Recursive partitioning analysis is predictive of overall survival for patients undergoing spine stereotactic radiosurgery.

Spine stereotactic radiosurgery (SRS) offers excellent radiographic and pain control for patients with spine metastases. We created a prognostic index using recursive partitioning analysis (RPA) to allow better patient selection for spine SRS. Patients who underwent single-fraction spine SRS for spine metastases were included. Primary histologies were divided into favorable (breast/prostate), radioresistant (renal cell/sarcoma/melanoma) and other. Cox proportional hazards regression was done to identify factors associated with overall survival (OS). RPA was performed to identify factors to classify patients into distinct risk groups with respect to OS. A total of 444 patients were eligible. Median dose was 16 Gy (range 8-18) in 1 fraction and median follow-up was 11.7 months. At time of analysis, 103 (23.1%) patients were alive. Median OS was 12.9 months. RPA identified three distinct classes. Class 1 was defined as KPS > 70 with controlled systemic disease (n = 142); class 3 was defined as KPS ≤ 70 and age < 54 years or KPS ≤ 70 age ≥ 54 years and presence of visceral metastases (n = 95); all remaining patients comprise class 2 (n = 207). Median overall survival was 26.7 months for class 1, 13.4 months for class 2, and 4.5 months for class 3 (p < 0.01). Our analysis demonstrates that there is considerably variability in survival among patients undergoing spine SRS. We created an objective risk stratification via RPA for spine SRS. Given the safety and efficacy of spine SRS and good survival in class 1 and 2 patients, this RPA can help clinicians identify patients who may benefit from upfront spine SRS.

Validation of a Novel Surgical Data Capturing System Following Total Hip Arthroplasty.

BACKGROUND: The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes. METHODS: This study includes data from the first 100 primary THAs and 100 revision THAs performed by 15 surgeons at a single institution from January through April 2016. Surgeons prospectively entered procedural details into OME following surgery. The OME database and operative notes were compared to evaluate completion rates and agreement. Completion rates were compared using McNemar's test (with continuity correction), while agreement was analyzed using Cohen's kappa (κ) and concordance correlation coefficient. RESULTS: The OME database had significantly higher completion rates for 41% (39/96) of the variables. Proportion of data points that matched between the operative notes and OME data revealed that 54% (52/96) had a proportion agreement >0.90, and 79% (76/96) had a proportion agreement >0.80. In regard to measured agreement, 25% (24/96) of variables had almost perfect agreement, 29% (28/96) had substantial agreement, and 14% (13/96) had moderate agreement. Only 4% (4/96) had fair agreement, 8% (8/96) had slight agreement, and 6% (6/96) had poor agreement. CONCLUSION: The OME data capture system is an efficient tool to document procedural details following THA. The system is user-friendly, comprehensive, and accurate. It has the potential to be a valuable tool for future orthopedic research.

Role of Bone Biopsy During Kyphoplasty in the Setting of Known Cancer: A Case Report.

STUDY DESIGN: Case report. OBJECTIVE: The aim of this study was to emphasize the utility of routine biopsy during kyphoplasty and to report on a unique case of a patient with known history of prostate cancer found to have a new metastatic cancer. SUMMARY OF BACKGROUND DATA: Vertebral compression fractures (VCFs) may cause debilitating pain with nearly one-third of them leading to chronic pain resulting in a tremendous impact on quality of life in patients. Kyphoplasty has been established as an effective means of surgical treatment. However, routine biopsy during kyphoplasty is presently not the standard of care under the presumption that most VCFs are caused by osteoporosis. The role of biopsy in the setting of known malignancy with multiple other risk factors for VCFs is not well understood. METHODS: We report on a case of a 73-year-old male with known prostate cancer presenting with persistent unremitting low back pain failing conservative management. Patient develops multiple VCFs in the course of 6 months and is treated with multiple kyphoplasties. Routine biopsy at each level is negative until the last kyphoplasty results positive for malignancy. Surprisingly, the pathology is positive for malignancy other than the patient's known prostate cancer. RESULTS: Pathology results prompt oncology workup on the patient which reveals multiple metastases and a new diagnosis of adenocarcinoma of possible upper gastrointestinal origin. In addition, patient's known prostate cancer is also noted to be active. Patient is subsequently started on chemotherapy. CONCLUSION: We highlight the utility of routine biopsy during kyphoplasty especially in patients with known history of malignancy. We emphasize that presumptions about the etiology of a VCF are difficult to make with multiple risk factors and that routine biopsy prevents incorrect presumptions such as in this case.Level of Evidence: 5.

A Last-Ditch Effort and Personalized Surgeon Letter Improves PROMs Follow-Up Rate in Sports Medicine Patients: A Crossover Randomized Controlled Trial.

Patient-reported outcomes measures (PROMs) are important for the advancement of orthopaedic surgeries. The primary difficulty while collecting PROMs is obtaining adequate follow-up rates. Therefore, it is important to find methods to improve follow-up, especially in patients who have failed to respond to initial attempts. We hypothesized that PROMs follow-up could be effectively increased by sending a salvage-effort personalized surgeon letter to sports medicine patients who failed to respond to initial (centralized electronic, mail, and/or phone contacts) PROMs collection 1 year after surgery. Patients who failed to respond to 1-year follow-up of postoperative PROMs collection at our outpatient sports medicine surgery center were included. Patients were randomized into an intervention or control group. Patients in the intervention group were mailed PROMs form and an Institutional Review Board-approved letter that was personalized with surgical information, surgeon picture, and surgeon signature. Control group was mailed the same letter a month later. Chi-squared analysis was conducted at 5 weeks. Out of 843 surgeries, our initial 1-year PROMs follow-up rate was 65%, which allowed for 292 patients to be eligible for our study. After exclusions, 281 patients (randomized to 140 control group and 141 intervention group) were included in our study. We found a 20% response rate in the intervention group with 28 patients returning PROMs as compared with a 1.4% rate in the control group with two patients returning PROMs. The odds ratio was 17.1 (95% confidence interval: 4-73.3; p < 0.0001). A salvage-effort personalized surgeon letter is an efficient and relatively cost-effective method to increase PROMs follow-up rate, which means that a personalized surgeon letter can reach and engage patients who would otherwise be considered lost to follow-up, allowing for better outcomes monitoring after surgery.

Heparin for Vertebral Intraluminal Thrombus Causing Retroperitoneal Hemorrhage from Occult Renal Angiomyolipoma.

Stroke is a common cause of mortality and serious long-term disability worldwide. In the acute setting, current American Heart Association/American Stroke Association guidelines do not recommend routine anticoagulation for the management of acute ischemic strokes. However, short-term use of unfractionated heparin (UFH) in select subpopulations has demonstrated improved outcomes. While tools such as CHADSVASC and HASBLED scores are useful in stratifying risk of long-term anticoagulation in patients with nonvalvular atrial fibrillation and additional risk factors, the carefully selected patient populations for the design of these studies do not account for risk of hemorrhage from other preexisting conditions. Here, we present a patient with a posterior circulation intraluminal thrombus treated with UFH, who manifested with a near-fatal intra-abdominal hemorrhage from a previously undetected renal angiomyolipoma (AML).

What are the major drivers of outcomes in cervical deformity surgery?

BACKGROUND CONTEXT: Cervical deformity (CD) correction is becoming more challenging and complex. Understanding the factors that drive optimal outcomes has been understudied in CD correction surgery. PURPOSE: The purpose of this study is to assess the factors associated with improved outcomes (IO) following CD surgery. STUDY DESIGN SETTING: Retrospective review of a single-center database. PATIENT SAMPLE: Sixty-one patients with CD. OUTCOME MEASURES: The primary outcomes measured were radiographic and clinical "IO" or "poor outcome" (PO). Radiographic IO or PO was assessed utilizing Schwab pelvic tilt (PT)/sagittal vertical axis (SVA), and Ames cervical SVA (cSVA)/TS-CL. Clinical IO or PO was assessed using MCID EQ5D, Neck Disability Index (NDI), and/or improvement in Modified Japanese Orthopedic Association Scale (mJOA) modifier. The secondary outcomes assessed were complication and reoperation rates. MATERIALS AND METHODS: CD patients with data available on baseline (BL) and 1-year (1Y) radiographic measures and health-related quality of life s were included in our study. Patients with reoperations for infection were excluded. Patients were categorized by IO, PO, or not. IO was defined as "nondeformed" radiographic measures as well as improved clinical outcomes. PO was defined as "moderate or severe deformed" radiographic measures as well as worsening clinical outcome measures. Random forest assessed ratios of predictors for IO and PO. The categorical regression models were utilized to predict BL regional deformity (Ames cSVA, TS-CL, horizontal gaze), BL global deformity (Schwab PI-LL, SVA, PT), regional/global change (BL to 1Y), BL disability (mJOA score), and BL pain/function impact outcomes. RESULTS: Sixty-one patients met inclusion criteria for our study (mean age of 55.8 years with 54.1% female). The most common surgical approaches were as follows: 18.3% anterior, 51.7% posterior, and 30% combined. Average number of levels fused was 7.7. The mean operative time was 823 min and mean estimated blood loss was 1037 ml. At 1 year, 24.6% of patients were found to have an IO and 9.8% to have a PO. Random forest analysis showed the top 5 individual factors associated with an "IO" were: BL Maximum Kyphosis, Maximum Lordosis, C0-C2 Angle, L4-Pelvic Angle, and NSR Back Pain (80% radiographic, 20% clinical). Categorical IO regression model (R2 = 0.328, P = 0.007) found following factors to be significant: low BL regional deformity (ß = ‒0.082), low BL global deformity (ß = ‒0.099), global improve (ß = 0.532), regional improve (ß = 0.230), low BL disability (ß = 0.100), and low BL NDI (ß = 0.024). Random forest found the top 5 individual BL factors associated with "PO" (80% were radiographic): BL CL Apex, DJK angle, cervical lordosis, T1 slope, and NSR neck pain. Categorical PO regression model (R2 = 0.306, P = 0.012) found following factors to be significant: high BL regional deformity (ß = ‒0.108), high BL global deformity (ß = ‒0.255), global decline (ß = 0.272), regional decline (ß = 0.443), BL disability (ß = ‒0.164), and BL severe NDI (>69) (ß = 0.181). CONCLUSIONS: The categorical weight demonstrated radiographic as the strongest predictor of both improved (global alignment) and PO (regional deformity/deterioration). Radiographic factors carry the most weight in determining an improved or PO and can be ultimately utilized in preoperative planning and surgical decision-making to optimize the outcomes.

The 100 Most-Cited Papers in Traumatic Injury of the Spine.

BACKGROUND: Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion. OBJECTIVE: To identify the 100 most-cited articles on spine trauma. METHODS: The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles. RESULTS: The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list. CONCLUSIONS: We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.

Departmental Workload and Physician Errors in Radiation Oncology.

PURPOSE: The purpose of this work was to evaluate measures of increased departmental workload in relation to the occurrence of physician-related errors and incidents reaching the patient in radiation oncology. MATERIALS AND METHODS: All data were collected for the year 2013. Errors were defined as forms received by our departmental process improvement team; of these forms, only those relating to physicians were included in the study. Incidents were defined as serious errors reaching the patient requiring appropriate action; these were reported through a separate system. Workload measures included patient volumes and physician schedules and were obtained through departmental records for daily and monthly data. Errors and incidents were analyzed for relation with measures of workload using logistic regression modeling. RESULTS: Ten incidents occurred in the year. The number of patients treated per day was a significant factor relating to incidents (P < 0.003). However, the fraction of department physicians off-duty and the ratio of patients to physicians were not found to be significant factors relating to incidents. Ninety-one physician-related errors were identified, and the ratio of patients to physicians (rolling average) was a significant factor relating to errors (P < 0.03). The number of patients and the fraction of physicians off-duty were not significant factors relating to errors.A rapid increase in patient treatment visits may be another factor leading to errors and incidents. All incidents and 58% of errors occurred in months where there was an increase in the average number of fields treated per day from the previous month; 6 of the 10 incidents occurred in August, which had the highest average increase at 26%. CONCLUSIONS: Increases in departmental workload, especially rapid changes, may lead to higher occurrence of errors and incidents in radiation oncology. When the department is busy, physician errors may be perpetuated owing to an overwhelmed departmental checks system, leading to incidents reaching the patient. Insights into workload and workflow will allow for the development of targeted approaches to preventing errors and incidents.

Arthroplasty studies with greater than 1000 participants: analysis of follow-up methods.

BACKGROUND: The use of patient-reported outcome measures (PROMs) has become a mainstay of orthopedic joint arthroplasty research. Large studies with >1000 participants are vital to orthopedic research, as they allow for comprehensive multivariable analysis. Achieving high follow-up rates minimizes potential response bias. Maintaining adequate follow-up rates becomes more challenging as sample size increases. We aimed to systematically review the present literature to determine the follow-up rates of large cohorts/registries of total joint arthroplasty patients and to identify factors associated with successful collection of PROMs. METHODS: A comprehensive literature search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were: ≥1000 participants, ≥6 months of postoperative follow-up, and use of validated PROMs postoperatively. RESULTS: Of 720 abstracts screened, 21 studies met inclusion criteria. Only 2 studies reported achieving a PROM follow-up rate ≥80%, but neither collected PROMs preoperatively. The median rate of follow-up was 70%, and the median number of patients was 2970. Only 38% (8 of 21) of studies collected baseline PROMs prior to surgery. CONCLUSIONS: Very few studies in the present literature have collected validated PROMs on ≥1000 patients with ≥80% follow-up; these parameters are conducive to comprehensive multivariable analysis, while maintaining study validity and avoiding follow-up bias. Federal funding and a central coordinating site may be helpful in achieving follow-up in studies of this magnitude. LEVEL OF EVIDENCE: Level III, systematic review of studies with Level of Evidence I-III.

Outcomes in Organ Transplant Recipients With Prostate Cancer Treated With Radiotherapy.

BACKGROUND: Few data exist in the literature regarding outcomes of men with prostate cancer (CaP) who are receiving immunosuppression from prior organ transplantation. The aim of this study was to evaluate biochemical disease-free survival, distant metastasis-free survival, overall survival, and toxicity in patients with organ transplants who were later treated with definitive radiotherapy for CaP. PATIENTS AND METHODS: Our institutional CaP registry was reviewed to identify patients who had undergone an organ transplantation before CaP diagnosis. Between 1999 and 2013, a total of 28 organ transplant recipients treated with definitive radiotherapy for CaP were identified. Treatment consisted of either I-125 low-dose-rate brachytherapy or external-beam radiotherapy. All patients were receiving immunosuppressive medications. RESULTS: The median age was 66 years. Median follow-up time was 30 months. Twenty-four patients (86%) were treated with brachytherapy, and 4 patients (14%) were treated with external-beam radiotherapy. Nine patients (32%) had low-risk CaP, 14 (50%) had intermediate-risk CaP, and 5 (18%) had high-risk CaP. At the time of last follow-up, 2 patients had died, 1 from metastatic CaP and 1 from other causes. The 3-year biochemical disease-free survival was 95.8%. The 3-year distant metastasis-free survival was 93.1%. The 3-year overall survival was 93.8%. One patient developed grade 3 late gastrointestinal toxicity. CONCLUSION: This represents one of the largest reported series of outcomes in patients with organ transplantation and CaP. Organ transplant recipients treated with prostate radiotherapy have excellent 3-year outcomes.

Risk Factors for Loss to Follow-up in 3202 Patients at 2 Years After Anterior Cruciate Ligament Reconstruction: Implications for Identifying Health Disparities in the MOON Prospective Cohort Study.

BACKGROUND: Understanding the risk factors for loss to follow-up in prospective clinical studies may allow for a targeted approach to minimizing follow-up bias and improving the generalizability of conclusions in anterior cruciate ligament reconstruction (ACLR) and other sports-related interventions. PURPOSE: To identify independent risk factors associated with failure to complete (ie, loss to follow-up) patient-reported outcome measures (PROMs) at 2 years after ACLR within a well-funded prospective longitudinal cohort. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: All patients undergoing primary or revision ACLR enrolled in the prospectively collected database of the multicenter consortium between 2002 and 2008 were included. Multivariate regression analyses were conducted to determine which baseline risk factors were significantly associated with loss to follow-up at a minimum of 2 years after surgery. Predictors assessed for loss to follow-up were as follows: consortium site, sex, race, marital status, smoking status, phone number provided (home or cell), email address provided (primary or secondary), years of school completed, average hours worked per week, working status (full-time, part-time, homemaker, retired, student, or disabled), number of people living at home, and preoperative PROMs (Knee injury and Osteoarthritis Outcome Score, Marx Activity Rating Scale, and International Knee Documentation Committee). RESULTS: A total of 3202 patients who underwent ACLR were enrolled. The 2-year PROM follow-up rate for this cohort was 88% (2821 of 3202). Multivariate analyses showed that patient sex (male: odds ratio [OR], 1.80) and race (black: OR, 3.64; other nonwhite: OR, 1.81) were independent predictors of 2-year loss to follow-up of PROMs. Education level was a nonconfounder. CONCLUSION: While education level did not predict loss to follow-up, patients who are male and nonwhite are at increased risk of loss to follow-up of PROM at 2 years. Capturing patient outcomes with minimal loss depends on equitable, not equal, opportunity to maximize generalizability and mitigate potential population-level health disparities. REGISTRATION: NCT00478894 (ClinicalTrials.gov identifier).