Does obesity and varying body mass index affect the clinical outcomes and safety of biportal endoscopic lumbar decompression? A comparative cohort study.

BACKGROUND: Endoscopic spine surgery has recently grown in popularity due to the potential benefits of reduced pain and faster recovery time as compared to open surgery. Biportal spinal endoscopy has been successfully applied to lumbar disc herniations and lumbar spinal stenosis. Obesity is associated with increased risk of complications in spine surgery. Few prior studies have investigated the impact of obesity and associated medical comorbidities with biportal spinal endoscopy. METHODS: This study was a prospectively collected, retrospectively analyzed comparative cohort design. Patients were divided into cohorts of normal body weight (Bone Mass Index (BMI)18.0-24.9), overweight (BMI 25.0-29.9) and obese (BMI > 30.0) as defined by the World Health Organization (WHO). Patients underwent biportal spinal endoscopy by a single surgeon at a single institution for treatment of lumbar disc herniations and lumbar spinal stenosis. Demographic data, surgical complications, and patient-reported outcomes were analyzed. Statistics were calculated amongst treatment groups using analysis of variance and chi square where appropriate. Statistical significance was determined as p < 0.05. RESULTS: Eighty-four patients were followed. 26 (30.1%) were normal BMI, 35 (41.7%) were overweight and 23 (27.4%) were obese. Patients with increasing BMI had correspondingly greater American Society of Anesthesiologist (ASA) scores. There were no significant differences in VAS Back, VAS Leg, and ODI scores, or postoperative complications among the cohorts. There were no cases of surgical site infections in the cohort. All cohorts demonstrated significant improvement up to 1 year postoperatively. CONCLUSIONS: This study demonstrates that obesity is not a risk factor for increased perioperative complications with biportal spinal endoscopy and has similar clinical outcomes and safety profile as compared to patients with normal BMI. Biportal spinal endoscopy is a promising alternative to traditional techniques to treat common lumbar pathology.

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes.

¼ Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.¼ Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.¼ Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.¼ Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.¼ Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Cervical Spine Surgery Following COVID-19 Infection: When is it Safe to Proceed?

STUDY DESIGN: Retrospective. OBJECTIVE: We utilized the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile of patients undergoing spine surgery during multiple time windows following the COVID-19 infection. SUMMARY OF BACKGROUND DATA: While the impact of COVID-19 on various organ systems is well documented, there is limited knowledge regarding its effect on perioperative complications following spine surgery or the optimal timing of surgery after an infection. METHODS: We asked the National COVID Cohort Collaborative for patients who underwent cervical spine surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0-2 weeks, 2-6 weeks, or 6-12 weeks before surgery. RESULTS: A total of 29,449 patients who underwent anterior approach cervical spine surgery and 46,379 patients who underwent posterior approach cervical spine surgery were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events, sepsis, 30-day mortality, and 1-year mortality, irrespective of the anterior or posterior approach. Among patients undergoing surgery between 2 and 6 weeks after COVID-19 infection, the 30-day mortality risk remained elevated in patients undergoing a posterior approach only. Patients undergoing surgery between 6 and 12 weeks from the date of the COVID-19 infection did not show significantly elevated rates of any complications analyzed. CONCLUSIONS: Patients undergoing either anterior or posterior cervical spine surgery within 2 weeks from the initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events, sepsis, and mortality. Elevated perioperative complication risk does not persist beyond 2 weeks, except for 30-day mortality in posterior approach surgeries. On the basis of these results, it may be warranted to postpone nonurgent spine surgeries for at least 2 weeks following a COVID-19 infection and advise patients of the increased perioperative complication risk when urgent surgery is required.

Diagnostic prediction of gastrointestinal graft-versus-host disease based on a clinical- CT- signs nomogram model.

OBJECTIVE: Gastrointestinal graft-versus-host disease (GI-GVHD) is one of the complications that can easily occur after hematopoietic stem cell transplantation (HSCT). Timely diagnosis and treatment are pivotal factors that greatly influence the prognosis of patients. However, the current diagnostic method lacks adequate non-invasive diagnostic tools. METHODS: A total of 190 patients who suspected GI-GVHD were retrospectively included and divided into training set (n = 114) and testing set (n = 76) according to their discharge time. Least absolute shrinkage and selection operator (LASSO) regression was used to screen for clinically independent predictors. Based on the logistic regression results, both computed tomography (CT) signs and clinically independent predictors were integrated in order to build the nomogram, while the testing set was verified independently. The receiver operating characteristic (ROC), area under the curve (AUC), decision curve, and clinical impact curve were used to measure the accuracy of prediction, clinical net benefit, and consistency of diagnostic factors. RESULTS: Four key factors, including II-IV acute graft-versus-host disease (aGVHD), the circular target sign, multifocal intestinal inflammation, and an increased in total bilirubin, were identified. The combined model, which was constructed from CT signs and clinical factors, showed higher predictive performances. The AUC, sensitivity, and specificity of the training set were 0.867, 0.787, and 0.811, respectively. Decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) showed that the developed model exhibited a better prediction accuracy than the others. CONCLUSIONS: This combined model facilitates timely diagnosis and treatment and subsequently improves survival and overall outcomes in patients with GI-GVHD. CRITICAL RELEVANCE STATEMENT: GI-GVHD is one of the complications that can easily occur after HSCT. However, the current diagnostic approach lacks adequate non-invasive diagnostic methods. This non-invasive combined model facilitates timely treatment and subsequently improves patients with GI-GVHD survival and overall outcomes. KEY POINTS: • There is currently lacking of non-invasive diagnostic methods for GI-GVHD. • Four clinical CT signs are the independent predictors for GI-GVHD. • Association between the CT signs with clinical factors may improve the diagnostic performance of GI-GVHD.

Costs of revision operations for distal junctional kyphosis following thoracic posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: To assess direct costs and risks associated with revision operations for distal junctional kyphosis/failure (DJK) following thoracic posterior spinal instrumented fusions (TPSF) for adolescent idiopathic scoliosis (AIS). METHODS: Children who underwent TPSF for AIS by a single surgeon (2014-2020) were reviewed. Inclusion criteria were minimum follow-up of 2 years, thoracolumbar posterior instrumented fusion with a lower instrumented vertebra (LIV) cranial to L2. Patients who developed DJK requiring revision operations were identified and compared with those who did not develop DJK. RESULTS: Seventy-nine children were included for analysis. Of these, 6.3% developed DJK. Average time to revision was 20.8 ± 16.2 months. Comparing index operations, children who developed DJK had significantly greater BMIs, significantly lower thoracic kyphosis postoperatively, greater post-operative lumbar Cobb angles, and significantly more LIVs cranial to the sagittal stable vertebrae (SSV), despite having statistically similar pre-operative coronal and sagittal alignment parameters and operative details compared with non-DJK patients. Revision operations for DJK, when compared with index operations, involved significantly fewer levels, longer operative times, greater blood loss, and longer hospital lengths of stay. These factors resulted in significantly greater direct costs for revision operations for DJK ($76,883 v. $46,595; p < 0.01). CONCLUSIONS: In this single-center experience, risk factors for development of DJK were greater BMI, lower post-operative thoracic kyphosis, and LIV cranial to SSV. As revision operations for DJK were significantly more costly than index operations, all efforts should be aimed at strategies to prevent DJK in the AIS population.

Avoiding Pitfalls in Adult Spinal Deformity.

To avoid the high rate of complications associated with the surgical management of adult spinal deformity, it is important to recognize and avoid three major pitfalls. The first is patient selection and determining which cases are appropriately indicated. The second is optimizing modifiable medical issues that can lead to a poor outcome, such as smoking, vitamin D deficiency, nutritional status, and poor bone quality. The third is optimizing surgical factors such as defining clinically appropriate, patient-specific target alignment goals as well as using techniques to avoid proximal junctional kyphosis and proximal junctional failure. It is important to describe these three key pitfalls that are commonly seen in the treatment of patients with adult spinal deformity and to describe methods to avoid them.

Combined Anterior Thoracic Vertebral Body Tethering and Posterior Lumbar Tethering Results in Quicker Return to Sport and Activity Compared to Posterior Spinal Instrumented Fusion in Patients with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To compare patient-reported physical activity between anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) and posterior spinal instrumentation and fusion (PSIF) with minimum 2 year follow-up. METHODS: Consecutive skeletally immature patients with idiopathic scoliosis and a thoracic and lumbar curve magnitude ≥40° who underwent either ATVBT/PLST or PSIF from 2015-2019 were included. The primary outcome was rate of returning to sport. Secondary outcomes included ability to bend and satisfaction with sport performance as well as weeks until return to sport, school, physical education (PE) classes, and running. RESULTS: Ten patients underwent ATVBT/PLST and 12 underwent PSIF. ATVBT/PLST patients reported significantly faster return to sport (13.5 weeks vs 27.9 weeks, P = .04), running (13.3 weeks vs 28.8 weeks, P = .02), and PE class (12.6 weeks vs 26.2 weeks, P = .04) compared to PSIF patients. ATVBT/PLST patients reported that they had to give up activities due to their ability to bend at lower rates than PSIF patients while reporting "no changes" in their ability to bend after surgery at higher rates than PSIF patients (0% vs 4% giving up activities and 70% vs 0% reporting no changes in bending ability for ATVBT/PLST and PSIF, respectively, P = .01). Compared to PSIF patients, ATVBT/PLST patients experienced less main thoracic and thoracolumbar/lumbar curve correction at most recent follow-up (thoracic: 41 ± 19% vs 69 ± 18%, P = .001; thoracolumbar/lumbar: 59 ± 25% vs 78 ± 15%, P = .02). No significant differences in the number of revision surgeries were observed between ATVBT/PLST and PSIF patients (4 (40%) and 1 (8%) for ATVBT/PLST and PSIF, respectively, P = .221). CONCLUSIONS: ATVBT/PLST patients reported significantly faster rates of returning to sport, running, and PE. In addition, ATVBT/PLST patients were less likely to have to give up activities due to bending ability after surgery and reported no changes in their ability to bend after surgery more frequently than PSIF patients. However, the overall rate of return to the same or higher level of sport participation was high amongst both groups, with no significant difference observed between ATVBT/PLST and PSIF patients.

Limited number of spine surgeons among recipients of National Institutes of Health grants awarded for degenerative spine disease research.

OBJECTIVE: Surgeon scientists remain underrepresented among recipients of National Institutes of Health (NIH) grants despite their unique ability to perform translational research. This study elucidates the portfolio of NIH grants awarded for degenerative spine diseases and the role of spine surgeons in this portfolio. METHODS: The most common diagnoses and surgical procedures for degenerative spine diseases were queried on the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database (2011-2021). Total NIH funding was extracted for 20 additional clinical areas and compound annual growth rates (CAGRs) were calculated. A retrospective cohort study of principal investigators (PIs) was conducted. NIH grants and funding totals were extracted and compared to those from other clinical areas. RESULTS: The total NIH research budget increased from $31 to $43 billion over the 10-year period (CAGR 3.4%). A total of 273 unique grants equaling $91 million (CAGR 0%) were awarded for degenerative spine diseases. Diabetes ($11.8 billion, CAGR 0%), obesity ($10.6 billion, CAGR 3%), and chronic pain ($5.6 billion, CAGR 7%) received the most funding. Most NIH funding for degenerative spine disease research was awarded through the R01 (66%) and R44 (8%) grant mechanisms. The National Institute of Arthritis and Musculoskeletal and Skin Diseases awarded the most NIH funding (64%). Departments of orthopedic surgery were awarded the most funding (32%). NIH funding supported clinical (28%), translational (37%), and basic science (35%) research. Disease mechanisms (58%), imaging modalities (20%), and emerging technologies (16%) received the most funding. Nineteen spine surgeons were identified as PIs (16%). There were no significant differences in NIH funding totals by PI demographic and academic characteristics (p > 0.05)-except for full professors, who had the most NIH funding (p = 0.007) and highest h-index values (p < 0.001). CONCLUSIONS: Few spine surgeons receive NIH grants for degenerative spine disease research. Future opportunities may exist for spine surgeons to collaborate in identified areas of clinical interest. Additional strategies are needed to increase NIH funding in spine surgery.

Perioperative Outcomes of Open Anterior Vertebral Body Tethering and Instrumented Posterior Spinal Fusion for Skeletally Immature Patients With Idiopathic Scoliosis.

BACKGROUND: Correcting adolescent idiopathic scoliosis (AIS) without fusion can be achieved with anterior vertebral body tethering (AVBT). However, little is known about the perioperative outcomes, pain control, and clinical outcomes in patients undergoing AVBT compared with instrumented posterior spinal fusion (IPSF). METHODS: In this retrospective cohort study, we compared pediatric patients with AIS who underwent either AVBT or IPSF. Inclusion criteria were based on the AVBT group, which included primary thoracic idiopathic scoliosis, Risser ≤1, curve magnitude 40 to 70 degrees, age 9 to 15, no prior spine surgery, index surgery between 2014 and 2019, and minimum 2-year follow-up. Patient demographics, perioperative metrics, pain visual analog scale scores, opiate morphine equivalent usage, cost data, and radiographic outcomes were compared. RESULTS: We identified 23 patients who underwent AVBT and 24 matched patients in the IPSF group based on inclusion criteria. Patients undergoing AVBT and PSF were similar in age (12±1 y vs. 13±1 y, P =0.132) and average follow-up time (3.8±1.6 y vs. 3.3±1.4 y, P =0.210). There were 23 female patients (87%) in the AVBT group and 24 female (92%) patients in the IPSF group. Intraoperatively, estimated blood loss (498±290 vs. 120±47 mL, P <0.001) and procedure duration (419±95 vs. 331±83 min, P =0.001) was significantly greater in the IPSF group compared with AVBT. Length of stay was lower in the AVBT group compared with PSF (4±1 vs. 5±2 d, P =0.04). PSF patients had significantly greater total postoperative opiate morphine equivalent use compared with AVBT (2.2±1.9 vs. 5.6±3.4 mg/kg, P <0.001). Overall direct costs following PSF and AVBT were similar ($47,655+$12,028 vs. $50,891±$24,531, P =0.58). Preoperative radiographic parameters were similar between both the groups, with a major thoracic curve at 51±10 degrees for AVBT and 54±9 degrees for IPSF ( P =0.214). At the most recent follow-up, IPSF patients had greater curve reduction to a mean major thoracic curve of 11±7 degrees (79%) compared with 19±10 degrees (63%) in AVBT patients ( P =0.002). Nine patients (39%) required revision surgery following AVBT compared with 4 patients(17%) following IPSF ( P =0.09). CONCLUSIONS: In a select cohort of patients, AVBT offers decreased surgical time, blood loss, length of stay, and postoperative opiate usage compared with IPSF. Although IPSF resulted in greater deformity correction at 2-year follow-up, the majority of patients who underwent AVBT had ≤35 major curves and avoided fusion. There is optimism for AVBT as a treatment option for select AIS patients, but long-term complications are still being understood, and the risk for revision surgeries remains high. LEVEL OF EVIDENCE: Level III.

Posterior Displacement of L1 May be a Risk Factor for Proximal Junctional Kyphosis After Adult Spinal Deformity Correction.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Overcorrection in adult spinal deformity (ASD) surgery may lead to proximal junctional kyphosis (PJK) because of posterior spinal displacement. The aim of this paper is to determine if the L1 position relative to the gravity line (GL) is associated with PJK. METHODS: ASD patients fused from the lower thoracic spine to sacrum by 4 spine surgeons at our hospital were retrospectively studied. Lumbar-only and upper thoracic spine fusions were excluded. Spinopelvic parameters, the L1 plumb line (L1PL), L1 distance to the GL (L1-GL), and Roussouly type were measured. RESULTS: One hundred fourteen patients met inclusion criteria (63 patients with PJK, 51 without). Mean age and follow up was 65.51 and 3.39 years, respectively. There was no difference between the PJK and the non-PJK groups in baseline demographics, pre-operative and immediate post-operative pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, or coronal Cobb. The immediate postoperative L1-GL was -7.24 cm in PJK and -3.45 cm in non-PJK (P < 0.001), L1PL was 1.71 cm in PJK and 3.07 cm in non-PJK (P = 0.004), and PT (23.76° vs 18.90°, P = 0.026) and TK (40.56° vs 31.39°, P < 0.001) were larger in PJK than in non-PJK. After univariate and multivariate analyses, immediate postoperative TK and immediate postoperative L1-GL were independent risk factors for PJK without collinearity. CONCLUSIONS: A dorsally displaced L1 relative to the GL was associated with an increased risk of PJK after ASD surgery. The postoperative L1-GL distance may be a factor to consider during ASD surgery.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014.

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Diagnosis and Management of Spondylolysis and Spondylolisthesis in Children.

¼: Spondylolysis is defined as a defect of the pars interarticularis, and spondylolisthesis is defined as a slippage of a vertebra relative to the immediately caudal vertebra. ¼: Most cases of spondylolysis and low-grade spondylolisthesis can be treated nonoperatively. Depending on a patient's age, nonoperative treatment may include a thoracolumbosacral orthosis (TLSO), physical therapy, and activity modification. Bracing and physical therapy have been found to be more effective than activity modification alone. ¼: Patients with dysplastic spondylolisthesis are at higher risk for progression and should be monitored with serial radiographs every 6 to 9 months. ¼: Operative management is recommended for symptomatic patients with failure of at least 6 months of nonoperative management or patients with high-grade spondylolisthesis. ¼: Surgical techniques include pars defect repair, reduction, and fusion, which may include posterior-only, anterior-only, or circumferential fusion.

The accuracy of patient-reported weight prior to total joint arthroplasty and arthroscopy of the lower extremity.

PURPOSE: The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight. METHODS: Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors. RESULTS: There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05). CONCLUSION: Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.

A study protocol for a Pilot Masked, Randomized Controlled Trial Evaluating Locally-applied Gentamicin versus Saline in Open Tibia Fractures (pGO-Tibia) in Dar es Salaam, Tanzania.

BACKGROUND: Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings. METHODS: We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures. DISCUSSION: The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.

Return to Work Following Tibial Tubercle Osteotomy for Patellofemoral Osteoarthritis and Pain.

PURPOSE: To evaluate the ability of patients to return to work following anteromedialization (AMZ) tibial tubercle osteotomy (TTO) due to isolated patellofemoral osteoarthritis or pain. METHODS: Consecutive patients undergoing AMZ TTO were reviewed retrospectively at a minimum of 1 year postoperatively. Patients completed a subjective work questionnaire, a visual analog scale for pain, as well as a Kujala questionnaire and satisfaction questionnaire. RESULTS: Fifty-seven patients (61 knees; average age: 32.7 ± 9.6 years) were contacted at an average follow-up of 4.86 ± 2.84 years postoperatively. The preoperative Kujala score improved from 55.7 ± 17.8 to 84.6 ± 15.8 at final follow-up (P < 0.001). Thirty-seven patients (64.9%) were employed within 3 years prior to surgery and 34 patients (91.9%) were able to return to work by 2.8 ± 2.6 months postoperatively. However, only 27 patients (73.0%) of patients were able to return to the same level of occupational intensity. Patients who held sedentary, light-, medium-, or high-intensity occupations were able to return to work at a rate of 100.0%, 93.8%, 77.8%, and 100.0% by 2.2 months, 3.0 months, 3.1 months, and 4.0 months, postoperatively. No patients underwent revision TTO or conversion to arthroplasty by the time of final follow-up. CONCLUSION: In patients with focal patellofemoral osteoarthritis or pain, AMZ TTO provides a high rate of return to work (91.9%) by 2.8 ± 2.6 months postoperatively. Patients with higher intensity occupations may take longer to return to work than those with less physically demanding occupations. LEVEL OF EVIDENCE: III.

Concurrent and overlapping surgery: perspectives from surgeons on spinal posterior instrumented fusion for adolescent idiopathic scoliosis.

PURPOSE: The purpose of this study was to determine perspectives of surgeons regarding simultaneous surgery in patients undergoing posterior spine instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). METHODS: A survey was administered to orthopaedic trainees and faculty regarding simultaneous surgery for primary PSIF for AIS. A five-point Likert scale (1: 'Strongly Disagree' to 5: 'Strongly Agree') was used to assess agreement with statements about simultaneous surgery. We divided simultaneous surgery into concurrent, when critical portions of operations occur at the same time, and overlapping, when noncritical portions occur at the same time. RESULTS: The 72 respondents (78.3% of 92 surveyed) disagreed with concurrent surgery for 'one of my patients' (response mean 1.76 (sd 1.03)) but were more accepting of overlapping surgery (mean 3.94 (sd 0.99); p < 0.0001). The rating difference between concurrent and overlapping surgery was smaller for paediatric and spine surgeons (-1.25) than for residents or those who did not identify a subspecialty (-2.17; p = 0.0246) or other subspecialty surgeons (-2.57; p = 0.0026). Respondents were more likely to agree with explicit informed consent for concurrent surgery compared with overlapping (mean 4.32 (sd 0.91) versus 3.44 (sd 1.14); p < 0.001). CONCLUSION: Orthopaedic surgeons disagreed with concurrent but were more accepting of overlapping surgery and anaesthesia for PSIF for AIS. Respondents were in greater agreement that patients should be explicitly informed of concurrence than of overlap. The surgical community's evidence and position regarding simultaneous surgery, in particular overlapping, must be more effectively presented to the public in order to bridge the gap in perspectives. LEVEL OF EVIDENCE: IV.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents.

BACKGROUND: The national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown. AIM: To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents. METHODS: This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10-18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses. RESULTS: In total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02). CONCLUSION: There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up.

OBJECTIVE: Patients undergoing long-segment fusions from the lower thoracic (LT) spine to the sacrum for adult spinal deformity (ASD) correction are at risk for proximal junctional kyphosis (PJK). One mechanism of PJK is fracture of the upper instrumented vertebra (UIV) or higher (UIV+1), which may be related to bone mineral density (BMD). Because Hounsfield units (HUs) on CT correlate with BMD, the authors evaluated whether HU values were correlated with PJK after long fusions for ASD. METHODS: The authors performed a retrospective study of patients older than 50 years who had undergone ASD correction from the LT spine to the sacrum in the period from October 2007 to January 2018 and had a minimum 2-year follow-up. Demographic and spinopelvic parameters were measured. HU values were measured on preoperative CT at the UIV, UIV+1, and UIV+2 (2 levels above the UIV) levels and were assessed for correlations with PJK. RESULTS: The records of 127 patients were reviewed. Fifty-four patients (19 males and 35 females) with a mean age of 64.91 years and mean follow-up of 3.19 years met the study inclusion criteria; there were 29 patients with PJK and 25 patients without. There was no statistically significant difference in demographics or follow-up between these two groups. Neither was there a difference between the groups with regard to postoperative pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), PI minus LL (PI-LL), thoracic kyphosis (TK), or sagittal vertical axis (SVA; all p > 0.05). Postoperative pelvic tilt (p = 0.003) and T1 pelvic angle (p = 0.014) were significantly higher in patients with PJK than in those without. Preoperative HUs at UIV, UIV+1, and UIV+2 were 120.41, 124.52, and 129.28 in the patients with PJK, respectively, and 152.80, 155.96, and 160.00 in the patients without PJK, respectively (p = 0.011, 0.02, and 0.018). Three receiver operating characteristic (ROC) curves for preoperative HU values at the UIV, UIV+1, and UIV+2 as a predictor for PJK were established, with areas under the ROC curve of 0.710 (95% CI 0.574-0.847), 0.679 (95% CI 0.536-0.821), and 0.681 (95% CI 0.539-0.824), respectively. The optimal HU value by Youden index was 104 HU at the UIV (sensitivity 0.840, specificity 0.517), 113 HU at the UIV+1 (sensitivity 0.720, specificity 0.517), and 110 HU at the UIV+2 (sensitivity 0.880, specificity 0.448). CONCLUSIONS: In patients undergoing long-segment fusions from the LT spine to the sacrum for ASD, PJK was associated with lower HU values on CT at the UIV, UIV+1, and UIV+2. The measurement of HU values on preoperative CTs may be a useful adjunct for ASD surgery planning.

Wearable activity sensors and early pain after total joint arthroplasty.

A prospective observational cohort of 20 primary total hip arthroplasty (n = 12) and total knee arthroplasty (n = 8) patients (mean age: 63 ± 6 years) was passively monitored with a consumer-level wearable activity sensor before and 6 weeks after surgery. Patients were clustered by minimal change or decreased activity using sensor data. Decreased postoperative activity was associated with greater pain reduction (-5.5 vs -2.0, P = .03). All patients surpassed minimal clinical benefit thresholds of total joint arthroplasty (TJA) (Hip Disability and Osteoarthritis Score Junior 30.5 vs 20.8, P = .23; Knee Injury and Osteoarthritis Outcome Score Junior 23.3 vs 18.2, P = .77) within 6 weeks. Patients who objectively "take it easy" after TJA may experience less pain with no difference in early subjective outcome. Remote, passive analysis of outpatient wearable sensor data may permit real-time detection of early problems after TJA.

Development of Squat-and-Smile Test as Proxy for Femoral Shaft Fracture-Healing in Patients in Dar es Salaam, Tanzania.

BACKGROUND: There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test. METHODS: The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed. RESULTS: Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78). CONCLUSIONS: The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S. CLINICAL RELEVANCE: The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.