Precision soft tissue balancing: grid-assisted pie-crusting in total knee arthroplasty.

Introduction: The varus and valgus knee deformities result from imbalance in tension between medial and lateral soft tissue compartments. These conditions need to be addressed during total knee arthroplasty (TKA). However, there is no consensus on optimal soft-tissue release techniques for correcting varus and valgus deformities during TKA. We assessed the efficacy of a novel grid-based pie-crusting technique on soft-tissue release. Methods: Cadaver knees were dissected, leaving only the femur and tibia connected by an isolated MCL or the femur and fibula connected by an isolated LCL. Bone cuts were made as performed during primary TKA. Mechanical testing was performed using an MTS machine. A 3D-printed 12-hole grid was placed directly over the MCL and LCL. Using an 18-gauge needle, horizontal in-out perforations were made 3 mm apart. Deformation and stiffness of the ligaments were collected after every 2 perforations. Means were calculated, and regression analyses were performed. Results: A total of 7 MCL and 6 LCL knees were included in our analysis. The mean medial femorotibial (MFT) space increased from 6.018 ± 1.4 mm-7.078 ± 1.414 mm (R2 = 0.937) following 12 perforations. The mean MCL stiffness decreased from 32.15 N/mm-26.57 N/mm (R2 = 0.965). For the LCL group, the mean gap between the femur and fibula increased from 4.287 mm-4.550 mm following 8 perforations. The mean LCL stiffness decreased from 29.955 N/mm-25.851 N/mm. LCL stiffness displayed a strong inverse relationship with the number of holes performed (R2 = 0.988). Discussion: Our results suggest that using this novel grid for pie-crusting of the MCL and LCL allows for gradual lengthening of the ligaments without sacrificing their structural integrity. Our proposed technique may serve as a valuable piece in the soft-tissue release toolkit for orthopaedic surgeons performing TKA in varus and valgus deformed knees.

Distal Femur Valgus Deformity After Rigid Intramedullary Nailing of Adolescent Femoral Shaft Fracture.

A 12-year-old girl developed a distal femoral shaft fracture treated with lateral trochanteric entry intramedullary nail fixation. The nail was retained after union because of a persistent nonossifying fibroma at the previous fracture site. At 16 months after surgery, marked valgus deformity was noted at the distal femur, with signs of implant haloing and loosening, suggesting repetitive motion and stress concentration of forces at the distal femur. Owing to recognition before skeletal maturity, the valgus was corrected with hemiepiphysiodesis. This finding illustrates the importance of follow-up up to skeletal maturity for pediatric femoral shaft fractures and consideration of routine removal of implants after fracture union to avoid this previously unreported complication.

Impact of drainage catheter material, size, and anti-dislodgement mechanism on percutaneous nephrostomy exchange intervals: a systematic review protocol.

Background: Percutaneous nephrostomy (PCN) is a commonly performed procedure by interventional radiology and urology to treat urinary obstruction. In this procedure, a catheter is percutaneously placed into the renal pelvis for urinary diversion or hemorrhagic cystitis. Material type, catheter size, and catheter shape (anti-dislodgement feature) ultimately contribute to the inherent traits of longevity in drainage catheter device. Reviewing the relative strengths or weaknesses of products in the existing clinical market may help clinicians critically appraise the devices they use with evidence-based findings from this review. Furthermore, a deeper understanding of the relative strengths and weaknesses of existing devices may help inform the next generation of drainage catheter devices to prolong the interval between exchanges without detriment to patient safety. Methods: The following electronic databases will be queried: PubMed, Web of Science, Cochrane from their inception to January 2023 to identify randomized controlled trials (RCTs) and cohort studies to investigate the differences that our interventions of catheter material, size, and dislodgement mechanism will have on the exchange interval (standard of care 90 days vs. 60 days vs. 45 days vs. 30 days). The primary outcomes will be the drainage catheter exchange frequency. Ethics and dissemination: We aim to share our findings through high-impact peer reviewed journals. As drainage catheters and minimally invasive interventional radiology procedures become more popular, it is important for healthcare providers taking case of these populations to understand which variables might optimize patient care and minimize emergent exchanges. Data will be made available to readers. Registration: PROSPERO ( CRD42023432788, 16 June 2023).

Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication.

Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 - 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 - 480). Results: Median operative time was 144 minutes (90 - 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 - 312). Median follow up was 157 months (6 - 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.

Multicenter analysis of neutrophil extracellular trap dysregulation in adult and pediatric COVID-19.

Dysregulation in neutrophil extracellular trap (NET) formation and degradation may play a role in the pathogenesis and severity of COVID-19; however, its role in the pediatric manifestations of this disease, including multisystem inflammatory syndrome in children (MIS-C) and chilblain-like lesions (CLLs), otherwise known as "COVID toes," remains unclear. Studying multinational cohorts, we found that, in CLLs, NETs were significantly increased in serum and skin. There was geographic variability in the prevalence of increased NETs in MIS-C, in association with disease severity. MIS-C and CLL serum samples displayed decreased NET degradation ability, in association with C1q and G-actin or anti-NET antibodies, respectively, but not with genetic variants of DNases. In adult COVID-19, persistent elevations in NETs after disease diagnosis were detected but did not occur in asymptomatic infection. COVID-19-affected adults displayed significant prevalence of impaired NET degradation, in association with anti-DNase1L3, G-actin, and specific disease manifestations, but not with genetic variants of DNases. NETs were detected in many organs of adult patients who died from COVID-19 complications. Infection with the Omicron variant was associated with decreased NET levels when compared with other SARS-CoV-2 strains. These data support a role for NETs in the pathogenesis and severity of COVID-19 in pediatric and adult patients.

Surgical resection, radiotherapy and percutaneous thermal ablation for treatment of stage 1 non-small cell lung cancer: protocol for a systematic review and network meta-analysis.

INTRODUCTION: Non-small cell lung cancer (NSCLC) makes up the majority of lung cancer cases. Currently, surgical resection is the gold standard of treatment. However, as patients are becoming medically more complex presenting with advanced disease, minimally invasive image-guided percutaneous ablations are gaining popularity. Therefore, comparison of surgical, ablative and second-line external beam therapies will help clinicians, as management of NSCLC changes. We will conduct a meta-analysis, reviewing literature investigating these therapies in adult patients diagnosed with stage 1 NSCLC, with neither hilar nor mediastinal nodal involvement, confirmed either through cytology or histology regardless of type. METHODS AND ANALYSIS: We will search electronic databases (MEDLINE, Embase, Web of Science, Scopus, ClinicalTrials.gov, Cochrane) from their inception to January 2021 to identify randomised controlled trials (RCTs), cluster RCTs and cohort studies comparing survival and clinical outcomes between any two interventions (lobectomy, wedge resection, video-assisted thoracoscopic surgery/robot-assisted thoracoscopic surgery, radiofrequency ablation, microwave ablation, cryoablation and consolidated radiation therapies (external beam radiation therapy, stereotactic body radiation therapy, and 3D conformal radiation therapy). The primary outcomes will include cancer-specific survival, lung disease-free survival, locoregional recurrence, death, toxicity and non-target organ injury. We will also search published and unpublished studies in trial registries and will review references of included studies for possible inclusion. Risk of bias will be assessed using tools developed by the Cochrane collaboration. Two reviewers will independently assess the eligibility of studies and conduct the corresponding risk of bias assessments. For each outcome, given enough studies, we will conduct a network meta-analysis. Finally, we will use the Confidence in Network Meta-Analysis tool to assess quality of the evidence for each of the primary outcomes. ETHICS AND DISSEMINATION: We aim to share our findings through high-impact peer review. As interventional techniques become more popular, it will be important for providers in multidisciplinary teams caring for these patients to receive continuing medical education related to these interventions. Data will be made available to readers. PROSPERO REGISTRATION NUMBER: CRD42021276629.

Multicenter analysis of neutrophil extracellular trap dysregulation in adult and pediatric COVID-19.

Dysregulation in neutrophil extracellular trap (NET) formation and degradation may play a role in the pathogenesis and severity of COVID-19; however, its role in the pediatric manifestations of this disease including MIS-C and chilblain-like lesions (CLL), otherwise known as "COVID toes", remains unclear. Studying multinational cohorts, we found that, in CLL, NETs were significantly increased in serum and skin. There was geographic variability in the prevalence of increased NETs in MIS-C, in association with disease severity. MIS-C and CLL serum samples displayed decreased NET degradation ability, in association with C1q and G-actin or anti-NET antibodies, respectively, but not with genetic variants of DNases. In adult COVID-19, persistent elevations in NETs post-disease diagnosis were detected but did not occur in asymptomatic infection. COVID-19-affected adults displayed significant prevalence of impaired NET degradation, in association with anti-DNase1L3, G-actin, and specific disease manifestations, but not with genetic variants of DNases. NETs were detected in many organs of adult patients who died from COVID-19 complications. Infection with the Omicron variant was associated with decreased levels of NETs when compared to other SARS-CoV-2 strains. These data support a role for NETs in the pathogenesis and severity of COVID-19 in pediatric and adult patients. Summary: NET formation and degradation are dysregulated in pediatric and symptomatic adult patients with various complications of COVID-19, in association with disease severity. NET degradation impairments are multifactorial and associated with natural inhibitors of DNase 1, G-actin and anti-DNase1L3 and anti-NET antibodies. Infection with the Omicron variant is associated with decreased levels of NETs when compared to other SARS-CoV-2 strains.

Acetazolamide enhanced drug-eluting beads: manipulating the hepatocellular carcinoma microenvironment.

Hepatocellular carcinoma (HCC) is the most common type of primary liver malignancy. Intra-arterial therapies such as drug-eluting bead transarterial chemoembolization (DEB-TACE) can be effective forms of locoregional treatment for HCC. Solid liver tumors such as HCC promote a biochemical tumor microenvironment (TME) that allows tumor recurrence. The TME creates an environmental acidic pH, which induces chemotherapy resistance and immunosuppression. To address TME acidity, pharmacological agents like acetazolamide could be combined with primary transarterial therapies to optimize HCC treatment. We present a case of a 51-year-old male with a history of alcoholic cirrhosis and recently diagnosed HCC who underwent DEB-TACE with acetazolamide, resulting in complete tumor response on 1.5, 4.5, and 7.5 months follow-up.

In vivo detection of distal tumor glycolytic flux stimulated by hepatic ablation in a breast cancer model using hyperpolarized 13C MRI.

PURPOSE: Hepatic thermal ablation therapy can result in c-Met-mediated off-target stimulation of distal tumor growth. The purpose of this study was to determine if a similar effect on tumor metabolism could be detected in vivo with hyperpolarized 13C MRI. MATERIALS AND METHODS: In this prospective study, female Fisher rats (n = 28, 120-150 g) were implanted with R3230 rat breast adenocarcinoma cells and assigned to either: sham surgery, hepatic radiofrequency ablation (RFA), or hepatic RFA + adjuvant c-Met inhibition with PHA-665752 (RFA + PHA). PHA-665752 was administered at 0.83 mg/kg at 24 h post-RFA. Tumor growth was measured daily. MRI was performed 24 h before and 72 h after treatment on 14 rats, and the conversion of 13C-pyruvate into 13C-lactate within each tumor was quantified as lactate:pyruvate ratio (LPR). Comparisons of tumor growth and LPR were performed using paired and unpaired t-tests. RESULTS: Hepatic RFA alone resulted in increased growth of the distant tumor compared to sham treatment (0.50 ± 0.13 mm/day versus 0.11 ± 0.07 mm/day; p < 0.001), whereas RFA + PHA (0.06 ± 0.13 mm/day) resulted in no significant change from sham treatment (p = 0.28). A significant increase in LPR was seen following hepatic RFA (+0.016 ± 0.010, p = 0.02), while LPR was unchanged for sham treatment (-0.048 ± 0.051, p = 0.10) or RFA + PHA (0.003 ± 0.041, p = 0.90). CONCLUSION: In vivo hyperpolarized 13C MRI can detect hepatic RFA-induced increase in lactate flux within a distant R3230 tumor, which correlates with increased tumor growth. Adjuvant inhibition of c-Met suppresses these off-target effects, supporting a role for the HGF/c-Met signaling axis in these tumorigenic responses.

Contact allergy to nickel: still #1 after all these years.

Nickel is ubiquitous in our daily environment and remains the most common cause of contact allergy worldwide. Regulation of nickel release exists in Europe but unfortunately continues to be absent in the United States. Nickel contact allergy most often is associated with earrings and other jewelry; however, novel exposures to nickel through diet and electronic devices and other materials also occur. Once diagnosed, allergen avoidance is key for improvement of symptoms.

Tethered Cord Syndrome in the United States Cluster Analysis of Presenting Anomalies and Associated.

PURPOSE: Tethered cord syndrome (TCS) is an occult spinal dysraphism that includes low lying conus, tight filum terminale, lipomeningomyelocele, split cord malformations, dermal sinus tracts, and dermoids. This congenital disorder has been associated with musculoskeletal, neurological, and gastrointestinal abnormalities. This study presents a retrospective review of the prospectively collected data of TCS patients and their concurrent diagnoses or associated anomalies. METHODS: The National Inpatient Sample (NIS) database from 2003 to 2012 was used for data collection. Hospital- and year-adjusted weights allowed for accurate assessment of the incidence of TCS, as well as cardiac and gastrointestinal (GI) and genitourinary (GU) anomalies. K-means clustering analysis was run to discover patterns of concurrent cardiac, GI, GU, and other system anomalies in TCS patients. RESULTS: A total of 13,470 discharges with a diagnosis of TCS were identified in the NIS database, and at least one additional anomaly was identified in 40.7% of TCS patients. The most common secondary anomalies by system were: spine (24.48%), cardiac (6.27%), and urinary (5.37%). For patients with multiple anomalies, the most common combinations were GI and cardiac (4.55%), urinary and GI (4.26%), and urinary and cardiac (4.19%). The most common spinal association was spina bifida (13.65%). The most common neurological or musculoskeletal anomaly was any VACTERL association (13.45%). The top relation in GI and GU anomalies was cervix and female genitalia anomalies (69.1%). The most common specific anomalies were spina bifida, large intestine atresia, Rubenstein-Taybi syndrome, and atrial and ventral septal defects. CONCLUSION: This study provides a nationwide prospective on congenital anomalies and concurrent conditions present in tethered cord syndrome patients in the United States and demonstrates that 40.7% of TCS patients have at least one associated anomaly. The most common congenital anomalies studied were spina bifida, urogenital with or without cardiac septal defects, and cystourethral anomaly or cystic kidney disease with or without large intestinal atresia.

Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures.

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.

Robotic Fundoplication for Large Paraesophageal Hiatal Hernias.

PURPOSE: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. METHODS: Seventy patients (23 males and 47 females) with mean age 64 y old (22-92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. RESULTS: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180-360). Mean length of stay was 38 h (24-96). Median follow-up was 29 mo (7-51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. CONCLUSIONS: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.

The Impact of Adult Thoracolumbar Spinal Deformities on Standing to Sitting Regional and Segmental Reciprocal Alignment.

BACKGROUND: Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting; however, alignment changes in the cervical and thoracic spine have yet to be investigated. So, the aim of this study was to assess cervical and thoracic regional and segmental changes in patients with thoracolumbar deformity versus a nondeformed thoracolumbar spine population. METHODS: This study was a retrospective cohort study of a single center's database of full-body stereoradiographic imaging and clinical data. Patients were ≥ 18 years old with nondeformed spines (nondegenerative, nondeformity spinal pathologies) or thoracolumbar deformity (ASD: PI-LL > 10°). Patients were propensity-score matched for age and maximum hip osteoarthritis grade and were stratified by Scoliosis Research Society (SRS)-Schwab classification by PI-LL, SVA, and PT. Patients with lumbar transitional anatomy or fusions were excluded. Outcome measures included changes between standing and sitting in global alignment parameters: sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), pelivc tilt (PT), thoracic kyphosis, cervical alignment, cervical SVA, C2-C7 lordosis (CL), T1 slop minus CL (TS-CL), and segmental alignment from C2 to T12. Another analysis was performed using patients with cervical and thoracic segmental measurements. RESULTS: A total of 338 patients were included (202 nondeformity, 136 ASD). After propensity-score matching, 162 patients were included (81 nondeformity, 81 ASD). When categorized by SRS-Schwab classification, all nondeformity patients were nonpathologically grouped for PI-LL, SVA, and PT, whereas ASD patients had mix of moderately and markedly deformed modifiers. There were significant differences in pelvic and global spinal alignment changes from standing to sitting between nondeformity and ASD patients, particularly for SVA (nondeformed: 49.5 mm versus ASD: 27.4 mm; P < .001) and PI-LL (20.12° versus 13.01°, P < .001). With application of the Schwab classification system upon the cohort, PI-LL (P = .040) and SVA (P = .007) for severely classified deformity patients had significantly less positional alignment change. In an additional analysis of patients with segmental measurements from C2 to T12, nondeformity patients showed significant mobility of T2-T3 (-0.99° to -0.54°, P = .023), T6-T7 (-3.39° to -2.89°, P = .032), T7-T8 (-2.68° to -2.23°, P = .048), and T10-T11 (0.31° to 0.097°, P = .006) segments from standing to sitting. ASD patients showed mobility of the C6-C7 (1.76° to 3.45°, P < .001) and T11-T12 (0.98° to 0.54°, P = 0.014) from standing to sitting. The degree of mobility between nondeformity and ASD patients was significantly different in C6-C7 (-0.18° versus 1.69°, P = .003), T2-T3 (0.45° versus -0.27°, P = .034), and T10-T11 (0.45° versus -0.30°, P = .001) segments. With application of the Schwab modifier system upon the cohort, mobility was significant in the C6-C7 (nondeformed: 0.18° versus moderately deformed: 2.12° versus markedly deformed: 0.92°, P = .039), T2-T3 (0.45° versus -0.08° versus -0.63°, P = .020), T6-T7 (0.48° versus 0.36° versus -1.85°, P = .007), and T10-T11 (0.45° versus -0.21° versus -0.23°, P = .009) segments. CONCLUSIONS: Nondeformity patients and ASD patients have significant differences in mobility of global spinopelvic parameters as well as segmental regions in the cervical and thoracic spine between sitting and standing. This study aids in our understanding of flexibility and compensatory mechanisms in deformity patients, as well as the possible impact on unfused segments when considering deformity corrective surgery.

Predictors of Hospital-Acquired Conditions Are Predominately Similar for Spine Surgery and Other Common Elective Surgical Procedures, With Some Key Exceptions.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: To predict the occurrence of hospital-acquired conditions (HACs) 30-days postoperatively and to compare predictors of HACs for spine surgery with other common elective surgeries. METHODS: Patients ≥18 years undergoing elective spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Outcome measures included any HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI). Spine surgery patients were compared with those undergoing other common procedures. Random forest followed by multivariable regression analysis was used to determine risk factors for the occurrence of HACs. RESULTS: A total of 90 551 elective spine surgery patients, of whom 3021 (3.3%) developed at least 1 HAC, 1.4% SSI, 1.3% UTI, and 0.8% VTE. The occurrence of HACs for spine patients was predicted with high accuracy (area under the curve [AUC] 77.7%) with the following variables: female sex, baseline functional status, hypertension, history of transient ischemic attack (TIA), quadriplegia, steroid use, preoperative bleeding disorders, American Society of Anesthesiologists (ASA) class, operating room duration, operative time, and level of residency supervision. Functional status and hypertension were HAC predictors for total knee arthroplasty (TKA), bariatric, and cardiothoracic patients. ASA class and operative time were predictors for most surgery cohorts. History of TIA, preoperative bleeding disorders, and steroid use were less predictive for most other common surgical cohorts. CONCLUSIONS: Occurrence of HACs after spine surgery can be predicted with demographic, clinical, and surgical factors. Predictors for HACs in surgical spine patients, also common across other surgical groups, include functional status, hypertension, and operative time. Understanding the baseline patient risks for HACs will allow surgeons to become more effective in their patient selection for surgery.

Suboptimal Age-Adjusted Lumbo-Pelvic Mismatch Predicts Negative Cervical-Thoracic Compensation in Obese Patients.

BACKGROUND: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. METHODS: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index < 30kg/m2) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts. RESULTS: Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle (P = .004), KA, AA, PS, GSA (all P < .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle (P = .002), higher KA (P = .008), PS (P = .002), and GSA (P = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P < .001), high T1 pelvic angle (P < .001), cervical thoracic pelvic angle (P = .03), and T1 slope (P < .001), with increased thoracic kyphosis (P = .015) and decreased LL (P < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal. CONCLUSIONS: Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database.

BACKGROUND: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. METHODS: The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05. RESULTS: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001). CONCLUSIONS: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Ponte Osteotomies Increase the Risk of Neuromonitoring Alerts in Adolescent Idiopathic Scoliosis Correction Surgery.

STUDY DESIGN: Observational cohort study of prospective database registry. OBJECTIVE: To determine the incidence of neurological complications in AIS patients undergoing surgical treatment with PO. SUMMARY OF BACKGROUND DATA: Despite the widespread use of Ponte Osteotomies (PO) in adolescent idiopathic scoliosis (AIS) correction, outcomes and complications in patients treated with this technique have not been well characterized. METHODS: A multicenter prospective registry of patients undergoing surgical correction of AIS was queried at 2-year follow-up for patient demographics, surgical data, deformity characteristics, and peri-operative complications. A neurological complication was defined as perioperative nerve root or spinal cord injury as identified by the surgeon. Patients were divided into those who underwent peri-apical PO and those without, and further stratified by Lenke curve classification into 3 groups (I-types 1 and 2, II-types 3, 4, 6, and III-type 5). Patients with- and without neurological complications were compared with respect to baseline demographics, surgical variables, curve types, fusion construct types (screws vs. hybrid), curve magnitude (coronal and sagittal Cobb), apical vertebral translation, and coronal-deformity angular ratios (C-DAR). RESULTS: Of 2210 patients included in the study, 1611 underwent PO. Peri-operative neurological complications occurred in 7 patients, with 6 in the PO group (0.37%) and 1 in non-PO group (0.17%) though this was not a statistically significant risk factor for peri-operative neurological injury (P = 0.45). Neuromonitoring alerts were recorded in 168 patients (7.6%: 9.3% PO group; 4.2% no-PO group (P < 0.001)). Multivariate logistic regression analysis found PO and curve magnitude to be independent risk factors for intraoperative neuromonitoring alerts (P < 0.01). CONCLUSION: PO and curve magnitude were independent risk factors for intraoperative neuromonitoring alerts in surgical AIS correction. The effect of Ponte osteotomy on neurological complications remains unknown due to the low incidence of these complications. LEVEL OF EVIDENCE: 3.