The fragility index and reverse fragility index of FDA investigational device exemption trials in spinal fusion surgery: a systematic review.

PURPOSE: FDA investigational device exemption (IDE) studies are considered a gold standard of assessing safety and efficacy of novel devices through RCTs. The fragility index (FI) has emerged as a means to assess robustness of statistically significant study results and inversely, the reverse fragility index (RFI) for non-significant differences. Previous authors have defined results as fragile if loss to follow up is greater than the FI or RFI. The aim of this study was to assess the FI, RFI, and robustness of data supplied by IDE studies in spinal surgery. METHODS: This was a systematic review of the literature. Inclusion criteria included randomized controlled trials with dichotomous outcome measures conducted under IDE guidelines between 2000 and 2023. FI and RFI were calculated through successively changing events to non-events until the outcome changed to non-significance or significance, respectively. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI and RFI, respectively, by the sample size. RESULTS: Thirty-two studies met inclusion criteria with a total of 40 unique outcome measures; 240 outcomes were analyzed. Twenty-six studies reported 96 statistically significant results. The median FI was 6 (IQR: 3-9.25), and patients lost to follow up was greater than the FI in 99.0% (95/96) of results. The average FQ was 0.027. Thirty studies reported 144 statistically insignificant results and a median RFI of 6 (IQR: 4-8). The average RFQ extrapolated was 0.021, and loss to follow up was greater than the RFI in 98.6% (142/144) of results. CONCLUSIONS: IDE studies in spine surgery are surprisingly fragile given their reputations, large sample sizes, and intent to establish safety in investigational devices. This study found a median FI and RFI of 6. The number of patients lost to follow-up was greater than FIand RFI in 98.8% (237/240) of reported outcomes. FQ and RFQ tell us that changes of two to three patients per hundred can flip the significance of reported outcomes. This is an important reminder of the limitations of RCTs. Analysis of fragility in future studies may help clarify the strength of the relationship between reported data and their conclusions.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws.

Background: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80). Conclusion: Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal. Level of Evidence: Level III, retrospective cohort study.

Spine Surgeon Assessments of Patient Psychological Distress are Inaccurate and Bias Treatment Recommendations.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: This study determined (1) the surgeon accuracy of psychological assessment in patients in spine clinic, (2) the impact of psychological distress on surgical recommendation, and (3) the correlation between patient-reported disability and psychological distress. SUMMARY OF BACKGROUND DATA: Psychological distress is common among patients presenting for spine surgery. Surgeon estimations of patients' distress may influence treatment recommendations, but little is known as to whether these assessments accurately mirror patient-perceived psychological distress. MATERIALS AND METHODS: A sample of new patients was recruited from an academic spine center. Prior to their initial consultation, patients completed the Modified Somatic Perception Questionnaire and Zung Depression Index to assess mental and physical manifestations of distress, which generated a Distress and Risk Assessment Method (DRAM) score of N (normal), R (at risk), or D (distressed). The Oswestry Disability Index and Neck Disability Index scores were also collected. Surgeons provided their estimates of the DRAM score after the visit and indicated their surgery recommendation. RESULTS: Of 296 patients, 40.5% reported some level of psychological distress (DRAM=R) and 15.9% had a high level of distress (DRAM=D). All three surgeons' ability to accurately assess the participant DRAM score was poor, with an overall kappa of 0.13 (0.08-0.18), biased toward underestimating the patient's true level of psychological distress. Patients rated as normal (N) by the surgeon were 3.78 times more likely to be recommended for surgery compared to those assessed as distressed (D) ( P =0.007). Patients with higher DRAM scores had higher Oswestry Disability Index ( P =0.008) and Neck Disability Index ( P =0.005) scores compared to those with lower DRAM scores. CONCLUSIONS: Spine surgeons have limited ability to detect psychological profiles in patients, with a tendency to underestimate levels of distress. The finding that these inaccurate assessments influence surgical recommendations underscores the importance of limiting surgeon bias in the decision-making process. LEVEL OF EVIDENCE: Diagnostic Level 2.

A Modified Method of Triggered Electromyography Monitoring in Minimally Invasive Spine Surgery: Comparison to Conventional Techniques and Correlation with Body Mass Index.

PURPOSE: Conventional triggered electromyography (EMG) in percutaneous pedicle screw (PPS) systems may be unreliable due to the interaction between the insertion apparatus and patient's soft tissue. Our aim was 1) to describe a modified technique of triggered EMG monitoring using insulated Kirschner wire (K-wires), 2) to compare EMG potentials with conventional techniques, and 3) to demonstrate the relationship between patient body mass index (BMI) and triggered EMG potentials. METHODS: This was a prospective cross-sectional study of 50 patients undergoing minimally invasive PPS placement. Triggered EMG measurements using K-wires before and after insulation were compared. The difference between EMG measurements before and after insulation was correlated with patient BMI. RESULTS: A total of 50 patients, 22 females and 28 males, underwent triggered EMG testing using K-wires prior to final PPS placement in the thoracic and lumbosacral spine for a total of 472 triggered EMG measurements. When compared to standard triggered EMG monitoring, insulated triggered EMG monitoring demonstrated an average 55.4% decrease in EMG values (P < 0.001). Increasing BMI correlated to increasing % decrease in EMG values (r-coefficient, 0.376; P < 0.01). CONCLUSIONS: We describe a cost-effective, efficient, and reliable technique for triggered EMG during PPS placement which may help ensure accurate screw placement and minimize potentially devastating complications.

Functional somatic syndromes are associated with suboptimal outcomes and high cost after shoulder arthroplasty.

BACKGROUND: The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs. METHODS: We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores. RESULTS: Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P < .001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P < .001). CONCLUSIONS: Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.

State-level Google search volumes for neck and shoulder pain correlate with psychosocial and behavioral health indicators.

BACKGROUND: There is growing interest in passively-generated online search data for health sciences research, but limited use to address musculoskeletal illness. QUESTIONS/PURPOSES: (1) To determine geographic and seasonal patterns in Google queries for shoulder, knee, hip, and neck pain across the United States, and (2) to quantify the state-level correlation of the volume of online symptom searches with rates of various population health indicators. METHODS: Using Google trends, we identified queries for shoulder, knee, hip, and neck pain in every state of the United States during 2018. We assessed the correlation of state-level Google search volumes with 9 population health indicators extracted from the 2018 Behavioral Risk Factor Surveillance System survey: tobacco use, obesity, diabetes, hyperlipidemia, depression, arthritis, cardiovascular disease, participation in physical activities, and college education. RESULTS: Neck and shoulder pain were the most common queries in most Southern states, while knee pain was generally the top query elsewhere. Queries for neck and shoulder pain peaked during the late fall and winter, while searches for knee and hip pain peaked in the spring. State-level search volumes for shoulder and neck pain correlated closely with all health indicators--particularly with tobacco use, obesity, cardiovascular disease, hyperlipidemia, participation in physical activities and college education. The only strong correlation of hip pain queries was with self-reported prevalence of arthritis. Knee pain queries were not associated with any of the studied health indicators. CONCLUSION: This study highlights the potential of search engine data to be utilized as population-level health indicators. The state-level correlation of psychosocial and behavioral health indicators with online search volumes for neck and shoulder pain may reflect the influence of mental and social health on the experience of pain.

External Fixation Devices Within the Magnetic Resonance Imaging Bore: A Safety and Radiologic Analysis.

OBJECTIVES: To (1) report the thermal changes encountered at the pin/skin interface in a cadaver with a knee-spanning external fixator inside the magnetic resonance imaging (MRI) bore and (2) report on the quality of the MRI sequences collected. METHODS: Three commonly used external fixation systems were placed on cadaveric lower extremities to simulate knee external fixation. Fiber optic thermal probes were placed at the pin/skin interface of a femoral and tibial pin. A control probe was embedded in the soft tissues of the thigh. Full knee MRI scans were performed using a 1.5-Tesla magnet. Real-time thermal data were collected. A clinically significant increase in temperature compared with the control was defined as 2°C. Two blinded radiologists evaluated the images for image quality and overall diagnostic utility using a standardized 5-point grading scale. RESULTS: There were statistically significant differences in the temperature changes between the femoral/tibial pin sites and the control probe sites during each phase of the MRI scan. However, there was only one clinically significant difference in temperature change during a single sequence of one MRI scan of one of the external fixator devices. Overall image quality was graded as a 4 for each image set with 100% interobserver agreement (k = 1.0). CONCLUSIONS: Despite significant differences in temperature changes between the pin sites and controls over multiple MRI sequences in commonly used external fixator devices, the differences in temperature change are likely not clinically relevant. Overall image quality and interpretability of the images were excellent.

Impact of body mass index on opioid consumption in lumbar spine fusion surgery.

BACKGROUND: in the United States from 1999 to 2000 through 2017-2018, the prevalence of obesity increased from 30.5 to 42.4%, while the prevalence of severe obesity nearly doubled. In lumbar spine surgery, obesity is associated with increased complications, worse perioperative outcomes, and higher costs. The purpose of this study was to examine the association between body mass index (BMI) and opioid consumption in patients undergoing lumbar spine fusion surgery. We hypothesized that obese patients would require more opioids postoperatively. METHODS: retrospective review of 306 patients who underwent one- or two-level posterior lumbar interbody fusion surgery between 2016 and 2020. Patients were stratified by BMI as follows: normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), and obese II-III (≥ 35.0 kg/m2). Patient demographics and preoperative characteristics were compared across BMI cohorts using one-way ANOVA and chi-square analysis. Patients with prior history of opioid use were excluded. Primary outcome measure was postoperative opioid consumption. Secondary outcomes included operative time, length of stay (LOS), discharge destination, and 30-day re-encounter rates. Outcomes were analyzed using multivariable linear regression adjusted for potential confounders. RESULTS: of 306 total patients, 17.3% were normal weight, 39.9% were overweight, 25.5% were obese I, and 17.3% were obese II-III. Obesity was associated with longer operative times and length of stay (p < 0.001, p = 0.024). For opioid naïve patients, there was no difference in-house opioid consumption when adjusted for kilograms of body mass and LOS (p = 0.083). Classes II-III patients were prescribed more than twice the number of postoperative opioids (p < 0.001) and were on opioids for a longer time postoperatively (p = 0.019). CONCLUSION: obesity is associated with longer operative times, longer LOS, and increased consumption of postoperative opioids. This should be considered when counseling patients preoperatively prior to lumbar spine fusion procedures.

Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study.

BACKGROUND: Gastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion. METHODS: Ten fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion. RESULTS: Overall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively. CONCLUSION: Increased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.

Inflammatory and Coagulative Considerations for the Management of Orthopaedic Trauma Patients With COVID-19: A Review of the Current Evidence and Our Surgical Experience.

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature. LEVEL OF EVIDENCE:: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases.

Background: Spinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines. Case description: Case 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities.Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity. Outcome: The first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively. Conclusions: CPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.

Phrenic nerve palsy after cervical laminectomy and fusion.

BACKGROUND: Phrenic nerve palsy is a rare complication of cervical spine surgery. There are no previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. Here, we present a case of a 69 year-old Caucasian male with severe cervical stenosis with myelopathy who underwent posterior spinal instrumentation and fusion (PSIF) from C2 to T2, with laminectomies at C3-C7. OUTCOME: The patient developed respiratory distress post-operatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. He was also noted to have a left C5 palsy affecting his deltoid function and proximal upper extremity sensation which gradually improved. CONCLUSIONS: This is the first reported case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Total Joint Arthroplasty in Patients With Cerebral Palsy.

INTRODUCTION: Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA? METHODS: The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting. RESULTS: A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05). CONCLUSION: Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study.

PURPOSE: The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. METHODS: Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. RESULTS: In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0-20) and 12.6 mm (SD 0.7, range 0-35), respectively. CONCLUSIONS: Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.

Patients with musculoskeletal dysplasia undergoing total joint arthroplasty are at increased risk of surgical site Infection.

INTRODUCTION: Musculoskeletal dysplasias (MSD) are inherited conditions of abnormal cartilage and bone development and remodeling which include, amongst others, multiple epiphyseal dysplasia (MED), spondyloepiphyseal dysplasia (SED), achondroplasia, and hypochondroplasia. The aim of this study was to compare patient characteristics and in-hospital complications between MSD and non-MSD patients undergoing total joint arthroplasty (TJA). HYPOTHESIS: MSD patients undergoing TJA are at increased risk of in-hospital post-operative complications and mortality compared to non-MSD patients. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) from the years 2005 to 2014 was used for this retrospective cohort study. International Classification of Diseases, Clinical Modifications (ICD-9-CM) procedure codes identified primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures and were used to separate MSD and non-MSD patients. Patients with trauma or malignancy as primary diagnoses, non-elective procedures, revision procedures, and concurrent bilateral surgeries were excluded. Patients were compared using linear regression or multivariate logistic regression analysis to control for confounders. All statistical analyses were performed taking into account the NIS sampling scheme and associated sampling weights. RESULTS: A total of 1,255 patients comprised the MSD group and 8,027,181 patients the non-MSD group. MSD patients were younger than non-MSD patients (50.9 vs. 65.8 years, p<0.001), with less comorbidities including: hypertension (40.2% vs. 64.5%, p<0.001), coronary artery disease (5.5% vs. 12.9%, p<0.001), diabetes mellitus (9.4% vs. 19.0%, p<0.001), and hypothyroidism (7.8% vs. 14.7%, p=0.002). MSD patients had higher risks of surgical site infection (0.8% vs. 0.2%; OR, 4.16; 95% CI, 1.03-16.75; p=0.044), and perioperative hemorrhage (2.1% vs. 0.7%; OR, 3.20; 95% CI, 1.32-7.76; p=0.010). DISCUSSION: MSD patients undergoing TJA were younger with less co-morbidity compared to non-MSD patients, and had no significant difference in overall perioperative medical and surgical complication rates. However, they are at increased risk for surgical site infection and perioperative hemorrhage possibly due to the anatomical complexity encountered. LEVEL OF EVIDENCE: III, Retrospective Cohort.

Current concepts in vitamin D and orthopaedic surgery.

INTRODUCTION: Vitamin D plays an important role in the musculoskeletal system of the human body. Here, we review the most current literature on vitamin D as it relates to orthopaedic surgery and the musculoskeletal system, focusing largely on non-fracture applications. MATERIALS AND METHODS: A literature review was performed on the basic science of vitamin D metabolism, epidemiology of vitamin D levels, role of vitamin D within the musculoskeletal system, and the correlation of vitamin D with injuries and orthopaedic surgical outcomes. RESULTS: The existing literature suggests vitamin D plays multiple roles in the musculoskeletal system. Recent research has shed light on the importance of vitamin D in the setting of soft tissue healing and recovery in addition to affecting postoperative outcomes after common orthopaedic procedures. CONCLUSIONS: Given the widespread prevalence of vitamin D deficiency, orthopaedic surgeons should be aware of the current evidence regarding clinical implications in patients with musculoskeletal complaints.

Traumatic hyperextension-distraction injuries of the thoracolumbar spine: a technical note on surgical positioning.

PURPOSE: Hyperextension-distraction type injury of the thoracolumbar spine is an unstable fracture pattern that generally necessitates surgical stabilization by posterior instrumentation. Care must be taken when positioning these patients from supine to prone due to the unstable nature of their injury. The study objectives were (1) to describe a novel modification of the Jackson table turn technique, which may be safer and more effective than the conventional log-roll method and traditional Jackson table technique for positioning patients with hyperextension-distraction injuries of the thoracolumbar spine from supine to prone in the operating room and (2) to present two cases in which this technique was successfully performed. METHODS: Two patients were carefully positioned from supine to prone by our modification of the Jackson table turn technique, which utilizes a Wilson frame sandwiched between two flat-top Jackson frames. Case 1: a 65-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury, requiring T7-T12 posterior spinal instrumented fusion (PSIF). Case 2: a 72-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury and an unstable L1 burst fracture, requiring T7-L2 PSIF. RESULTS: Both patients remained hemodynamically stable and neurologically intact throughout positioning and postoperatively. CONCLUSIONS: This technique is safe and effective for positioning patients with hyperextension-distraction type injuries of the thoracolumbar spine from supine to prone in the operating room and may be superior to conventional methods. These slides can be retrieved under Electronic Supplementary Material.

Marijuana use and mortality following orthopedic surgical procedures.

Background: The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. Methods: The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing 5 common orthopedic procedures: total hip (THA), total knee (TKA), and total shoulder (TSA) arthroplasties, spinal fusion, and traumatic femur fracture fixation. Results: Of 9,561,963 patients who underwent one of the 5 selected procedures in the 4-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared with no marijuana use (P < .0001) and increased odds of HF (P = .018), stroke (P = .0068), and CD (P = .0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (P = .0483), HF (P = .0076), and CD (P = .0003). For spinal fusions, marijuana use was associated with increased odds of stroke (P < .0001) and CD (P < .0001). Marijuana use in patients undergoing total shoulder arthroplasty was associated with decreased odds of mortality (P < .001) and stroke (P < .001). Conclusions: In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA, and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.