Leading an Organization in the 21st Century: The Importance of Environmental Sustainability, Social Responsibility, and Good Governance.

The concept of environmental sustainability, social responsibility, and good governance (ESG) is now well established in the corporate world and in for-profit organizations. However, it is not a concept that has reached medical and surgical association boardrooms in a meaningful way. It is important to define the concept of physician and corporate author expertise and objectives of ESG, provide a rationale for using ESG within orthopaedic organizations, and identify specific areas (primarily the "S" and the "G") where the American Academy of Orthopaedic Surgeons and other groups can align with this strategy.

Developmental Dysplasia of the Hip From Birth to Adolescence: Clear Indications and New Controversies.

It is important to be knowledgeable about the latest information on the diagnosis and the evidence-based management of developmental hip dysplasia and dislocation from birth through adolescence. The focus should be on the effect of the problem; normal growth and development of the hip joint; and the pathoanatomy, natural history, and long-term outcomes of developmental dysplasia of the hip, hip subluxation, and dysplasia. Many controversies exist in the management of this complex spectrum of disorders.

How and When to Transition to the Next Phase: Reflections.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event.

Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis.

PURPOSE: Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique. METHODS: A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction. RESULTS: A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24-108 months). The RSH was significantly improved from - 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P < 0.0001). Clavicle angle was improved from 2.13° to 1.31° (P < 0.0001). T1 tilt was improved from 5.6° to 2.2° (P < 0.0001). At last follow-up, 95.8% of patients were shoulder balanced. There was a significant improvement of Cobb angle with an average correction of the upper thoracic curve of 42% and main thoracic curve of 67%. CONCLUSION: The PHDS demonstrates the potential for additional shoulder balance improvement. Extension of fusion to structural proximal thoracic spine is the key to success for shoulder balance. It remains to be seen whether these improvements will translate into improved clinical outcomes in the longer term.

Developmental Dysplasia of the Hip From Birth to Arthroplasty: Clear Indications and New Controversies.

Developmental dysplasia of the hip is the all-encompassing term used to describe the wide spectrum of disorders of the development of the hip that manifest in various forms and at different ages. Developmental dysplasia of the hip often evolves over time because the structures of the hip are normal during embryogenesis but gradually become abnormal. Such variability in pathology is associated with a similarly wide range in management options and recommendations aimed at preventing hip joint arthrosis. These options may be instituted at any time between birth and adulthood as techniques aimed at preserving the native hip or replacing the arthritic hip. Many of these management options are clearly indicated and considered standard practice. However, with the evolution of the understanding of hip biomechanics, better knowledge of the long-term outcomes of hip joint-preserving surgeries, and ever-improving technology influencing hip arthroplasty come new controversies, especially whether to preserve or replace the mature hip.

Ruptured Appendicitis and Retrocecal Abscess Masquerading as Knee Pain in a Pediatric Patient: A Case Report.

BACKGROUND: Knee pain has a variety of etiologies in the pediatric population, including septic arthritis, osteomyelitis, fracture, ligamentous injury, and neoplasms. Extrinsic sources of knee pain may also be intra-abdominal, although abdominal pathology is much more likely to manifest as hip or proximal thigh musculature pain. CASE REPORT: A 5-year-old healthy male presented with atraumatic right knee pain, discomfort with weightbearing, fever, and elevated inflammatory laboratory markers. Physical examination and magnetic resonance imaging findings of the knee were benign, leading to low clinical suspicion for knee septic arthritis. Blood cultures were positive for a gastrointestinal organism, Granulicatella adiacens, suggesting abdominal pathology leading to referred pain. Ultrasound evaluation and computed tomography (CT) of the abdomen revealed a large abscess secondary to perforated appendicitis, which was treated with CT-guided drainage and i.v. antibiotics. The patient's musculoskeletal pain subsided with treatment of the appendicitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute appendicitis may present as knee pain, with other signs and symptoms mimicking septic arthritis, such as fever, inability to bear weight, and elevated inflammatory markers. Considering an array of differential diagnoses in pediatric patients with apparent knee septic arthritis is crucial to prevent delay in diagnosis of alternative infectious sources.

The Importance of Natural History.

In a traditional view, the natural history of a condition or a disease tells us of the adult consequences of that entity, be it benign or otherwise. This knowledge then provides guidance as to who needs treatment, and allows us to assess whether our treatments alter an otherwise adverse natural history in a positive way without introducing iatrogenic complications. However, in the new paradigm for health care delivery of value-based care, we need to be able to express natural history in additional terms of burden of disease. This is something that lawmakers and people who pay for health care can understand and has a comparative value. It also serves as a benchmark to show the effectiveness of interventions aimed at reducing disease burden. In this paper, I will discuss why this POSNA symposium is important and make some recommendations on directions where we as individuals and as a professional society should be putting in our efforts and resources.

The Natural History of Adolescent Idiopathic Scoliosis.

INTRODUCTION: Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. METHODS: The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. RESULTS: Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. CONCLUSIONS: The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.

The 2018 Nicholas Andry Award: The Evidence Base for the Treatment of Developmental Dysplasia of the Hip: The Iowa Contribution.

This review summarizes evidence developed at the University of Iowa concerning the management and outcomes of developmental dysplasia of the hip beginning with the observations and analyses of Dr Arthur Steindler in the early 1900s. The strong evidence-based practice tradition established by Steindler 100 years ago continues as we critically evaluate our procedures and patient outcomes, only altering approaches when warranted by strong personal and research evidence. Our practice continues to be conservative in that we strive to produce the best environment possible for the hip to develop on its own and operate only when less invasive methods have failed.

What Does a Shoulder MRI Cost the Consumer?

BACKGROUND: More than 100 MRIs per 1000 inhabitants are performed in the United States annually, more than almost every other country. Little is known regarding the cost of obtaining an MRI and factors associated with differences in cost. QUESTIONS/PURPOSES: By surveying all hospital-owned and independent imaging centers in Iowa, we wished to determine (1) the cost to the consumer of obtaining a noncontrast shoulder MRI, (2) the frequency and magnitude of discounts provided, and (3) factors associated with differences in cost including location (hospital-owned or independent) and Centers for Medicare & Medicaid Services designation (rural, urban, and critical access). METHODS: There were 71 hospitals and 26 independent imaging centers that offered MRI services in Iowa. Each site was contacted via telephone and posed a scripted request for the cost of the technical component of a noncontrast shoulder MRI. Radiologists' reading fees were not considered. Statistical analysis was performed using standard methods and significance was defined as a probability less than 0.05. RESULTS: The mean technical component cost to consumers for an MRI was USD 1874 ± USD 694 (range, USD 500-USD 4000). Discounts were offered by 49% of imaging centers, with a mean savings of 21%. Factors associated with increased cost include hospital-owned imaging centers (USD 2062 ± USD 664 versus USD 1400 ± USD 441 at independent imaging centers; p < 0.001; mean difference, USD 662; 95% CI, USD 351-USD 893) and rural imaging centers, unless designated as a critical access hospital (USD 2213 ± USD 668 versus USD 1794 ± USD 680; p = 0.0202; mean difference, USD 419; 95% CI, USD 66-USD 772). CONCLUSIONS: In Iowa, the cost to the consumer of a shoulder MRI is significantly less at independent imaging centers compared with hospital-owned centers. Referring physicians and healthcare consumers should be aware that there may be substantial price discrepancies between centers that provide advanced imaging services. LEVEL OF EVIDENCE: Level IV, Economic and decision analysis.

Outcomes of Primary Posterior Spinal Fusion for Scoliosis in Spinal Muscular Atrophy: Clinical, Radiographic, and Pulmonary Outcomes and Complications.

BACKGROUND: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. METHODS: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. RESULTS: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). CONCLUSIONS: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV.

Body Image and Quality of Life and Brace Wear Adherence in Females With Adolescent Idiopathic Scoliosis.

BACKGROUND: Clinical evidence regarding the ability of braces to decrease the risk of curve progression to surgical threshold in patients with adolescent idiopathic scoliosis (AIS) continues to strengthen. Unfortunately, there is still a great deal of uncertainty regarding the impact of brace wear on psychosocial well-being or the impact of psychological well-being on brace wear adherence. The purpose of this study is to evaluate psychosocial well-being, in particular body image and quality of life (QOL), and brace wear adherence in female AIS patients undergoing brace treatment. METHODS: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) was a multicenter, controlled trial using randomized and preference assignments into an observation or brace treatment group. BrAIST patients were skeletally immature adolescents diagnosed with AIS having moderate curve sizes (20 to 40 degrees). Patients in the bracing group were instructed to wear a thoracolumbosacral orthosis, at least 18 h/d. Scores on the Spinal Appearance Questionnaire and the PedsQL4.0 Generic Scales from 167 female BrAIST patients who were randomized to brace treatment (n=58) and patients who chose brace treatment (n=109) were analyzed. RESULTS: At baseline and at 12 months, no differences were found between the least-adherent brace wear group (<6 h/d) and most-adherent brace wear group (≥12 h/d) patients in terms of major curve, body image, and QOL. In the most-adherent group, poorer body image scores were significantly correlated with poorer QOL scores at baseline, at 6 months, and at 12 months but not at 18 months. In general, body image scores and QOL scores were not significantly correlated in the least-adherent group. When comparing patients that had a ≥6 degree increase of their major curve between baseline and 12 months to patients that did not, there were no significant differences in body image or QOL scores. CONCLUSIONS: For females adolescents with AIS, body image and QOL do not have a significant impact on brace wear adherence and are subsequently not significantly impacted by brace wear. LEVEL OF EVIDENCE: Level II-therapeutic (prospective comparative study).

Effects of bracing in adolescents with idiopathic scoliosis.

BACKGROUND: The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. METHODS: We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). RESULTS: The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). CONCLUSIONS: Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.).

Evidence, Quality, Costs, and Reimbursement: Connecting the Dots.

Healthcare costs in the United States continue to rise, and substantial variations in the type, quality, and location of that care persist. It is critically important for all healthcare stakeholders to address and define value in orthopaedic care delivery. Evidence-based orthopaedic care delivery, reliable quality and performance measurement, and the delivery of the best care at the lowest cost are the key strategies to improve the value of musculoskeletal care. A failure to implement these strategies could negatively affect the reimbursement of all healthcare providers--at both the private and government payer levels.

The effect of resident participation on short-term outcomes after orthopaedic surgery.

BACKGROUND: The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown. QUESTIONS/PURPOSES: The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training. METHODS: The 2005­2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level. RESULTS: Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4­1.9), lower extremity trauma (OR, 1.3; range, 1.2­1.5), and fusion (OR, 1.4; range, 1.2­1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes. CONCLUSIONS: Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Intraoperative push-prone test: a useful technique to determine the lowest instrumented vertebra in adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective review of 24 cases of adolescent idiopathic scoliosis (AIS). Intraoperative push-prone test to determine the lowest instrumented vertebrae (LIV). OBJECTIVE: To determine the LIV using intraoperative push-prone test. BACKGROUND: Determination of the LIV in surgical treatment of the AIS remains controversial. Different classifications schemes have been proposed to help surgeons in making this decision. Most schemes depend on flexibility views. However, variability in technique of obtaining flexibility views and interpretation of these views in relation to the classification schemes make decision making in choosing the LIV difficult. METHODS: An intraoperative push-prone image was used to determine LIV. RESULTS: We were able to stop 1 or 2 levels above the stable vertebra in most cases. All patients had a well-balanced thorax over the pelvis. CONCLUSIONS: Intraoperative push-prone test is a useful adjunct to predict the LIV in AIS.

Fundamental concepts of developmental dysplasia of the hip.

To provide the best possible care to patients with developmental dysplasia of the hip, it is helpful to understand the normal growth and development of the hip joint; the pathoanatomy, epidemiology, and diagnosis of the condition; and the natural history of a missed diagnosis of dislocation, subluxation, and dysplasia.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

BrAIST-Calc: Prediction of Individualized Benefit From Bracing for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective multicenter study data were used for model derivation and externally validated using retrospective cohort data. OBJECTIVE: Derive and validate a prognostic model of benefit from bracing for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) demonstrated the superiority of bracing over observation to prevent curve progression to the surgical threshold; 42% of untreated subjects had a good outcome, and 28% progressed to the surgical threshold despite bracing, likely due to poor adherence. To avoid over-treatment and to promote patient goal setting and adherence, bracing decisions (who and how much) should be based on physician and patient discussions informed by individual-level data from high-quality predictive models. MATERIALS AND METHODS: Logistic regression was used to predict curve progression to <45° at skeletal maturity (good prognosis) in 269 BrAIST subjects who were observed or braced. Predictors included age, sex, body mass index, Risser stage, Cobb angle, curve pattern, and treatment characteristics (hours of brace wear and in-brace correction). Internal and external validity were evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n=299) through estimates of discrimination and calibration. RESULTS: The final model included age, sex, body mass index, Risser stage, Cobb angle, and hours of brace wear per day. The model demonstrated strong discrimination ( c -statistics 0.83-0.87) and calibration in all data sets. Classifying patients as low risk (high probability of a good prognosis) at the probability cut point of 70% resulted in a specificity of 92% and a positive predictive value of 89%. CONCLUSION: This externally validated model can be used by clinicians and families to make informed, individualized decisions about when and how much to brace to avoid progression to surgery. If widely adopted, this model could decrease overbracing of AIS, improve adherence, and, most importantly, decrease the likelihood of spinal fusion in this population.