The 100 Most Impactful Articles on Total Shoulder Arthroplasty: An Altmetric Analysis.

Background: To use the top 100 articles pertaining to total shoulder arthroplasty (TSA) to understand the impact that social media platforms have on the dissemination of shoulder research while highlighting bibliometric factors associated with Altmetric Attention Score (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications. Methods: In June 2023, the Altmetric database was searched using the following PubMed MeSH terms: "total shoulder arthroplasty" or "TSA." Articles with the highest AAS were screened to exclude other topics unrelated to TSA. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with prior studies. Results: The Altmetric Database query yielded 1,283 studies. After applying our inclusion criteria, the top 118 articles with the highest AAS were identified. The mean AAS was 29.14 ± 42.35, with a range of 13 to 402. The included articles represented 27 journals, with 70 articles attributed to 2 journals: Journal of Shoulder and Elbow Surgery (JSES; 43%) and the Journal of Bone and Joint Surgery (JBJS; 16%). There was a significant increase in AAS for the presence of a conflict of interest (p = 0.042) and open access status (p < 0.01), but no association between the score and citation rate (p > 0.05). Conclusions: Top articles on TSA, as defined by high AAS, mostly comprise original clinical research performed in the United States or Europe. The presence of a conflict of interest and open access status is associated with an increase in AAS, but there was no association between AAS score and citation rate.

Should my recommendation letter be written by artificial intelligence?

SummaryLetters of recommendation are increasingly important for the residency match. We assessed whether an artificial intelligence (AI) tool could help in writing letters of recommendation by analyzing recommendation letters written by 3 academic staff and AI duplicate versions for 13 applicants. The preferred letters were selected by 3 blinded orthopedic program directors based on a pre-determined set of criteria. The first orthopedic program director selected the AI letter for 31% of applicants, and the 2 remaining program directors selected the AI letter for 38% of applicants, with the staff-written versions selected more often by all of the program directors (p < 0.05). The first program director recognized only 15% of the AI-written letters, the second was able to identify 92%, and the third director identified 77% of AI-written letters (p < 0.05).

Analysis of the reliability of KEOPS version 2 for the measurement of coronal and sagittal parameters in spinal deformity.

BACKGROUND: The purpose of the study is to evaluate the updated version of this software in patients with various spinal deformity. METHODS: Sixty patients were included in this study and were divided into three categories: 20 patients with AIS, 20 patients with ASD, and 20 patients having undergone corrective surgery for spinal deformity. The measurements were performed by two senior and two junior orthopedic surgery residents, and were done at two points in time separated by a 3-week interval with the cases being randomized every time to reduce the risk of memory bias. Measured parameters included coronal, sagittal, global alignment parameters, and pelvic parameters. RESULTS: When assessing the inter- and intra-observer reliability across all the groups of patients, none of the coefficients was smaller than 0.8 with a very high level of agreement. The standard error ranged from 0.7° to 1.5° demonstrating a high level of accuracy. Fairly similar results were seen when the groups were divided into the three categories except for the post-operative groups where a strong and not perfect level of agreement was reported. CONCLUSION: This is the first study to assess the reproducibility of the new version of KEOPS, showing a very high agreement in all measurements. In the post-operative group, although it showed a strong agreement, the lower performance can be explained by the presence of surgical material making it harder to identify the anatomical landmarks accurately. Nevertheless, we can recommend the usage of this software in a clinical setting.

Lumbar Disc Replacement Versus Interbody Fusion: Meta-analysis of Complications and Clinical Outcomes.

Background: Lumbar spinal fusion is a commonly performed operation with relatively high complication and revision surgery rates. Lumbar disc replacement is less commonly performed but may have some benefits over spinal fusion. This meta-analysis aims to compare the outcomes of lumbar disc replacement (LDR) versus interbody fusion (IBF), assessing their comparative safety and effectiveness in treating lumbar DDD. Methods: PubMed, Cochrane, and Google Scholar (pages 1-2) were searched up until February 2024. The studied outcomes included operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), complications, reoperations, Oswestry Disability Index (ODI), back pain, and leg pain. Results: Ten studies were included in this meta-analysis, of which six were randomized controlled trials, three were retrospective studies, and one was a prospective study. A total of 1720 patients were included, with 1034 undergoing LDR and 686 undergoing IBF. No statistically significant differences were observed in OR time, EBL, or LOS between the LDR and IBF groups. The analysis also showed no significant differences in the rates of complications, reoperations, and leg pain between the two groups. However, the LDR group demonstrated a statistically significant reduction in mean back pain (p=0.04) compared to the IBF group. Conclusion: Both LDR and IBF procedures offer similar results in managing CLBP, considering OR time, EBL, LOS, complication rates, reoperations, and leg pain, with slight superiority of back pain improvement in LDR. This study supports the use of both procedures in managing degenerative spinal disease.

Impact of Sacroiliac Belt Utilization on Balance in Patients with Low Back Pain.

Background: Low back pain (LBP) is a common problem which can affect balance and, in turn, increase fall risk. The aim of this investigation was to evaluate the impact of a Sacroiliac Belt (SB) on balance and stability in patients with LBP. Methods: Subjects with LBP and without LBP ("Asymptomatic") were enrolled. Baseline balance was assessed using the Berg Balance Scale. In a counterbalanced crossover design, LBP and Asymptomatic subjects were randomized to one of two groups: 1) start with wearing the SB (Serola Biomechanics, Inc.) followed by not wearing the SB or 2) start without wearing the SB followed by wearing the SB. For subjects in both groups, dynamic balance was then assessed using the Star Excursion Balance Test (SEBT) with each leg planted. Results: Baseline balance was worse in LBP subjects (Berg 51/56) than Asymptomatic subjects (Berg 56/56) (p<0.01). SB significantly improved SEBT performance in LBP subjects regardless of which leg was planted (p<0.01). SB positively impacted Asymptomatic subjects' SEBT performance with the left leg planted (p=0.0002). Conclusion: The Serola Sacroiliac Belt positively impacted dynamic balance for subjects with low back pain. Further research is needed to examine additional interventions and outcomes related to balance in patients with back pain, and to elucidate the mechanisms behind improvements in balance related to sacroiliac belt utilization.

Laminoplasty Versus Laminectomy and Posterior Fusion for Cervical Myelopathy: A Meta-analysis of Radiographic and Clinical Outcomes.

STUDY DESIGN: Meta-analysis. OBJECTIVE: This meta-analysis investigates the outcomes of laminoplasty (LP) and laminectomy with fusion (LF) to guide effective patient selection for these two procedures. BACKGROUND: While LF traditionally offers the ability for excellent posterior decompression, it may alter cervical spine biomechanics and increase the risk of adjacent segment degeneration. LP aims to preserve the natural kinematics of the spine but has not been universally accepted, and may be associated with inadequate decompression, neck pain, and recurrent stenosis. METHODS: PubMed, Cochrane, and Google Scholar (Pages 1-20) were searched up until March 2024. The outcomes studied were surgery-related outcomes (operating room (OR) time, estimated blood loss (EBL), and length of stay (LOS)), adverse events (overall complications, C5 palsy, and reoperations), radiographic outcomes (cervical lordosis (CL), cervical sagittal vertical axis (cSVA), and T1 slope angle (T1SA)), and patient-reported outcome measures (PROMs) (Neck Disability Index (NDI), Visual Analog Scale (VAS) for neck pain, and Japanese Orthopaedic Association (JOA)). RESULTS: Twenty-two studies were included in this meta-analysis, of which 19 were retrospective studies, two were prospective non-randomized studies, and one was a randomized controlled trial. A total of 2,128 patients were included, with 1,025 undergoing LP and 1,103 undergoing LF. LP patients experienced significantly shorter OR time (P=0.009), less EBL (P=0.02), a lower rate of overall complications (P<0.00001) and C5 palsy (P=0.003), a lower T1SA (P=0.02), and a lower NDI (P=0.0004). No significant difference was observed in the remaining outcomes. CONCLUSION: This meta-analysis demonstrates that for cervical myelopathy, LP has the benefits of shorter OR time, less EBL, and reduced incidence of C5 palsy as well as overall complication rate. Given these findings, LP remains an important surgical option with a favorable complication profile in patients with cervical myelopathy, although careful patient selection is still paramount in choosing the right procedure for individual patients.

Segmental Sagittal Alignment in Lumbar Spinal Fusion: A Review of Evidence-Based Evaluation of Preoperative Measurement, Surgical Planning, Intraoperative Execution, and Postoperative Evaluation.

BACKGROUND AND OBJECTIVES: Maintaining and restoring global and regional sagittal alignment is a well-established priority that improves patient outcomes in patients with adult spinal deformity. However, the benefit of restoring segmental (level-by-level) alignment in lumbar fusion for degenerative conditions is not widely agreed on. The purpose of this review was to summarize intraoperative techniques to achieve segmental fixation and the impact of segmental lordosis on patient-reported and surgical outcomes. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, Cochrane, and Web of Science databases were queried for the literature reporting lumbar alignment for degenerative lumbar spinal pathology. Reports were assessed for data regarding the impact of intraoperative surgical factors on postoperative segmental sagittal alignment and patient-reported outcome measures. Included studies were further categorized into groups related to patient positioning, fusion and fixation, and interbody device (technique, material, angle, and augmentation). RESULTS: A total of 885 studies were screened, of which 43 met inclusion criteria examining segmental rather than regional or global alignment. Of these, 3 examined patient positioning, 8 examined fusion and fixation, 3 examined case parameters, 26 examined or compared different interbody fusion techniques, 5 examined postoperative patient-reported outcomes, and 3 examined the occurrence of adjacent segment disease. The data support a link between segmental alignment and patient positioning, surgical technique, and adjacent segment disease but have insufficient evidence to support a relationship with patient-reported outcomes, cage subsidence, or pseudoarthrosis. CONCLUSION: This review explores segmental correction's impact on short-segment lumbar fusion outcomes, finding the extent of correction to depend on patient positioning and choice of interbody cage. Notably, inadequate restoration of lumbar lordosis is associated with adjacent segment degeneration. Nevertheless, conclusive evidence linking segmental alignment to patient-reported outcomes, cage subsidence, or pseudoarthrosis remains limited, underscoring the need for future research.

Gabapentinoid prescriptions for neuropathic and musculoskeletal pain in Lebanon.

Aim: The purpose of this study is to analyze the different characteristics of gabapentinoids prescription by Lebanese orthopedics surgeons. Methods: This is an observational, cross-sectional study using a survey which was carried out in collaboration with the Lebanese Orthopedic Society over a 3-month period. Results: Forty-two orthopedic surgeons responded, most of them prescribing gabapentinoids in their daily practice with only half of the patients feeling relief after taking them. Furthermore, most of the surgeons prescribed these drugs for patients above 18 years old and for both acute and chronic pain. Conclusion: Even though almost half of the patients do not experience relief after taking gabapentinoids, these drugs are becoming more and more prescribed.

With pain being a major concern in orthopedic surgery, a lot of surgeons prescribe drugs before surgical procedures for their patients. One of these drugs categories include Gabapentinoids. This class of medications was shown to be prescribed more and more by orthopedic surgeons despite it not granting successful pain relief for half of the patients and not being US FDA approved.

The Efficacy of Bone Wax in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

Objectives: This meta-analysis was conducted to study the hemostatic efficacy of bone wax in total joint arthroplasty (TJA) defined in this manuscript as total knee arthroplasty and total hip arthroplasty. Methods: PubMed, Embase, Google Scholar (page 1-20), and Scopus were searched updated to November 2023. Only comparative studies were included. The clinical outcomes evaluated were the transfusion rate, total blood loss, and the loss of hemoglobin on day 1, 3, and 5 post-operatively. Results: Only 3 studies met the inclusion criteria and were included in this meta-analysis. Bone wax was associated with a reduced transfusion rate (p=0.01), reduced total blood loss (p=0.001), and a decrease in hemoglobin loss on day 1 (p<0.00001), day 3 (p<0.0001), and day 5 (p<0.00001) after the surgery. Conclusion: Bone wax reduced the rate of transfusion, total blood loss, and hemoglobin loss after the surgery. This may induce a reduction the cost of correcting post-operative anemia as well as decrease hospital stay and improving functional outcomes in patients undergoing TJA. Better-conducted randomized controlled studies and cost-effectivity studies could strengthen these findings.

Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes.

PURPOSE: With variable and conflicting results to date, it remains unclear whether the percutaneous or open surgical A1 pulley release technique is superior regarding safety and efficacy. The goal of this meta-analysis was to compare the two techniques. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2023. Eight randomized controlled trials met the inclusion criteria and were included in this meta-analysis. RESULTS: Of the eight included studies and 548 total patients, there were 278 subjects in the percutaneous release group and 270 subjects in the open release group. There was no significant difference between the two surgical techniques in postoperative rates of revision, complications, or pain. CONCLUSIONS: This meta-analysis found no significant difference between open and percutaneous techniques regarding the need for revision procedures, complications, or postoperative pain. Therefore, both open and percutaneous releases are appropriate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Dual Versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis.

BACKGROUND: The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss. RESULTS: Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25-0.99, P = 0.05). Furthermore, operative room time (mean differences = -82.73; 95% CI: -111.42 to -54.03, P < 0.001) and LOS (mean differences = -0.91; 95% CI: -1.12 to -0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes. CONCLUSIONS: The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.

Sleep disturbances in rotator cuff pathology: insights into mechanisms and clinical implications.

Rotator cuff disease is highly prevalent and can have a detrimental effect on the quality of life of affected patients. One of the most common complaints from rotator cuff disease is sleep disturbance due to shoulder pain. Numerous studies have attempted to explore the relationship between rotator cuff disease and sleep disturbance, but results are inconsistent and limited. In this setting, the Pittsburgh Sleep Quality Index (PSQI) plays an important role in preoperative assessment and evaluation of sleep in rotator cuff patients. However, despite the current efforts, the literature presents conflicting results regarding the relationships between magnetic resonance imaging characteristics of rotator cuff tear and PSQI score, signifying a gap in understanding. That being said, it has been shown that rotator cuff repair surgery can alleviate sleep disturbances witnessed preoperatively in and can restore quality of life.

Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics.

Overhead athletes undergo significant biomechanical adaptations due to repetitive overhead movements, primarily affecting the glenohumeral joint. These adaptations can lead to glenohumeral internal rotation deficit (GIRD), which is characterized by posterior capsule stiffness that results in glenohumeral joint translation and a shift in the center of gravity. The severity of GIRD is dependent upon the presence of asymmetry between gained external and lost internal rotation, which is defined clinically as an asymmetry exceeding 20º; this reduces the total range of motion compared to the unaffected limb or baseline measurements. Diagnosis is challenging, as it can be mistaken for chronic scapular adaptations. To mitigate misdiagnosis, a high clinical suspicion is crucial in overhead athletes, especially those who began performing forceful overhead movements before closure of growth plates. Periodic physical examinations should establish baseline values for glenohumeral rotation and track changes in glenohumeral motion to aid in diagnosis. Symptoms of GIRD include shoulder pain, stiffness, and decreased force exertion. Magnetic resonance imaging is the preferred imaging method for evaluating GIRD and assessing concomitant soft tissue pathologies. Untreated GIRD can lead to rotator cuff strength imbalances. Treatment mainly involves conservative measures, such as physical therapy, to improve internal rotation and alleviate posterior tightness. Surgical interventions are considered when symptoms persist despite conservative treatment with physical therapy or in the presence of concomitant pathologies.

Implant density in adolescent idiopathic scoliosis: a meta-analysis of clinical and radiological outcomes.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) affects 1-3% of adolescents, and treatment approaches, including the density of constructs in surgical fusion, vary among orthopedic surgeons. Studies have sought to establish whether high-density or low-density constructs offer superior clinical and radiological outcomes, yet conclusive results are lacking. This meta-analysis aims to provide a definitive answer to the controversial and ambiguous question surrounding the efficacy of different pedicle screw densities in treating AIS. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. The studied outcomes were Major Cobb angle, major curve correction, lumbar curve, kyphosis (T5-T12), lumbar lordosis, coronal balance, LIV Tilt angle, TAV translation, LAV translation, apical trunk rotation, trunk shift, SRS-22, operative time, blood loss, complications and cost. RESULTS: Twenty-four studies (total of 1985 patients, 1045 in LD group and 940 in HD group) were included in this meta-analysis. A statistically significant better improvement in ATR (p = 0.02) and LIV tilt angle (p = 0.02) was seen in the high-density group. On the other hand, longer operative time (p = 0.002), blood loss (p = 0.0004) and costs (p = 0.02) were seen in the high-density group. No difference was seen in the remaining radiographic and clinical outcomes between both surgeries. CONCLUSION: Both low-density (LD) and high-density (HD) screw constructs show comparable and satisfactory radiographic and QOL for AIS patients. Furthermore, HD constructs had increased costs, operative time, and blood loss associated. However, a definitive conclusion cannot be made and more studies taking into account multiple additional variables are necessary to do so.

Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment.

Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent post-surgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.

Pulsed lavage in joint arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Knee and hip osteoarthritis affects millions of people around the world and is expected to rise even more in frequency as the population ages. Joint arthroplasty is the surgical management of choice in these articulations. Heterotopic ossification and radiolucent lines formation are two frequent problems faced in hip and knee replacements respectively. Some studies show that the usage of pulsed lavage may prevent their formation. AIM: To compare pulsed lavage to standard lavage in joint arthroplasty. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. Only comparative studies were included. The clinical outcomes evaluated were the heterotopic ossification formation in hip replacements, radiolucent lines formation, and functional knee scores in knee replacements. RESULTS: Four studies met the inclusion criteria and were included in this meta-analysis. Pulsed lavage was shown to reduce the formation of radiolucent lines (P = 0.001). However, no difference was seen in the remaining outcomes. CONCLUSION: Pulsed lavage reduced the formation of radiolucent lines in knee replacements. No difference was seen in the remaining outcomes. Furthermore, the clinical significance of these radiolucent lines is poorly understood. Better conducted randomized controlled studies and cost-effectivity studies are needed to reinforce these findings.

Intensive Care Unit Admission After Spine Surgery: A Narrative Review.

INTRODUCTION: Intensive care unit (ICU) admissions constitute a substantial financial challenge for health care systems and patients and are linked to various potentially life-altering complications. A wide range of patient-related, surgical, and medical factors are associated with an increased risk of ICU admission following spine surgery. DISCUSSION: The most notable examples include lung, heart, and kidney disease, as well as estimated blood loss and length of surgery. Various scores that include the most significant patient- and procedure-related factors have been described to assess the risk associated with surgery for individual patients. To date, the fusion risk score and the American Society of Anesthesiologists score have been the most useful in predicting postoperative complications and admission to the ICU. However, other risk factors have also been implicated in ICU admission and length of stay. The current scores must further adapt by using the available evidence to fulfill their intended purpose. Moreover, a handful of measures have shown efficacy in decreasing ICU admission and length of stay, with their benefits still to be demonstrated by future research. CONCLUSION: This review underscores the risk factors predictive of ICU admission following spine surgery and will help surgeons and clinicians in patient stratification. However, future studies are needed to validate the role of protective measures in preventing ICU admissions and the significance of certain risk factors.

Preoperative Resilience and Improvement in Patient-Reported Outcomes After Lumbar Spinal Fusion.

BACKGROUND: It is incompletely understood how preoperative resilience affects 1-year postoperative outcomes after lumbar spinal fusion. METHODS: Patients undergoing open lumbar spinal fusion at a single-center institution were identified between November 2019 and September 2022. Preoperative resilience was assessed using the Brief Resilience Scale. Demographic data at baseline including age, gender, comorbidities, and body mass index (BMI) were extracted. Patient-reported outcome measures including Oswestry Disability Index, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Physical Health, PROMIS Global Mental Health (GMH), and EuroQol5 scores were collected before the surgery and at 3 months and 1 year postoperatively. Bivariate correlation was conducted between Brief Resilience Scale scores and outcome measures at 3 months and 1 year postoperatively. RESULTS: Ninety-three patients had baseline and 1 year outcome data. Compared with patients with high resilience, patients in the low-resilience group had a higher percentage of females (69.4% vs. 43.9%; P = 0.02), a higher BMI (32.7 vs. 30.1; P = 0.03), and lower preoperative Global Physical Health (35.8 vs. 38.9; P = 0.045), GMH (42.2 vs. 49.2; P < 0.001), and EuroQol scores (0.56 vs. 0.61; P = 0.01). At 3 months postoperatively, resilience was moderately correlated with GMH (r = 0.39) and EuroQol (r = 0.32). Similarly, at 1 year postoperatively, resilience was moderately correlated with GMH (r = 0.33) and EuroQol (r = 0.34). Comparable results were seen in multivariable regression analysis controlling for age, gender, number of levels fused, BMI, Charlson Comorbidity Index, procedure, anxiety/depression, and complications. CONCLUSIONS: Low preoperative resilience can negatively affect patient-reported outcomes 1 year after lumbar spinal fusion. Resiliency is a potentially modifiable risk factor, and surgeons should consider targeted interventions for at-risk patient groups.