Patterns of Misdiagnosis and Discordance in Detecting Osteoporosis: A Comparison of Dual-energy X-ray Absorptiometry and Lumbar Computed Tomography Hounsfield Units.

STUDY DESIGN: This was a retrospective chart review. OBJECTIVE: This study aims to identify the prevalence of osteoporosis (OP) by lumbar computed tomography (CT) Hounsfield units (HUs) in patients who have normal or osteopenic bone determined by dual-energy x-ray absorptiometry (DEXA). SUMMARY OF BACKGROUND DATA: OP is a critical issue in the postmenopausal and aging population. Bone mineral density assessment by DEXA has been described as insensitive for diagnosing OP in the lumbar spine. Improving the detection of OP can bring more patients to treatment and reduce the risks associated with low bone mineral density. PATIENTS AND METHODS: We retrospectively reviewed all patients with DEXA scans and noncontrast CTs of the lumbar spine over a 15-year period. Patients were diagnosed as non-OP if they had a normal DEXA T -score (≥ -1) or osteopenic DEXA T -score (between -1.1 and -2.4). Patients in this cohort were considered osteoporotic by CT if L1-HU ≤110. Demographics and lumbar HUs were compared between these stratified groups. RESULTS: A total of 74 patients were included for analysis. All patients were demographically, similar, and the average patient age was 70 years. The prevalence of OP determined by CT L1-HU ≤110 was 46% (normal DEXA: 9%, osteopenic DEXA: 63%). A significant number of males in our study were considered osteoporotic by L1-HU ≤110 (74%, P = 0.03). All individual axial and sagittal lumbar HU measurements including L1-L5 average lumbar HUs were statistically significant among non-OP and OP groups except for the lower lumbar levels ( P > 0.05 for L4 axial HUs, and L4-L5 sagittal HUs). CONCLUSIONS: The prevalence of OP in patients with normal or osteopenic T -scores is high. Among those with osteopenia by DEXA, more than 50% may lack appropriate medical treatment. The DEXA scan may be particularly insensitive to male bone quality making the CT HU the diagnostic method of choice for detecting OP. LEVEL OF EVIDENCE: Level III.

Patient Perspectives on Artificial Intelligence in Healthcare Decision Making: A Multi-Center Comparative Study.

Objective: Investigate the patient opinion on the use of Artificial Intelligence (AI) in Orthopaedics. Methods: 397 orthopaedic patients from a large urban academic center and a rural health system completed a 37-component survey querying patient demographics and perspectives on clinical scenarios involving AI. An average comfort score was calculated from thirteen Likert-scale questions (1, not comfortable; 10, very comfortable). Secondary outcomes requested a binary opinion on whether it is acceptable for patient healthcare data to be used to create AI (yes/no) and the impact of AI on: orthopaedic care (positive/negative); healthcare cost (increase/decrease); and their decision to refuse healthcare if cost increased (yes/no). Bivariate and multivariable analyses were employed to identify characteristics that impacted patient perspectives. Results: The average comfort score across the population was 6.4, with significant bivariate differences between age (p = 0.0086), gender (p = 0.0001), education (p = 0.0029), experience with AI/ML (p < 0.0001), survey format (p < 0.0001), and four binary outcomes (p < 0.05). When controlling for age and education, multivariable regression identified significant relationships between comfort score and experience with AI/ML (p = 0.0018) and each of the four binary outcomes (p < 0.05). In the final multivariable model gender, survey format, perceived impact of AI on orthopaedic care, and the decision to refuse care if it were to increase cost remained significantly associated with the average AI comfort score (p < 0.05). Additionally, patients were not comfortable undergoing surgery entirely by a robot with distant physician supervision compared to close supervision. Conclusion: The orthopaedic patient appears comfortable with AI joining the care team.

Physician Perspectives on Telemedicine at an Integrated Health System During the COVID-19 Pandemic.

Introduction: The use of telemedicine (TM) for patient care greatly increased during the COVID pandemic. This study presents data from a single health system regarding physician's perspectives on TM, which could ultimately determine how it is used in the future. Methods: A questionnaire was distributed to physicians throughout the health system. Physicians were divided based on the standard level of patient interaction in each specialty, as well as practice locations and years in practice. Physician perspectives were categorized by their opinions on different aspects of telehealth visits. Results: Of 1,794 physicians, 379 (20.7%) responded to the survey. Psychiatrists used TM significantly more than other groups and project the most future use. Surgeons were least likely to incorporate TM in the future. Ability to perform a physical examination via TM differed significantly by specialty and practice environment, but not by years in practice. Frequency of being able to complete a treatment plan via TM differed significantly by specialty, but not by years in practice or practice environment. Overall, 76.3% of physicians reported feeling "satisfied" with performing TM visits. Satisfaction with TM varied significantly by specialty and practice environment, but not by years in practice. There were no significant differences regarding physician expectations on reimbursement or billing for TM visits based on specialty, age, or practice environment. Conclusions: Discrepancies exist among physicians with respect to their satisfaction and expected future use of TM. Consensus may be difficult to reach regarding reimbursement for these visits, and further work is needed to clarify the optimal practice setting for TM.

The Impact of Global Spinal Alignment on Standing Spinopelvic Alignment Change After Total Hip Arthroplasty.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The interactions between hip osteoarthritis (OA) and spinal malalignment are poorly understood. The purpose of this study was to assess the influence of total hip arthroplasty (THA) on standing spinopelvic alignment. METHODS: In this retrospective cohort study, patients undergoing THA for OA with pre-and postoperative full-body radiographs were included. Standing spinopelvic parameters were measured. Contralateral hip was graded on the Kellgren-Lawrence scale. Pre-and postoperative alignment parameters were compared by paired t-test. The severity of preoperative thoracolumbar deformity was measured using TPA. Linear regression was performed to assess the impact of preoperative TPA and changes in spinal alignment. Patients were separated into low and high TPA (<20 or >/=20 deg) and change in parameters were compared between groups by t-test. Similarly, the influence of K-L grade, age, and PI were also tested. RESULTS: 95 patients were included (mean age 58.6 yrs, BMI 28.7 kg/m2, 48.2% F). Follow-up radiographs were performed at mean 220 days. Overall, the following significant changes were found from pre-to postoperative: SPT (14.2 vs. 16.1, P = 0.021), CL (-8.9 vs. -5.3, P = .001), TS-CL (18.2 vs. 20.5, P = .037) and SVA (42.6 vs. 32.1, P = .004). Preoperative TPA was significantly associated with the change in PI-LL, SVA, and TPA. High TPA patients significantly decreased SVA more than low TPA patients. There was no significant impact of contralateral hip OA, PI, or age on change in alignment parameters. CONCLUSION: Spinopelvic alignment changes after THA, evident by a reduction in SVA. Preoperative spinal sagittal deformity impacts this change. Level of evidence: III.

Patient physiology influences the MRI-based vertebral bone quality score.

BACKGROUND CONTEXT: Osteoporosis is a critical issue affecting postmenopausal women and the aging population. A novel magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score has been proposed as a method to identify poor bone quality and predict fragility fractures. The diagnostic accuracy of this tool is not well understood. PURPOSE: To examine the ability of VBQ to predict osteoporosis and osteopenia, its correlation with dual-energy x-ray absorptiometry (DEXA), and the influence of patient-specific factors upon the score. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Patients over the age of 18 with a DEXA scan and noncontrast, T1-weighted MRI of the lumbar spine completed within a 2-year period. OUTCOME MEASURES: Area-under-curve (AUC) values of the VBQ score predicting osteopenia and osteoporosis when controlling for patient characteristics. METHODS: Patients with noncontrast, T1-weighted MRIs of the lumbar spine and DEXA scans completed within a 2-year time frame were retrospectively reviewed. Patient demographics and medical risk factors for osteoporosis were identified and compared. VBQ scores were measured by two trained researchers and interrater reliability was calculated. Patients were separated into three groups defined by lowest DEXA T-score: Healthy Bone, Osteopenia, and Osteoporosis. analysis of variance, Kruskal-Wallis test, chi-square, t tests, Mann-Whitney U tests, and multivariate linear regression were performed to examine the relationship between patient characteristics, DEXA t-scores, and VBQ scores. Receiver operating characteristic analysis and AUC values were generated for the prediction of osteopenia and osteoporosis. RESULTS: A total of 156 patients were included for analysis. Sufficient inter-rater reliability was determined for VBQ measures (intraclass correlation coefficient: 0.81). Most patients were female (83%), postmenopausal (81%), and had hyperlipidemia (64%). Patients with hyperlipidemia and healthy bone density by DEXA had elevated baseline VBQ scores (p<.001) reflective of values seen in osteopenia and osteoporosis. The AUC of the VBQ score predicting osteopenia and osteoporosis changed to be more concordant with DEXA results after controlling for hyperlipidemia (AUC=0.72, 0.70 vs. AUC=0.88, 0.89; p<.001). Sub-analysis of hyperlipidemia subtypes revealed that elevated high-density lipoprotein is associated with elevated VBQ scores. CONCLUSIONS: Hyperlipidemia increased the MRI-based VBQ score in our healthy bone population. The high signal intensities resembled values seen in osteopenia and osteoporosis, suggesting that physiologic variables which impact bone composition may influence the VBQ score. Specifically, elevated high-density lipoprotein may contribute to this. The microarchitectural changes and the clinical implications of these factors need further exploration.

The effect of low preoperative platelet count on adverse outcomes following lumbar microdiscectomy.

Background: Low preoperative platelet count, or thrombocytopenia, has previously been associated with increased complications in elective spine surgeries. No other study has investigated the effects of abnormal coagulation profiles on postoperative outcomes specific to lumbar microdiscectomy (MLD) using a propensity matched cohort. Methods: Patient data was retrospectively retrieved from the National Surgical Quality Improvement Program database using Current Procedural Terminology (CPT) code 63030 to isolate patients who solely underwent MLD. Data was collected from 2010 to 2019 and included preoperative, perioperative, and 30-day postoperative variables. Patients were grouped into four platelet categories for ANOVA analysis and pairwise comparisons: Severe Thrombocytopenia (≤100), Thrombocytopenia (101-150), Moderate (151-199), and Normal (200-450). Variables that were significant in the univariate analysis were used in the multivariate analysis to determine the likelihood of experiencing adverse postoperative events - unplanned return to the operating room and surgical site infection. A propensity matched analysis was performed to control for confounding variables. Results: A total of 64,747 patients were identified within the 10-year period. The results of the multivariate analysis and the propensity matched analysis showed no significant differences in low preoperative platelet count as an independent predictor of experiencing a return to the operating room or surgical site infection. Furthermore, patients who had diabetes, history of smoking, or had emergency cases were associated with a high likelihood of experiencing these negative adverse events. Conclusion: Thrombocytopenia does not appear to independently predict return to the operating room or postoperative infection following MLD. Proper preoperative management strategies should be implemented to monitor comorbidity burden which would otherwise influence adverse outcomes in patients with thrombocytopenia undergoing MLD.

Readability of Online Spine Patient Education Resources.

OBJECTIVE: We assessed the readability of spine-related patient education materials on professional society websites to determine whether this had improved since last studied. We also compared the readability of these materials to a more patient-centered source, such as WebMD. METHODS: Patient education pages from the American Association of Neurologic Surgeons (AANS), North American Spine Society (NASS), and spine-related pages from the American Academy of Orthopaedic Surgeons (AAOS), and WebMD were reviewed. Readability was evaluated using the Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas. The mean FKGL and FRE scores of the societies were compared using one-way analysis of variance. The rate of a reading level at or below an eighth grade level was compared using the χ2 test. RESULTS: We analyzed a total of 156 sites. The mean FKGL score for the professional society sites was 11.4. The mean FRE score for the professional societies was 45.8, with 14.4% written at or below an eighth grade reading level. We found a significant difference in the FKGL scores and materials at or below the eighth grade level between the AAOS and AANS and AAOS and NASS. The mean FKGL and FRE scores for WebMD were 7.57 and 68.1, respectively, with a significant difference compared with the scores for the AAOS, NASS, and AANS. In addition, 80% of the WebMD materials had been written at or below the eighth grade reading level. A significant difference compared with the AANS and NASS (P < 0.0001) but not for the AAOS (P = 0.059). CONCLUSIONS: The average readability of spine-related topics exceeded the eighth grade reading level. The AAOS resources had better readability compared with the NASS and AANS. We found no improvement in readability since last studied. The readability of professional societies' materials was significantly worse than those from WebMD.

The State of Machine Learning in Spine Surgery: A Systematic Review.

STUDY DESIGN: This was a systematic review of existing literature. OBJECTIVE: The objective of this study was to evaluate the current state-of-the-art trends and utilization of machine learning in the field of spine surgery. SUMMARY OF BACKGROUND DATA: The past decade has seen a rise in the clinical use of machine learning in many fields including diagnostic radiology and oncology. While studies have been performed that specifically pertain to spinal surgery, there have been relatively few aggregate reviews of the existing scientific literature as applied to clinical spine surgery. METHODS: This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to review the scientific literature from 2009 to 2019 with syntax specific for machine learning and spine surgery applications. Specific data was extracted from the available literature including algorithm application, algorithms tested, database type and size, algorithm training method, and outcome of interest. RESULTS: A total of 44 studies met inclusion criteria, of which the majority were level III evidence. Studies were grouped into 4 general types: diagnostic tools, clinical outcome prediction, surgical assessment tools, and decision support tools. Across studies, a wide swath of algorithms were used, which were trained across multiple disparate databases. There were no studies identified that assessed the ethical implementation or patient perceptions of machine learning in clinical care. CONCLUSIONS: The results reveal the broad range of clinical applications and methods used to create machine learning algorithms for use in the field of spine surgery. Notable disparities exist in algorithm choice, database characteristics, and training methods. Ongoing research is needed to make machine learning operational on a large scale.

Lumbar Spine Fusion and Symptoms of Leg Length Discrepancy After Hip Arthroplasty.

BACKGROUND: Hip length discrepancy (HLD) is common after total hip arthroplasty (THA); however, the effect of spinal fusion on perceived leg length discrepancy (LLD) symptoms after THA has not been examined. This study tested the hypothesis that LLD symptoms are increased in patients who underwent lumbar spinal fusion and THA, compared with patients with THA only. METHODS: This retrospective cohort study included 67 patients who underwent lumbar spinal fusion and THA, along with 78 matched control patients who underwent THA only. Hip and spine measurements were taken on postoperative, standing anterior-posterior pelvic, lateral lumbar, and anterior-posterior lumbar spinal radiographs. Perceived LLD symptoms were assessed via telephone survey. RESULTS: Between the spinal fusion and control groups, there was no significant difference in HLD (M = 7.10 mm, SE = 0.70 and M = 5.60 mm, SE = 0.49) (P = .403). The spinal fusion patients reported more frequently noticing a difference in the length of their legs than the control group (P = .046) and reported limping "all the time" compared with the control group (P = .001). Among all patients with an HLD ≤10 mm, those in the spinal fusion group reported limping at a higher frequency than patients in the control group (P = .008). Patients in the spinal fusion group were also more likely to report worsened back pain after THA (P = .011) than the control group. CONCLUSION: Frequencies of a perceived LLD, limping, and worsened back pain after THA were increased in patients with THA and a spinal fusion compared with patients who had THA only, even in a population with HLD traditionally considered to be subclinical. The results indicate that in patients with prior spinal fusion, precautions should be taken to avoid even minor LLD in the setting of THA.

Utility of Upright Weight-bearing Imaging in Total Hip Arthroplasty.

Planning for total hip arthroplasty (THA) has traditionally been performed using static supine anteroposterior radiographs of the pelvis. Recent advances in imaging technology and the understanding of human spinopelvic kinematics have made weight-bearing radiography an important adjunct to supine imaging. Hip surgeons can use weight-bearing imaging to optimize THA component position to prevent hip instability and early component wear. The goal of this narrative review is to delineate the fundamentals of spinopelvic kinematics, the benefits of surgical planning using weight-bearing radiography, and the underpinnings of upright full-body stereoradiography as a useful adjunct to traditional supine radiographs.

Current trends in ambulatory spine surgery: a systematic review.

Spine surgery continues to move into the ambulatory setting in an effort to pair high-quality care delivery with low-cost facilities. The purpose of this review was to assess the current literature for trends in the practice of ambulatory spine surgery. A systematic review of the English language literature from the past five years was performed utilizing PRISMA standards. The results demonstrate that current focus of research emphasizes the safety of ambulatory surgery-with several studies commenting on complication rates, patient selection, and postoperative protocols to prevent readmissions or complications. Research is also focused on quality of care, and ensuring non-inferiority of ambulatory surgery when compared with traditional inpatient hospitalizations. Importantly, no level I or II literature has been published on the topic in the past five years, suggesting a renewed need for high quality prospective studies.

Measuring ambulation with wrist-based and hip-based activity trackers for children with cerebral palsy.

AIM: To assess the accuracy of consumer available wrist-based and hip-based activity trackers in quantitatively measuring ambulation in children with cerebral palsy (CP). METHOD: Thirty-nine children (23 males, 16 females; mean age [SD] 9y 7mo [3y 5mo]; range 4-15y) with CP were fitted with trackers both on their wrist and hip. Each participant stood for 3 minutes, ambulated in a hallway, and sat for 3 minutes. The number of steps and distance were recorded on trackers and compared to manually counted steps and distance. Pearson correlation coefficients were determined for the number of steps during ambulation from each tracker and a manual count. Mean absolute error (MAE) and range of errors were calculated for steps during ambulation for each tracker and a manual count and for distance for each tracker and hallway distance. RESULTS: For the number of steps, a weak inverse relationship (r=-0.033) was found for the wrist-based tracker and a strong positive relationship (r=0.991) for the hip-based tracker. The MAE was 88 steps for the wrist-based and seven steps for the hip-based tracker. The MAE for distance was 0.06 miles for the wrist-based and 0.07 miles for the hip-based tracker. INTERPRETATION: Only the hip-based tracker provided an accurate step count; neither tracker was accurate for distance. Thus, ambulation of children with CP can be accurately quantified with readily available trackers. WHAT THIS PAPER ADDS: Consumer available activity trackers accurately measure ambulation in children with cerebral palsy (CP). The hip-based tracker is more accurate than the wrist-based tracker for children with CP. The hip-based Fitbit activity tracker accurately measures step counts of children with CP during ambulation.

MEDICIÓN DE LA AMBULACIÓN CON RASTREADORES DE ACTIVIDAD DE MUÑECA Y CADERA PARA NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Evaluar la precisión de los rastreadores de actividad basados ​​en la muñeca y en la cadera disponibles para el consumidor en la medición cuantitativa de la ambulación en niños con parálisis cerebral (PC) METODO: Treinta y nueve niños (23 varones, 16 mujeres; edad media [DS] 9 años y 7 meses [3 años y 5 meses]; rango 4-15 años) con PC fueron equipados con rastreadores en su muñeca y cadera. Cada participante se paró durante 3 minutos, caminó por un pasillo y se sentó durante 3 minutos. La cantidad de pasos y la distancia se registraron en los rastreadores y se compararon con los pasos y la distancia contados manualmente. Los coeficientes de correlación de Pearson se determinaron para el número de pasos durante la ambulación de cada rastreador y un conteo manual. El error absoluto medio (MAE) y el rango de errores se calcularon para los pasos durante la ambulación y la distancia del pasillo para cada rastreador y para el conteo manual. RESULTADOS: Para el número de pasos, se encontró una relación inversa débil (r = -0.033) para el rastreador ubicado en la muñeca y una relación positiva fuerte (r = 0.991) para el rastreador ubicado en la cadera. El MAE fue de 88 pasos para la muñeca y siete pasos para el rastreador de la cadera. El MAE para la distancia fue de 0.06 millas para la muñeca y 0.07 millas para el rastreador ubicado en la cadera. INTERPRETACIÓN: Solo el rastreador ubicado en la cadera proporcionó un conteo de pasos preciso; ninguno de los rastreadores era preciso para la distancia. Por lo tanto, la deambulación de los niños con PC se puede cuantificar con precisión con rastreadores fácilmente disponibles.

MEDINDO A DEAMBULAÇÃO COM RASTREADOR DE ATIVIDADE POSICIONADO NO PUNHO E QUADRIL COMERCIALMENTE DISPONÍVEL EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Avaliar a precisão de rastreadores de atividade posicionados no punho e quadril, disponíveis para o consumidor, para mensurar qualitativamente a deambulação em crianças com paralisia cerebral (PC). MÉTODO: Trinta e nove crianças (23 meninos, 16 meninas; média da idade [DP] 9 anos e 7 meses [3 anos e 5 meses]; amplitude 4-15 anos) com PC foram equipados com rastreadores em punho e quadril. Cada participante permaneceu em pé durante 3 minutos, andando em um corredor, e sentado por 3 minutos. O número de passos e distância foram registrados nos rastreadores e comparados com os passos e distância medidos manualmente. Coeficientes de correlação de Pearson foram determinados para o número de passos durante a deambulação para cada rastreador e a contagem manual. O Erro Médio Absoluto (EMA) e variância de erros foram calculados para os passos durante a deambulação para cada rastreador e a contagem manual e para a distância de cada rastreador e a distância do corredor. RESULTADOS: Para o número de passos, uma relação inversa fraca (r=-0,033) foi encontrada entre o rastreador do punho e uma relação positiva forte (r=0,991) para o reastreador do quadril. A EMA foi de 88 passos para o rastreador do punho e sete passos para o rastreador do quadril. A EMA para a distância foi de 0,06 milhas (9,66km) para o rastreador do punho e 0,07 milhas (11,26km) para o rastreador do quadril. INTERPRETAÇÃO: Somente o rastreador do quadril forneceu a contagem precisa dos passos; nenhum rastreador foi preciso para a distância. Assim, a deambulação em crianças com PC pode ser quantificada com precisão com os rastreadores atualmente disponíveis.

Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013.

INTRODUCTION: This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. METHODS: Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. RESULTS: 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ±â€¯0.43v0.18 ±â€¯0.39,p=0.026). CONCLUSIONS: Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

Impact of presenting patient characteristics on surgical complications and morbidity in early onset scoliosis.

This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients <10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6-9.4], p < 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19-1.37], p < 0.001) and mortality (OR: 2.05 [1.65-2.54], p < 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28-2.29], p < 0.001) and extLOS (OR: 2.83 [2.48-3.22], p < 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes. Level of Evidence: III - Retrospective Prognostic Study.

Decreased rates of 30-day perioperative complications following ASD-corrective surgery: A modified Clavien analysis of 3300 patients from 2010 to 2014.

The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ±â€¯4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1-1.7) and perioperative complication rates (55-29%) decreased, despite increasing surgical invasiveness (2.8-4.5) and increasing frailty score (0.14 ±â€¯0.15 vs 0.16 ±â€¯0.16). Rates of Clavien grade II (39.80-22.20%) and IV (9.40-3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics.

Radiological severity of hip osteoarthritis in patients with adult spinal deformity: the effect on spinopelvic and lower extremity compensatory mechanisms.

PURPOSE: Sagittal spinal deformity (SSD) patients utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. This study examines the effect of hip osteoarthritis (OA) on compensatory mechanisms in SSD patients. METHODS: Patients ≥ 18 years with SSD were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Patients were categorized as limited osteoarthritis (LOA: grade 0-2) and severe osteoarthritis (SOA: grade 3-4). Patients were matched for age and T1-pelvic angle (TPA). Spinopelvic [sagittal vertical axis (SVA), T1-pelvic angle, thoracic kyphosis (TK), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), T1-spinopelvic inclination (T1SPi)] and lower extremity parameters [sacrofemoral angle, knee angle, ankle angle, posterior pelvic shift (P. Shift), global sagittal axis (GSA)] were compared between groups using independent sample t test. RESULTS: 136 patients (LOA = 68, SOA = 68) were included in the study. SOA had less pelvic tilt (p = 0.011), thoracic kyphosis (p = 0.007), and higher SVA and T1Spi (p < 0.001) than LOA. SOA had lower sacrofemoral angle (p < 0.001) and ankle angle (p = 0.043), increased P. Shift (p < 0.001) and increased GSA (p < 0.001) compared to LOA. There were no differences in PI-LL, LL, knee angle, or cervical alignment (p > 0.05). CONCLUSIONS: Patients with coexisting spinal malalignment and SOA compensate by pelvic shift and thoracic hypokyphosis rather than PT, likely as a result of limited hip extension secondary to SOA. As a result, SOA had worse global sagittal alignment than their LOA counterparts. These slides can be retrieved under Electronic Supplementary Material.

Total Hip Arthroplasty in the Spinal Deformity Population: Does Degree of Sagittal Deformity Affect Rates of Safe Zone Placement, Instability, or Revision?

BACKGROUND: Changes in spinal alignment and pelvic tilt alter acetabular orientation in predictable ways, which may have implications on stability of total hip arthroplasty (THA). Patients with sagittal spinal deformity represent a subset of patients who may be at particularly high risk of THA instability because of postural compensation for abnormal spinal alignment. METHODS: Using standing stereoradiography, we evaluated the spinopelvic parameters, acetabular cup anteversion, and inclination of 139 THAs in 107 patients with sagittal spinal deformity. Standing images were compared with supine pelvic radiographs to evaluate dynamic changes in acetabular cup position. Dislocation and revision rates were procured through retrospective chart review. The spinal parameters and acetabular cup positions among dislocators were compared with those who did not dislocate. RESULTS: The rate of THA dislocation in this cohort was 8.0%, with a revision rate of 5.8% for instability. Patients who sustained dislocations had significantly higher spinopelvic tilt, T1-pelvic angle, and mismatch of lumbar lordosis and pelvic incidence. Among all patients, 78% had safe anteversion while supine, which decreased significantly to 58% when standing due to increases in spinopelvic tilt. Among dislocating THA, 80% had safe anteversion, 80% had safe inclination, and 60% had both parameters within the safe zone. CONCLUSION: In this cohort, patients with THA and concomitant spinal deformity have a particularly high rate of THA instability despite having an acetabular cup position traditionally thought of as within acceptable alignment. This dislocation risk may be driven by the degree of spinal deformity and by spinopelvic compensation. Surgeons should anticipate potential instability after hip arthroplasty and adjust their surgical plan accordingly.

Construct Choice for the Treatment of Displaced, Comminuted Olecranon Fractures: are Locked Plates Cost Effective?

BACKGROUND: Cost effective implant selection in orthopedic trauma is essential in the current era of managed healthcare delivery. Both locking and non-locking plates have been utilized in the treatment of displaced fractures of the olecranon. However, locking plates are often more costly and may not provide superior clinical outcomes. The primary aim of the present study is to assess the clinical and functional outcomes of olecranon fractures treated with locked and non-locking plate and screw constructs while providing insight into the cost of various implants. METHODS: We performed a retrospective chart review of a single institution database identifying Mayo IIB type olecranon fractures treated surgically from 2003 to 2012. All fractures were treated with either a locked plate or a one-third tubular hook plate construct. Clinical and radiographic outcomes were evaluated. Minimum 6-month follow-up was required. Outcomes were compared between fixation constructs, including rate of union, early failure, postoperative range of motion, and complication rates. Statistical analysis included Pearson's Chi-squared and Fisher's exact test for categorical variables, and the Student's ttest for continuous variables. RESULTS: The one-third tubular construct was equivalent to locking plate constructs with respect to union, post-operative range of motion, and rates of complications. There were no early or late failures. Locking plates were associated with a relative cost increase of $1,263.50 compared to the one-third tubular hook plate per case. CONCLUSION: Surgeons should consider the cost of implants when treating Mayo IIB olecranon fracture. In this cohort, one-third tubular plates provided equivalent outcomes to locked plates with a notable decrease in cost.

Subspine impingement: 2 case reports of a previously unreported cause of instability in total hip arthroplasty.

BACKGROUND: Instability is a common cause of revision hip arthroplasty and is frequently due to improper component placement and subsequent component impingement. Impingement of the greater trochanter upon the anterior inferior iliac spine (AIIS) has been described as a cause of symptomatic femoroacetabular impingement (FAI), but has never been described as a cause of instability following total hip arthroplasty (THA). CASE REVIEW: We present 2 cases of patients undergoing THA. Each patient was evaluated preoperatively and found to have a prominent AIIS, which was concerning due to it overhanging the anterolateral acetabular lip. Both patients had intraoperative posterior instability of their THA, the cause of which was determined to be impingement of the greater trochanter upon a prominent AIIS. Open resection of the AIIS was performed with subsequent resolution of impingement. LITERATURE REVIEW: AIIS impingement has been reported as a cause of symptomatic FAI. In these case reports, open or arthroscopic resection of the AIIS resulted in resolution of symptoms. Morphologically distinct subtypes of the AIIS have been previously described based upon computed tomography, and some subtypes are associated with a high risk of impingement in the native hip. No previous studies have described this phenomenon in the setting of THA. CLINICAL RELEVANCE: Instability is a common cause of revision THA. Impingement of the greater trochanter upon a prominent AIIS is a previously unreported cause of THA instability which can be addressed with intraoperative resection of the AIIS with good result.