AOA Critical Issues Symposium: Advancing Diversity, Equity, and Inclusion in Orthopaedic Surgery.

ABSTRACT: In recent years, the medical field has recognized the pivotal role of diversity, equity, and inclusion (DEI) in enhancing patient care and addressing health-care disparities. Orthopaedic surgery has embraced these principles to create a more inclusive and representative workforce. A DEI symposium that was sponsored by the American Orthopaedic Association convened orthopaedic surgeons, researchers, educators, and stakeholders to discuss challenges and strategies for implementing DEI initiatives. The symposium emphasized the importance of equity, and fostered conversations on creating equal opportunities and resources. Speakers covered key topics, including establishing DEI divisions, metrics for success, DEI leadership, and available resources, and promoted excellence and innovation in orthopaedic surgery through a more diverse and inclusive approach.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States.

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Academic and Demographic Characteristics of Pediatric Orthopaedic Division Chiefs in the United States.

INTRODUCTION: Division Chiefs (DCs) and department leadership play an integral role within the service. The goal of this study is to assess the demographics and scholarly work of the leadership in pediatric orthopaedics services across the United States and comment on the role of diversity within leadership positions. METHODS: Academic medical centers and pediatric hospitals were identified using the Electronic Residency Application Service website, the Pediatric Orthopaedic Society of North America website, and the Children's Hospital Association website. Leadership was identified using the hospitals' respective websites where data such as sex, race/ethnicity, fellowship institution, time since graduating fellowship, and academic rank were collected. Scopus database was used to determine h-indices and PubMed was used to determine the number of publications. RESULTS: Of 196 academic centers and 223 pediatric hospitals identified, 98 had a designated DC of the pediatric orthopaedics division. The majority of the DCs were male (85.7%), and leadership positions at hospitals with academic affiliations had a higher proportion of female DCs than nonacademic centers ( P =0.0317). DCs were mostly white (83.7%), followed by Asian (12.2%), and African American (2.0%). The average time since fellowship was 21.1 years and the average h-index was 15.7. The average age of the DCs was 56.8 years old. Of those in academic settings, 48.5% held the rank of professor. The fellowship programs that trained the most DCs were Boston Children's Hospital (16.3%) and Texas Scottish Rite for Children (14.3%). DISCUSSION: There is a paucity of available research on leadership characteristics in pediatric orthopaedic surgery. While progress has been made, there is still a lack of diversity that exists among leadership in pediatric orthopaedics, both within the academic setting as well as the private sector. The position of DC is held predominately by white males with a rank of either professor or no academic association. Intentional efforts are needed to continue to increase diversity in leadership positions within pediatric orthopaedic programs in the United States. LEVEL OF EVIDENCE: IV.

AOA Critical Issues: Perceptions on the State of Diversity, Equity, and Inclusion in Orthopaedic Surgery: A Survey of the AOA Membership.

BACKGROUND: Orthopaedic surgery continues to trail other specialties in increasing diversity among its physician workforce. Various efforts have been and are currently being made to not only increase diversity, but also promote equity and inclusion in the field. The purpose of this study was to survey members of the American Orthopaedic Association (AOA) to determine how leaders in orthopaedics view diversity, equity, and inclusion (DEI) at the present time and to understand their perspective while moving into the future. METHODS: An anonymous 11-question survey was disseminated online to AOA members in May 2022. These individuals were identified by the AOA membership directory and the email ListServe. The survey included free-response and multiple-choice questions. Demographic information was self-identified, and both qualitative and quantitative data were collected. RESULTS: Of the 1,657 AOA members who were provided the survey, 262 (15.8%) responded. Approximately 29.5% (77) and 45.6% (119) of the surveyed population ranked "retention of underrepresented populations in orthopaedic residency (women, URiM)" as "very important" or "absolutely essential," respectively. The answers to the free-response questions identified multiple core themes that responders were passionate about, namely resident and attending physician recruitment and retention, as well as resident selection. CONCLUSIONS: Leaders in the field of orthopaedic surgery desire for action to be taken in the field of DEI. The findings of this survey denote positive attitudes even though many inequalities still pervade the field of orthopaedics. Through mentorship, objective evaluation, transparency, and continued intentional action, orthopaedic surgery is well-positioned to continue to move forward with DEI.

Racial and Health Insurance Differences in Patient Outcomes After Surgical Treatment for Cauda Equina Syndrome: A United States Retrospective Hospital Claims Database Analysis.

STUDY DESIGN: Retrospective database evaluation. OBJECTIVES: To study the association between race, health care insurance, mortality, postoperative visits, and reoperation within a hospital setting in patients with cauda equina syndrome (CES) undergoing surgical intervention. SUMMARY OF BACKGROUND DATA: CES can lead to permanent neurological deficits if the diagnosis is missed or delayed. Evidence of racial or insurance disparities in CES is sparse. MATERIALS AND METHODS: Patients with CES undergoing surgery from 2000 to 2021 were identified from the Premier Health care Database. Six-month postoperative visits and 12-month reoperations within the hospital were compared by race ( i.e ., White, Black, or Other [Asian, Hispanic, or other]) and insurance ( i.e. , Commercial, Medicaid, Medicare, or Other) using Cox proportional hazard regressions; covariates were used in the regression models to control for confounding. Likelihood ratio tests were used to compare model fit. RESULTS: Among 25,024 patients, most were White (76.3%), followed by Other race (15.4% [ 8.8% Asian, 7.3% Hispanic, and 83.9% other]) and Black (8.3%). Models with race and insurance combined provided the best fit for estimating the risk of visits to any setting of care and reoperations. White Medicaid patients had the strongest association with a higher risk of 6-month visits to any setting of care versus White patients with commercial insurance (HR: 1.36 (1.26,1.47)). Being Black with Medicare had a strong association with a higher risk of 12-month reoperations versus White commercial patients (HR: 1.43 (1.10,1.85)). Having Medicaid versus Commercial insurance was strongly associated with a higher risk of complication-related (HR: 1.36 (1.21, 1.52)) and ER visits (HR: 2.26 (2.02,2.51)). Medicaid had a significantly higher risk of mortality compared with Commercial patients (HR: 3.19 (1.41,7.20)). CONCLUSIONS: Visits to any setting of care, complication-related, ER visits, reoperation, or mortality within the hospital setting after CES surgical treatment varied by race and insurance. Insurance type had a stronger association with the outcomes than race. LEVEL OF EVIDENCE: Level-III.

Disparities in Telemedicine Literacy and Access in the United States.

BACKGROUND: Because of the expansion of telehealth services through the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, the potential of telemedicine in plastic surgery has gained visibility. This study aims to identify populations who may have limited access to telemedicine. METHODS: The authors created a telemedicine literacy index (TLI) using a multivariate regression model and data from the US Census and Pew Research Institute survey. A multivariate regression model was created using backwards elimination, with TLI as the dependent variable and demographics as independent variables. The resulting regression coefficients were applied to data from the 2018 US Census at the county level to create a county-specific technological literacy index (cTLI). Significance was set at P < 0.05. RESULTS: On multivariable analysis, the following factors were found to be significantly associated with telemedicine literacy: age, sex, race, employment status, income level, marital status, educational attainment, and urban or rural classification. Counties in the lowest tertile had significantly lower median annual income levels ($43,613 versus $60,418; P < 0.001) and lower proportion of the population with at least a bachelor's degree (16.7% versus 26%; P < 0.001). Rural areas were approximately three times more likely to be in the lowest cTLI compared with urban areas ( P < 0.001). Additional associations with low cTLI were Black race ( P = 0.045), widowed marital status ( P < 0.001), less than high school education ( P = 0.005), and presence of a disability ( P = 0.01). CONCLUSIONS: These results highlight disadvantaged groups at risk of being underserved with telehealth. Using these findings, key stakeholders may be able to target these communities for interventions to increase telemedicine literacy and access.

Academic, Leadership, and Demographic Characteristics of Orthopaedic Sports Medicine Division Chiefs in the United States.

INTRODUCTION: Division chiefs (DCs) play an integral role within the department, making critical decisions and helping shape the future of both the division and the department. This study aimed to investigate the demographic characteristics and scholarly work of DCs in academic orthopaedic sports medicine division in the United States. METHODS: Orthopaedic residency programs at academic centers were identified using the Association of American Medical Colleges' Electronic Residency Application Service. DCs were identified using the program's respective websites where data points such as sex, race/ethnicity, fellowship training institution, time since graduating fellowship, academic rank, number of degrees, and additional leadership titles were collected. Scopus database was used to determine h-indices. RESULTS: From the 191 programs identified, 100 had a DC for the sports medicine subspecialty division, and 66 programs offered a sports medicine fellowship. Most DCs (96%) were men. The racial/ethnic demographics of the DCs were mostly White (86%), followed by Asian (11%), African American (1%), Hispanic/Latino (1%), and mixed ethnicity (1%). On average, the DCs were 19.6 years past their fellowship completion. The average h-index was 21.2. Many (48%) had an academic rank of professor, 28% associate professor, and 12% assistant professor. Four held additional graduate degrees. The fellowship programs that trained the most DCs were Hospital for Special Surgery (11), Kerlan Jobe Orthopaedic Clinic (8), University of Pittsburgh (7), American Sports Medicine Institution (5), Cleveland Clinic (5), Cincinnati Sports Medicine (4), Massachusetts General Hospital (4), and Steadman Hawkins Clinic (4). DISCUSSION: DCs in academic orthopaedic surgery plays a crucial role in the department and is a topic that is understudied. A lack of diversity exists among DCs in academic Sports Medicine in orthopaedics. The position is held predominately by White men with a rank of either full or associate professor and extensive leadership experience. More efforts are needed to increase the diversity of sports medicine leadership within academic orthopaedic programs in the United States.

A Cross-Sectional Evaluation of the Successful Minority Applicant to Orthopaedic Surgery Residency Programs.

The lack of diversity among orthopaedic health care providers is a pressing matter that must continue to be corrected at all levels. Improving diversity among orthopaedic physicians starts with improving diversity in residency training programs. This study brings light to the demographics and achievements of successful minority applicants, detailing what types of students are successfully matching into orthopaedic surgery. Between June and July 2020, the authors distributed a 12-question, anonymous survey to 53 URM students who successfully matched into orthopaedic surgery residencies for the 2020 application cycle. The survey inquiries about respondent demographics, academic accomplishments, and match process success as well as whether the presence of URM faculty, program director, and chairman influenced how they made their rank list. Overall, 37 students (71%) completed the entire survey. Most students indicated that the presence or absence of URM faculty influenced their rank list (n = 32, 88.9%) and that this distinction was meaningful to their orthopaedic candidacy (n = 28, 87.5%). Less than half of the respondents (n = 16; 44.4%) noted that the presence of a URM residency program director or department chairman influenced their rank list, while 20 (55.6%) noted that it did not. In conclusion, URM applicants with multiple academic achievements can be successful during the orthopaedic match process. Furthermore, the presence of URM faculty is an important factor that URM applicants consider. Residency directors must both identify the competitive URM applicants and strive to recruit more URM faculty when aiming to increase program diversity. Level of Evidence: Level IV.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Racial and Gender Shoulder Arthroplasty Utilization Disparities of High- and Low-Volume Centers in New York State.

INTRODUCTION: The literature has consistently demonstrated utilization disparities in joint replacement procedures, though no studies have evaluated disparities in total shoulder arthroplasty with regard to operative volume. METHODS: We queried the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database for 32 410 total shoulder arthroplasties performed between 2009 and 2017. Patients were identified using Clinical Classifications Software code 154 for Non-Hip/Knee Arthroplasty and All Patient Refined-Diagnosis Related Group code 322 for Shoulder. Racial groups included Hispanic, non-Hispanic white, non-Hispanic black, and Other. High-volume centers were facilities that performed 2 standard deviations above the mean annual procedures. Utilization rates were calculated by dividing total shoulder arthroplasties per group by the 2010 NY Census population of that group. The Fisher exact test was used to determine significance. RESULTS: Total shoulder arthroplasty utilization increased from 43/100 000 to 73/100 000, two-thirds of which was driven by an increase in white resident utilization. More White residents per 100 000 underwent shoulder arthroplasty than Black, Hispanic, and Other residents per 100 000 residents of their respective race. White residents were 90% more likely than Hispanic residents to undergo total shoulder arthroplasty at high-volume centers (P = .04). There were no differences in utilization rate regarding operative volume comparing Black or Other residents to White residents. More females underwent total shoulder arthroplasty than males, though there was no difference in utilization rate regarding operative volume. CONCLUSION: Though total shoulder arthroplasty utilization nearly doubled, disparities persisted across gender and minority groups particularly in Hispanic utilization as White residents were 90% more likely than Hispanic residents to undergo shoulder arthroplasty at high-volume centers.

Greater Socioeconomic Disadvantage Is Associated with Worse Symptom Severity at Initial Presentation in Patients Seeking Care for Lumbar Disc Herniation.

STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To determine the association of patient socioeconomic disadvantage, insurance type, and other characteristics on presenting symptom severity in patients with isolated lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Little is known of the impact of socioeconomic disadvantage and other patient characteristics on the level of self-reported symptom severity when patients first seek care for lumbar disc herniation. METHODS: Between April 2015 and December 2018, 734 patients newly presenting for isolated lumbar disc herniation who completed the Patient-Reported Outcomes Measurement Information System Physical Function (PF), Pain Interference (PI), and Depression Computer Adaptive Tests (CATs) were identified. Socioeconomic disadvantage was determined using the Area Deprivation Index, a validated measure of socioeconomic disadvantage at the census block group level (0-100, 100 = highest socioeconomic disadvantage). Bivariate analyses were used. Multivariable linear regression was used to determine if there was an association between socioeconomic disadvantage, insurance type, and other patient factors and presenting patient-reported health status. RESULTS: Significant differences in age, insurance type, self-reported race, marital status, and county of residence were appreciated when comparing patient characteristics by socioeconomic disadvantage levels (all comparisons, P < 0.01). In addition, significant differences in age, insurance type, marital status, and county of residence were appreciated when comparing patient characteristics by self-reported race (all comparisons, P < 0.01). Being in the most socioeconomically disadvantaged cohort was associated with worse presenting Patient-Reported Outcomes Measurement Information System scores (Physical Function: ß = -3.27 (95% confidence interval [CI]: -4.89 to -1.45), P < 0.001; Pain Interference: ß = 3.20 (95% CI: 1.58-4.83), P < 0.001; Depression: ß = 3.31 (95% CI: 1.08-5.55), P = 0.004. CONCLUSION: The most socioeconomically disadvantaged patients with symptomatic lumbar disc herniations present with worse functional limitations, pain levels, and depressive symptoms as compared to patients from the least socioeconomically disadvantaged cohort when accounting for other key patient factors.Level of Evidence: 3.

Complications and Mortality Rates Following Surgical Management of Extradural Spine Tumors in New York State.

STUDY DESIGN: Database analysis. OBJECTIVE: To evaluate complications and mortality in patients undergoing surgical management of extradural spinal tumors in New York State. SUMMARY OF BACKGROUND DATA: Metastatic spine surgery has a high rate of complications but most studies are limited to single institutions. METHODS: The Statewide Planning and Research Cooperative System was used to identify patients with extradural spinal tumors undergoing surgery in New York State from 2006 to 2015. Bivariate and multivariate logistic regression analyses were used to estimate outcomes. RESULTS: Four thousand seven hundred sixty-seven patients were identified, the majority of patients were male and white a median age of 61. The complication rate was 17.6% and the mortality rate within 30 days of discharge was 12.2%. Multivariate analysis showed the odds of complications were higher in males compared with females (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.05-1.52, P = 0.01), and patients on Medicaid compared with patients on private insurance (OR: 1.42; 95% CI: 1.03-1.96, P = 0.03). Analysis of hospital characteristics showed lower volume hospitals (OR 1.48; 95% CI: 1.03-2.13, P value = 0.03), and teaching hospitals (OR: 1.47; 95% CI: 1.03-2.09, P = 0.04), have higher odds of complications compared with high-volume hospitals and nonteaching hospitals. Multivariate analysis showed higher odds of mortality within 30 days of discharge in patients of older age (OR: 1.02; 95% CI: 1.01-1.03, P value = 0.001), low-volume hospitals compared with high-volume hospitals (OR: 1.36; 95% CI: 1.09-1.79, P value = 0.02), hospitals with low bed size compared with high bed size (OR: 1.43; 95% CI: 1.12-1.83, P value = 0.01), and urban hospitals compared with rural hospitals (OR: 3.04; 95% CI: 2.03-4.56, P value = 0.001). CONCLUSION: Low-volume hospitals are associated with complications and mortality in patients with metastatic spine disease. LEVEL OF EVIDENCE: 3.

Factors Influencing Resident Satisfaction and Fellowship Selection in Orthopaedic Training Programs: An American Orthopaedic Association North American Traveling Fellowship Project.

BACKGROUND: There is limited literature available about educational satisfaction and fellowship selection among orthopaedic surgery residents. The purpose of this study was to identify factors that influence resident subspecialty career choice, fellowship selection, and satisfaction with orthopaedic training programs. METHODS: A self-report survey was electronically administered to orthopaedic surgery residents at 44 academic centers in the United States and Canada. Basic demographic information and level of satisfaction with a number of factors (surgical independence, mentorship opportunities, etc.) were evaluated using a 5-point Likert scale ranging from "excellent" to "poor." Summary statistics and group differences for discrete variables were compared with use of a chi-square test. RESULTS: Of the 283 respondents, 77% rated residency program satisfaction as "very good" or "excellent," and 93% said they would choose the same training program again. Decreased surgical independence (p < 0.01), poor faculty reputation (p < 0.01), reduced volume and variety of cases (p < 0.01), inadequate mentorship (p < 0.01), and reduced educational opportunities (p < 0.01) were associated with low satisfaction. Surgical variety and job opportunities were the top 2 factors contributing to subspecialty choice. Sports medicine and joints were the most popular career choices; case volume, surgical variety, and program reputation were the top factors contributing to fellowship program selection. CONCLUSIONS: In order to achieve resident satisfaction, orthopaedic training programs should strive to improve resident surgical independence, surgical case variety, mentorship programs, faculty reputation, and educational opportunities. Important factors for fellowship program selection include case volume, surgical variety, and overall program reputation.

Performance Of Safety-Net Hospitals In Year 1 Of The Comprehensive Care For Joint Replacement Model.

The Comprehensive Care for Joint Replacement (CJR) model introduced in 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study we used Medicare's CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals' rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend could place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients could enable safety-net hospitals to compete effectively in CJR.

PROMIS Pain Interference Is Superior to the Likert Pain Scale for Pain Assessment in Spine Patients.

STUDY DESIGN: Cross-sectional cohort analysis. OBJECTIVE: (1) To assess the correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) in patients seeking spine care; (2) to assess the correlation between PROMIS PF and the Likert Pain Scale (LPS) in patients seeking spine care; (3) to determine which pain scale best correlates to physical function overall and by number of clinic visits. SUMMARY OF BACKGROUND DATA: An accurate understanding of a patient's pain level is beneficial in setting clinical and pain management expectations. There is limited work analyzing which instrument best captures pain and its impact on function in patients seeking spine care. METHODS: Spine center patients from February 2015 to November 2017 were asked to complete PROMIS PF and PI domains, as well as to report their pain level on a 0 (no pain) to 10 (worst pain) LPS at each visit. Pearson correlation coefficients were calculated between PROMIS PF and PROMIS PI; PROMIS PI and LPS; and PROMIS PF and LPS. Fisher r-z transformation method was utilized for confidence intervals (CIs) and to determine significant correlation differences. Analyses were performed for all data, as well as by office visit. Significance was set at P < 0.01. RESULTS: A total of 21,774 first visit, 11,130 second visit, 6575 third visit, 4202 fourth visit, and 2819 fifth visit patients' data were recorded. PROMIS PF demonstrated a moderate correlation with the LPS over all visits (r = 0.46-0.49, P < 0.01). PROMIS PF demonstrated a strong correlation with PROMIS PI over all visits (r = 0.73-0.77, P < 0.01). Overall, PROMIS PI demonstrated significantly better correlation to self-reported physical function than the LPS (P < 0.01). CONCLUSION: While PROMIS PI and the LPS both demonstrated significant correlation with self-reported physical function, PROMIS PI had a significantly stronger correlation. LEVEL OF EVIDENCE: 2.

Spinal Cord Injury From Spinal Tumors: Prevalence, Management, and Outcomes.

BACKGROUND: With the aging population in the United States, it can be anticipated that the prevalence of spinal cord injuries (SCIs) and cancer will increase. Primary or metastatic spine tumors sit at a unique intersection of these 2 realms. Our objective was to evaluate the prevalence, outcomes, and complications after the management of SCI arising from spinal tumors. METHODS: In the present retrospective evaluation, all patients with SCI and a diagnosis of primary or metastatic spinal cancer who had been admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were evaluated. The demographic data (age, sex, race/ethnicity), tumor characteristics, American Spinal Injury Association score, and complications were evaluated. RESULTS: A total of 757 SCI entries were identified, and 685 unique patients met our inclusion criteria. Of those, 81 had SCIs due to spinal tumors (11.8% of all SCIs and 19.2% of nontraumatic SCIs). Most tumors were located in the thoracic region (65.4%) and were primary central nervous system in origin (21.0%), including meningioma (7.4%), schwannoma (3.7%), and ependymoma (2.5%). The next most common origins of the spinal tumors were metastases from the lung (17.3%), prostate (9.9%), kidney (8.6%), lymphoma (7.4%), and multiple myeloma (7.4%). Of these patients, 76.5% underwent surgical management, with a complications rate of 61.3%. The overall mortality rate at the latest follow-up examination was 63.0%. CONCLUSIONS: SCI associated with spinal tumor is often managed surgically and associated with high rates of complications. The present study has demonstrated longer survival rates compared with the existing data.

Evaluating the Correlation and Performance of PROMIS to SRS Questionnaires in Adult and Pediatric Spinal Deformity Patients.

STUDY DESIGN: Retrospective cross-sectional cohort analysis. OBJECTIVES: 1) To assess the correlation of Patient-Reported Outcomes Management Information System (PROMIS) domains with SRS-22r/SRS-30 domains in all scoliosis patients; 2) to assess the correlation of PROMIS domains with SRS-30 domains in adult scoliosis patients; 3) to assess the correlation of PROMIS domains with SRS-22r/SRS-30 domains in pediatric scoliosis patients; and 4) to assess ceiling and floor effects of PROMIS and SRS-22r/SRS-30 domains. SUMMARY OF BACKGROUND DATA: Studies evaluating correlations between PROMIS and a number of legacy PRO tools have been conducted. To our knowledge, no literature exists examining the correlation of PROMIS and SRS questionnaires in adult and pediatric spinal deformity patients. METHODS: Outpatient visits from July 2015 to December 2017 with concurrent PROMIS and SRS questionnaires were analyzed. Pediatric patients completed the SRS-22r, whereas adults completed the SRS-30. PROMIS measured Physical Function/Mobility, Pain Interference, and Depression domains. Spearman correlation coefficients (ρ) were calculated. Ceiling and floor effects were calculated and compared. RESULTS: 227 (164 adult; 64 pediatric) patient visits representing 173 patients were included. Moderate to strong correlation existed between PROMIS Physical Function/Mobility and SRS Function/Activity (F/A) domains (ρ, range 0.59-0.84; p < .001). PROMIS Pain Interference and SRS Pain domains showed strong-moderate to strong correlation (ρ, range -0.68 to -0.83; p < .001). PROMIS Depression and SRS Mental Health (MH) domains demonstrated strong-moderate to strong correlation (ρ, range -0.67 to -0.80; p < .001). Ceiling and floor effects were all less in PROMIS domains (range, 0.44% to 0.88%) compared with SRS domains (range, 0.88% to 17.62%). CONCLUSIONS: PROMIS Physical Function/Mobility, Pain Interference, and Depression domains correlate well with SRS F/A, Pain, and MH. SRS SI/A and Satisfaction are not as well captured. PROMIS showed better ceiling and floor effects than SRS. LEVEL OF EVIDENCE: Level III.

National Trends in Spinal Fusion Surgery for Neurofibromatosis.

STUDY DESIGN: Analysis of a national database. OBJECTIVE: To analyze trends in spinal fusion surgery for neurofibromatosis type I (NF-1) patients and to compare the surgical approaches. SUMMARY OF BACKGROUND DATA: The preferred surgical approach for fusion treatment of spinal deformity in NF is not well established. METHODS: We identified 548 patients with a diagnosis of NF-1 who had received spinal fusion surgery between 2003 and 2014. We compared posterior spinal fusion (PSF), anterior-posterior spinal fusion (APSF), and anterior spinal fusion with respect to patient demographics, institutional characteristics, in-hospital complications, and hospitalization lengths and costs. Significance was set at a value of p less than .05. RESULTS: The number of spinal fusions for NF-1 significantly increased (p = .02) over the study period. The rate of PSF surgeries increased 2.9-fold, whereas the rate of APSF surgeries decreased 2.2-fold. There was also a significant association between the location of the fusion and surgical approach (p<.01), with 66% of ASF cases being cervical spine cases. Compared with patients undergoing PSF and ASF, patients undergoing APSF were significantly younger (p<.01) and had significantly higher hospitalization lengths and costs (p<.01). APSF costs were $180,714 as compared to $144,027 for PSF and $105,312 for ASF. CONCLUSIONS: There have been significant increases in the rate of spinal fusion surgeries for NF-1 patients. Surgical treatment has shifted over the years and is dependent on the location of the deformity. Patients undergoing APSF are significantly younger. LEVEL OF EVIDENCE: Level III.

Scholarly Success of Orthopaedic Surgeons Participating in the Clinician Scholar Career Development Program.

BACKGROUND: A concern exists about the decline in young orthopaedic surgeons pursuing careers as clinician-researchers. One program designed to address this concern is the American Academy of Orthopaedic Surgeons/Orthopaedic Research and Education Foundation/Orthopaedic Research Society (AAOS/OREF/ORS) Clinician Scholar Career Development Program (CSCDP). The aims of this study were to better understand the characteristics of CSCDP participants and how the experience effects involvement in career-impacting opportunities and scholarly activity. METHODS: This study was a retrospective analysis. CSCDP participants from 2003 to 2014 were recorded, and demographic information was collected. An Internet search was utilized to determine each surgeon's current practice environment. The National Institutes of Health (NIH) Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database was used to track NIH funding. The OREF and its web site were used to query OREF grant funding. American Orthopaedic Association (AOA) Traveling Fellowship awardees were recorded from the AOA web site. Specialty-specific traveling fellowship awardee information was collected via organization web sites, and direct-contact, scholarly activity, and impact were determined using the Scopus database Hirsch index (h-index). RESULTS: Two hundred and thirty-two individuals (229 confirmed current orthopaedic surgeons) participated in the CSCDP. Fifteen (6.6%), 41 (17.9%), 20 (8.7%), and 17 (7.4%) former CSCDP participants have been awarded NIH funding, OREF grant support, AOA Traveling Fellowships, and/or specialty-specific traveling fellowships, respectively. Those involved in any of the career-impactful opportunities post-CSCDP have had higher scholarly activity and impact compared with those who were not involved in the career-impactful opportunities (h-index: 15.9 [standard deviation (SD), 8.1] versus 10.0 [SD, 5.7], p < 0.0001). No scholarly activity and impact differences existed between orthopaedic subspecialties (p = 0.077). CONCLUSIONS: The CSCDP appears to play an important role in promoting clinician-researcher careers in orthopaedic surgery. CLINICAL RELEVANCE: The CSCDP must continue to adapt to the surrounding health-care landscape to achieve an even better success rate in creating clinician-researchers who will further advance musculoskeletal health and discovery for the betterment of the patients and the profession.