolved. Prevalence rates were calculated using the number of distinct subjects available for each radiographic location and age. RESULTS: Thirty-five tumors were identified in 33 subjects, including 19 nonossifying fibromas, 8 enostoses, 6 osteochondromas, and 2 enchondromas. The prevalence rate for all tumors combined increased with age and was 18.9% overall. The overall prevalence rates for specific tumor types were 7.5% for nonossifying fibromas, 5.2% for enostoses, 4.5% for osteochondromas, and 1.8% for enchondromas. Nonossifying fibromas demonstrated a bimodal distribution of prevalence, with a peak at 5 years (10.8%) and another after skeletal maturity (13.3%). The median age at the first appearance for all tumors combined was 9 years (range, 2 to 15 years), but varied by tumor type. Nonossifying fibromas often resolved (7 [37%] of 19), with further resolution possible beyond the last available radiograph. Enostoses, osteochondromas, and enchondromas persisted until the last available radiographs in all subjects. CONCLUSIONS: The prevalence of benign childhood bone tumors of the extremities was 18.9% in a historical asymptomatic population. Longitudinal radiographs allowed observation of the timing of the first appearance and the potential for resolution for each tumor type. These findings provide unique evidence to answer many commonly encountered questions when counseling patients and their families on benign bone tumors. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes Following Operative Treatment of Adolescent Mallet Fractures.

BACKGROUND: Many surgeons advocate for surgical intervention of adult mallet fractures that involve either subluxation of the distal interphalangeal (DIP) joint or those that involve more than one-third of the articular surface. However, the efficacy of operative treatment and complication rates are unclear regarding the adolescent population. QUESTIONS/PURPOSES: The goal of this study is to evaluate the clinical outcomes following operative fixation of bony mallet fractures in the adolescent population. METHODS: Seventeen patients with bony mallet fractures treated surgically were retrospectively reviewed. Twelve patients were treated by closed reduction with extension block pinning. The other patients underwent an open reduction and pin fixation. The average age was 15.2 years (13-18). Most injuries were sport related. The average time from injury to presentation was 17 days and from injury to surgery was 24.5 days. Nine patients had subluxation at the DIP joint and all involved at least one-third of the articular surface. RESULTS: The average time from surgery to pin removal was 28 days (19-46). All distal phalanx physis were closed or nearly closed. One patient reported pain at the final follow-up. Two patients (11.8%) had major complications. One had an extension contracture postoperatively, did not attend therapy, and re-fractured 5 months later requiring reoperation. The second was treated delayed (32 days) and lost fixation, requiring revision surgery and antibiotics for a superficial infection. Two patients with delayed treatment (32 and 44 days) had an extensor lag (11.8%). CONCLUSIONS: Operative treatment of mallet fractures with subluxation or involving more than one-third of the articular surface appears effective. Pin removal 4 weeks postoperatively appears adequate. Complications occurred with delayed presentation and non-compliance.

Hip-Spine Syndrome: Is There an Association Between Markers for Cam Deformity and Osteoarthritis of the Lumbar Spine?

PURPOSE: To examine a large osteological collection to assess the relations between the well-described means of quantifying cam deformities of the proximal femur-alpha angle (AA) and anterior femoral neck offset (AFNO)-and osteoarthritis of the lumbar spine. METHODS: AA and AFNO were measured on paired femurs of 550 well-preserved cadaveric skeletons by use of standardized cephalocaudal digital photographs. Degenerative disease of these specimens' lumbar spines was graded from 0 to 4 with a validated grading system. Proximal femurs showing obvious arthritic changes such as lipping or osteophytes were excluded. Correlations between AA and spine osteoarthritis (SOA), as well as between AFNO and SOA, were evaluated by multiple regression analysis. RESULTS: The average age for the skeletons was 47.8 ± 16.2 years. There were 456 male and 94 female specimens. The mean AA and AFNO were 52.4° ± 11.4° and 6.8 ± 1.5 mm, respectively. The average SOA score was 2.1 ± 0.9 (0 in 31 specimens, 1 in 82, 2 in 287, 3 in 106, and 4 in 44). There was a significant correlation between increasing AA and SOA (standardized ß = 0.061, P = .041). There was also a significant correlation between decreasing AFNO and SOA (standardized ß = -0.067, P = .025). There was a strong correlation between age and SOA (standardized ß = 0.582, P < .0005). CONCLUSIONS: This study provides important insight into the understanding of the hip-spine connection. Although it has no way of showing a causative or clinically significant relation, this study did show that the cam-type deformity markers of increasing AA and decreasing AFNO were significantly associated with SOA in a large osteological collection. CLINICAL RELEVANCE: Clinical and biomechanical studies to assess whether cam deformity in the younger individual may contribute to the accelerated development of SOA in later life are warranted.