A Survey for End-Stage Ankle Arthritis Treatment: Ankle Arthrodesis Versus Ankle Arthroplasty.

With promising technological advances, ankle arthroplasty has become an alternative to arthrodesis, traditionally the gold standard, for treating end-stage ankle arthritis. We collected knowledge and perceptions on both procedures to determine the need for a patient decision aid for these patients by administering a cross-sectional survey to 103 orthopaedic surgeons. Respondents were predominantly male and 41 to 50 years old. Half of those who stated that they do not perform arthroplasty said this was because they do not have adequate training. Additionally, certain variables were associated with the surgeon's choice of intervention: patient gender, age, body mass index, postoperative activity level, employment type, perceived risk of infection, neurovascular injury or wound complication, risk of developing or pre-existing adjacent arthritis, deformity, malalignment, bone loss or abnormal bone quality, number of prior ankle operations, cause of arthritis, and desire for motion preservation. The majority agreed that they always incorporate patient preferences into their decisions and that a decision aid would be beneficial. This survey revealed that several patient characteristics are influential in the surgeon's preference for either arthroplasty or arthrodesis for end-stage ankle arthritis. Because the majority of surgeons incorporate patient preferences in their decisions and report that a decision aid would be beneficial for informed decision-making in this clinical scenario, this survey identified an unmet need supporting the development of such a tool for these patients.

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report.

PURPOSE: We present a case of upper airway obstruction in a patient with an unstable cervical spine fracture in a halo orthosis. We also describe the mechanism by which the obstruction occurred and identify features that predispose patients in a halo orthosis to upper airway obstruction. CASE: An 81-yr-old female presenting to hospital with an unstable cervical spine fracture was scheduled for spinal fusion. She was fitted with a halo traction device in a flexed position, and an awake tracheal intubation was planned. The patient's airway was topicalized and 1 mg of midazolam was administered. Her oxygen saturation dropped, and mask ventilation was difficult and insufficient. She then became unresponsive and pulseless. Emergency release of the halo orthosis device was carried out and her neck was held in a neutral position. Mask ventilation was successfully performed and oxygenation improved. The patient's trachea was intubated via video laryngoscopy, and she was resuscitated and taken to the intensive care unit. The degree of cervical spine flexion resulting from the halo fixation was examined in subsequent radiographs, as defined by the occiput to C2 (O-C2) angle, and the oropharyngeal cross-sectional area was measured. Spine flexion from halo fixation in concert with the topical treatment and sedation predisposed the patient to acute airway obstruction. CONCLUSION: In this case, external cervical spine fixation in flexion resulted in a change to the O-C2 angle, which reduced the oropharyngeal area and predisposed to upper airway obstruction. This highlights the need for anesthesiologists to evaluate the degree of cervical spine flexion in patients with halo devices and to have the surgical team present during airway management in the event of acute airway obstruction.

Comparative outcomes of minimally invasive surgery for posterior lumbar fusion: a systematic review.

BACKGROUND: Although minimally invasive surgical (MIS) approaches to the lumbar spine for posterior fusion are increasingly being utilized, the comparative outcomes of MIS and open posterior lumbar fusion remain unclear. QUESTIONS/PURPOSES: In this systematic review, we compared MIS and open transforaminal or posterior lumbar interbody fusion (TLIF/PLIF), specifically with respect to (1) surgical end points (including blood loss, surgical time, and fluoroscopy time), (2) clinical outcomes (Oswestry Disability Index [ODI] and VAS pain scores), and (3) adverse events. METHODS: We performed a systematic review of MEDLINE(®), Embase, Web of Science, and Cochrane Library. Reference lists were manually searched. We included studies with 10 or more patients undergoing MIS compared to open TLIF/PLIF for degenerative lumbar disorders and reporting on surgical end points, clinical outcomes, or adverse events. Twenty-six studies of low- or very low-quality (GRADE protocol) met our inclusion criteria. No significant differences in patient demographics were identified between the cohorts (MIS: n = 856; open: n = 806). RESULTS: Equivalent operative times were observed between the cohorts, although patients undergoing MIS fusion tended to lose less blood, be exposed to more fluoroscopy, and leave the hospital sooner than their open counterparts. Patient-reported outcomes, including VAS pain scores and ODI values, were clinically equivalent between the MIS and open cohorts at 12 to 36 months postoperatively. Trends toward lower rates of surgical and medical adverse events were also identified in patients undergoing MIS procedures. However, in the absence of randomization, selection bias may have influenced these results in favor of MIS fusion. CONCLUSIONS: Current evidence examining MIS versus open TLIF/PLIF is of low to very low quality and therefore highly biased. Results of this systematic review suggest equipoise in surgical and clinical outcomes with equivalent rates of intraoperative surgical complications and perhaps a slight decrease in perioperative medical complications. However, the quality of the current literature precludes firm conclusions regarding the comparative effectiveness of MIS versus open posterior lumbar fusion from being drawn and further higher-quality studies are critically required.

Treatment of severe pediatric spinal deformities.

The management of severe pediatric spinal deformities continues to evolve as advances in spinal instrumentation, surgical techniques, and neuromonitoring occur. The techniques of spinal osteotomies have been refined to allow surgeons to perform better corrections with less operative time, more safely, and through a posterior approach alone, making multiple patient positioning changes during surgery a less common occurrence. With these techniques comes a learning curve for the entire surgical team, wherein communication and planning can help minimize major complications and morbidity. This overview will review various techniques used in the correction of severe spinal deformities. Topics reviewed include the role of anterior release, traction, posterior releases, and osteotomies. Indications, techniques, and pitfalls will be reviewed. A clear understanding of the patient's deformity, normal sagittal parameters, spinal anatomy, and the principles of neuromonitoring will help improve surgical planning and patient outcome.

The University of Colorado Virtual Physical Examination for Spine Surgeons: A Preliminary Study.

As coronavirus disease 2019 (COVID-19) reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical examination in a specialty reliant on direct patient contact for diagnosis and treatment. A prospective cohort of 52 patients consented to participate in a novel virtual physical examination protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the tele-medicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical examination and survey. Males and females were distributed evenly among the cohort at 50%. The mean age was 52.1±15.5 years. The average score for ease of understanding the examination (1=easiest, 5=hardest) was 1.1, while the average score for ease of performance was 1.5. Most participants (97.56%) felt their provider was better able to understand their condition using the virtual examination findings. This study highlights the utility of a virtual physical examination for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an examination can be implemented and performed to improve patient evaluation and satisfaction. [Orthopedics. 2022;45(1):e7-e10.].

Surgical Reduction of Spondylolisthesis During Lumbar Fusion: Are Complications Associated With Slip Correction?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to quantify the rates of complication following surgical treatment for symptomatic degenerative and isthmic spondylolisthesis and to examine the association between slip reduction and complication rates. SUMMARY OF BACKGROUND DATA: It is unclear if the degree of spondylolisthesis reduction during lumbar spine fusion in adults influences the rate of surgical complications. METHODS: This is a retrospective cohort study of 1-level and 2-level adult fusion patients with degenerative or isthmic spondylolisthesis. The degree of reduction and complications were calculated, and complication rates between those with and without reduction were compared. RESULTS: The surgical reduction was improved by 1 Meyerding grade in 56.5% of the 140 patients included in this analysis. Of those patients, 60% had a grade 1 spondylolisthesis. In addition, 62.5% of grade 2 slips had an improvement by 1 grade. Surgical reduction during lumbar fusion did not result in a higher rate of complications compared with in situ fusion. CONCLUSIONS: During 1-level or 2-level lumbar fusion for degenerative or isthmic spondylolisthesis, a 1-grade reduction of the slip was achieved in 56% of patients in this retrospective case series. Reduction of the spondylolisthesis was not associated with a higher rate of complication when compared with in situ fusion. LEVEL OF EVIDENCE: Level IV.

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

STUDY DESIGN: Retrospective study. PURPOSE: To identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective. OVERVIEW OF LITERATURE: Spine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking. METHODS: A retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed. RESULTS: For patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33-23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment. CONCLUSIONS: Spine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

Current Resident and Faculty Mentorship Satisfaction and Important Mentee Functions in Orthopedic Surgery: An American Orthopedic Association North American Traveling Fellowship Project.

OBJECTIVE: While mentorship remains important in orthopedic training, few studies have delineated specific priorities for creating successful mentorship programs and reciprocal satisfaction among contemporary trainees and faculty. The purpose of this study was to define beneficial mentor qualities along with specific mentee characteristics to facilitate improved mentoring relationships in orthopedic surgery. DESIGN: This is a cross-sectional study with a 16 multi-item self-reported survey. SETTING: This study was conducted at 11 tertiary orthopedic surgery training programs during the 2017 American Orthopaedic Association (AOA) North American Traveling Fellowship Tour. PARTICIPANTS: Eighty orthopedic resident trainees and 90 academic faculty members completed the survey. RESULTS: Around 55.0% of residents and 48.9% of faculty acknowledged a formal mentorship program at their institution. Furthermore, 61.3% of residents and 61.1% of faculty reported having a current mentor. The top 3 qualities valued by residents were a mentor who modeled work-life balance, remained in touch with contemporary issues in training, and provided timely counseling. Faculty valued a mentor who accepted their goals and priorities, provided counseling, and enhanced exposure in their subspecialty. Surveyed faculty were more satisfied than their corresponding residents with how their mentor promoted them, enhanced their exposure, was a friend, and protected them from exploitative collaborations. Mentee participation was considered the most important variable for a successful mentor relationship, while mentee acknowledgement of their mentors was the least prioritized quality. CONCLUSIONS: Faculty had a higher overall satisfaction with their mentoring relationships in orthopedic surgery. Residents reported more favorable results when their mentor was a role model of work-life balance. For optimal success, mentors identified active participation and openness to feedback as the most important quality for a mentee to display. These qualities contribute to a heightened sense of satisfaction among mentors and mentees and can be utilized to further guide development of both formal and informal programs for residents and faculty.

Comparison of different outcome instruments following foot and ankle trauma.

BACKGROUND: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the use of multiple available outcome measures with unproven reliability and validity. This prospective observational study aimed to measure the correlation between six functional outcome measures in patients with traumatic foot and ankle injuries. MATERIALS AND METHODS: Patients 18 years of age or older with a traumatic foot or ankle injury completed the Short Form-12 (SF-12), Short Musculoskeletal Functional Assessment (SMFA), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS), Foot and Ankle Questionnaire and American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale at a single followup visit. Raw scores for each of the outcome measures were calculated. Fifty-two patients were enrolled in our study. Pearson correlation coefficients provided measures of correlation. RESULTS: Moderate to strong correlations were found for most pairwise comparisons of raw scores and functional categorical rankings (ρ=|0.5243 to 0.92|, p < 0.002). The strongest correlations were found between the SMFA, FFI, FAAM and AAOS Foot and Ankle Questionnaire. CONCLUSION: High correlations between scores on six commonly used functional outcome instruments suggest it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. However, inconsistencies between measures in the same patient population suggest a need for further validation and scrutiny.

Rapid Neurologic Deterioration due to an Enlarging Thoracic Spine Synovial Cyst: A Case Report.

CASE: We present the case of a 69-year-old man arriving to our clinic after a previous outside hospital recommendation of L1-S1 fusion due to degenerative scoliosis. A thoracic spine synovial cyst was identified through magnetic resonance imaging. The patient had rapid progression of his neurologic deficit due to cyst enlargement. We elected to perform cyst decompression and instrumented fusion of the involved thoracic segment. The patient rapidly regained full neurologic function. After the one-year follow-up, he remained asymptomatic with no progression of thoracolumbar degeneration. CONCLUSIONS: Thoracic spine synovial facet cysts are uncommonly encountered. Decompression alone or decompression and fusion are both viable treatment options depending on the surgeon's assessment of spine stability after decompression. This diagnosis should be considered in patients presenting with unilateral lower extremity upper motor neuron findings.

Effect of Dibasic Calcium Phosphate Incorporation on Cellulose Nanocrystal/Chitosan Hydrogel Properties for the Treatment of Vertebral Compression Fractures.

Vertebral compression fractures account for approximately 700,000 out of the 1.5 million total osteoporotic fractures that occur annually in the USA. There is growing interest in substituting currently utilized clinical treatments for vertebral compression fractures with an injectable, degradable, and bioactive system. In this research we studied the osteoinductive effect of calcium phosphate incorporation into cellulose nanocrystal/chitosan hydrogels with varying ratios of carbonate as an ionic crosslinker and genipin as a covalent crosslinker. As calcium and phosphate ions have been shown to be osteoinductive in time and concentration dependent manners, dibasic calcium phosphate was chosen as a bioactive additive due to its desirable controlled ion delivery potential. Gelation time, swelling ratio, erosion, compressive strength, and ion release behavior of different dibasic calcium phosphate incorporated hydrogels were evaluated. Mesenchymal stem cells were then exposed to mechanically competent hydrogels found capable of maintaining calcium and phosphate concentrations within the established bioactive range in order to assess their cytotoxicity and osteoinductivity. Our results demonstrate that hydrogels with higher covalent crosslinking possessed better mechanical properties and stabilities as well as more controlled calcium and phosphate ion release. Interestingly, dibasic calcium phosphate incorporation not only improved hydrogel bioactivity but also resulted in greater compressive strength.

The Importance of Determining Trainee Perspectives on Procedural Competencies During Spine Surgery Clinical Fellowship.

STUDY DESIGN: Longitudinal survey. OBJECTIVE: It remains important to align competence-based objectives for training as deemed important by clinical fellows to those of their fellowship supervisors and program educators. The primary aim of this study was to determine trainee views on the relative importance of specific procedural training competencies. Secondarily, we aimed to evaluate self-perceived confidence in procedural performance at the commencement and completion of fellowship. METHODS: Questionnaires were administered to 68 clinical fellows enrolled in the AOSNA fellowship program during the 2015-2016 academic year. A Likert-type scale was used to quantify trainee perspectives on the relative importance of specific procedural competencies to their training base on an established curriculum including 53 general and 22 focused/advanced procedural competencies. We measured trainee self-perceived confidence in performing procedures at the commencement and completion of their program. Statistical analysis was performed on fellow demographic data and procedural responses. RESULTS: Our initial survey response rate was 82% (56/68) and 69% (47/68) for the follow-up survey. Although most procedural competencies were regarded of high importance, we did identify several procedures of high importance yet low confidence among fellows (ie, upper cervical, thoracic discectomy surgery), which highlights an educational opportunity. Overall procedural confidence increased from an average Likert score of 4.2 (SD = 1.3) on the initial survey to 5.4 (SD = 0.8) by follow-up survey (P < .0001). CONCLUSIONS: Understanding trainee goals for clinical fellowship remains important. Identification of areas of low procedural confidence and high importance to training experience will better guide fellowship programs and supervisors in the strategic delivery of the educational experience.

Inductive co-crosslinking of cellulose nanocrystal/chitosan hydrogels for the treatment of vertebral compression fractures.

Vertebral compression fractures are a very common consequence of osteoporosis for which injection of a non-biodegradable, non-bioactive, mechanically-stiff polymer bone cement into the vertebral body is the most common treatment. Recently, there has been growing interest in using bioactive, degradable, and bone biomechanics-matching products as an alternative approach for treating these fractures. In this research, we focused on creating injectable, chitosan-based hydrogels that can convey mechanical strength similar to vertebral bone as well as possess inherent osteoinductivity. First, we investigated the effects of three different factors - 1) bioactive phosphate ionic crosslinking; 2) genipin covalent crosslinking; 3) mechanically reinforcing cellulose nanocrystal incorporation - on the material properties of chitosan-based hydrogels. Mesenchymal stem cells were then exposed to hydrogels with optimum mechanical properties and stability in order to assess the biological effects of the bioactive phosphate ionic crosslinker. Our results show that hydrogels with higher ionic and covalent crosslinking ratios supplemented with neutral cellulose nanocrystals possessed desirable compressive strength and stability. Also, the significant osteoinductivity of these composite hydrogels demonstrated their potential to function as an injectable system for the future treatment of vertebral compression fractures.

Dispersal Pattern of Injectate After Cervical Epidural Steroid Injection Evaluated With Magnetic Resonance Imaging.

STUDY DESIGN: Prospective, nonrandomized, clinical study. OBJECTIVE: Epidural steroid injections (ESIs) are an important diagnostic and treatment modality for spine pathology. The success of these injections has been attributed to the anatomic location reached by the injectate. This study evaluates injectate dispersal patterns after cervical interlaminar ESI using magnetic resonance imaging (MRI). METHODS: Patients between the ages of 18 and 85 years with cervical radiculopathy were identified. After obtaining consent for study participation, a gadolinium-enhanced cervical ESI was administered via an interlaminar approach under fluoroscopic guidance. Study participants underwent a cervical spine MRI within 15 minutes of administering the injection. Craniocaudal dispersal and the presence or absence of circumferential dispersal was assessed. RESULTS: The injectate dispersed a mean of 8.11 cm in the cranial direction, 6.63 cm in the caudal direction, and 360° circumferentially. No adverse events related to the ESI were reported. CONCLUSIONS: Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multilevel migration in the cranial and caudal directions. MRI is a safe and accurate tool to evaluate spinal injectate dispersal.

The 2017 American Orthopaedic Association North American Traveling Fellowship.

Initially established in 1967, the American Orthopaedic Association (AOA) North American Traveling Fellowship was designed to promote leadership development, network creation, and knowledge exchange among emerging leaders in orthopaedic surgery, and it remains one of the AOA's flagship tours. In 2017, the fellows visited 10 academic medical centers on the West Coast of Canada and the United States, participating in leadership, academic, clinical, and team-building activities. On the tour, we formed countless new friendships and collaborations, including exceptionally strong ones with each other. Because the 5 fellows came from diverse social, ethnic, religious, political, educational, and clinical backgrounds, the group discussions were lively and engaging. We all agree that the friendships that were made, the experiences that were encountered, and the lessons that were learned during the tour are priceless and will never be forgotten.

Chiari I malformation and syringomyelia in mucopolysaccharidosis type I (Hurler syndrome) treated with posterior fossa decompression: Case report and review of the literature.

BACKGROUND: Hurler Syndrome is the most severe phenotype of mucopolysaccharidosis type I. With bone marrow transplant and enzyme replacement therapy, the life expectancy of a child with Hurler syndrome has been extended, predisposing them to multiple musculoskeletal issues most commonly involving the spine. CASE DESCRIPTION: This is the case report of a 6-year-old male with Hurler syndrome who was diagnosed with Chiari I malformation and cervicothoracic syringomyelia on a preoperative magnetic resonance imaging (MRI) for his thoracolumbar kyphosis. This report details the successful management of a Chiari I malformation and syringomyelia with posterior fossa decompression in a child with Hurler syndrome. CONCLUSION: Children born with MPS I can have complex spine issues that require surgical management. The most common orthopedic spinal condition for these patients, thoracolumbar kyphosis, requires evaluation with an MRI before performing surgery. This resulted in the diagnosis of a Chiari I malformation and syringomyelia in our patient with Hurler syndrome. This was successfully treated with decompression of the posterior fossa.

Emerging Techniques in Degenerative Thoracolumbar Surgery.

There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.

Airway adverse events following posterior occipito-cervical spinal fusion.

Management of the airway may be challenging in patients undergoing occipito-cervical spine fusions (OCF). Changes in the occipito-cervical angle (dOC2A) of fusion after surgery may result in acute airway obstruction, dyspnea and/or dysphagia. Objectives of the study were to review the airway management of patients during posterior OCF, determine the incidence, nature and risk factors for postoperative airway adverse events (AEs), and to determine the relationship between airway AEs and the change in dOC2A. In this retrospective cohort of 59 patients, following extubation in the operating room (OR), there were no complications in 43 (73%) patients (Group 1). Sixteen (27%) patients (Group 2) had airway complications; 4 requiring reintubation and 12 having delayed extubation. The number of vertebral levels fused (>6), presence of difficult intubation and duration of surgery (>5h) were significantly associated with AEs. There was no significant difference in the dOC2A between the groups (-1.070±5.527 versus -4.375±10.788, p=0.127). Airway management in patients undergoing OCF poses a challenge for the anesthesiology and surgical teams. The incidence of AEs was 27%. The decision to extubate immediately after surgery needs to be individualized. Factors such as difficult intubation, number of vertebral levels fused and duration of surgery have to be considered. A significant correlation between dOC2A and postoperative AEs could not be established. Risk factors for postoperative AEs are multifactorial and prospective evaluation of these factors is indicated.

Novel Osteobiologics and Biomaterials in the Treatment of Spinal Disorders.

Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.