A Comparative Evaluation of Unilateral and Bilateral Sequential Lung Isolation for Vertebral Body Tethering: A Retrospective Propensity Matched Analysis.

BACKGROUND: Vertebral body tethering (VBT) requires a thoracoscopic approach to visualize the vertebral bodies. Lung collapse and re-expansion have the potential to cause acute lung injury, resulting in increased oxygen and ventilation requirements. AIMS: We compared the intraoperative ventilator management, intra- and postoperative blood gas determinations, and hospital stay information between adolescents undergoing unilateral versus bilateral lung isolation for vertebral body tethering. METHODS:  A study cohort of 132 propensity-matched cases (66 unilateral and 66 bilateral) was derived from 351 consecutive VBT cases. Patient demographic information, case information, fluid administration, ventilatory settings data, blood gas parameters, and complete blood count and differential data were entered into a datasheet. Derived parameters included values calculated from the alveolar gas equation to develop an oxygen cascade and measures of inflammatory response. Chi-square was used for categorical data, and independent samples and t-tests were used for continuous data. RESULTS: The double lung isolation group required higher peak inspiratory pressures (SL 29±5 vs. DL 31±5, p=0.026), resulting in higher tidal volume (SL 246±63 vs. DL 334±101, p<0.001) and tidal volume per kg (SL 5.6±1.4 vs. DL 6.9±2, p<0.001) as compared to the single lung group. The double lung group required a higher partial pressure of inspired and alveolar oxygen as well as a higher alveolar to arterial oxygen tension gradient (SL 417±126 vs. DL 485±96, p=0.001) to achieve optimal arterial oxygen tension. Patients with double lung isolation had similar intensive care lengths of stay but a longer hospital stay than single lung isolation patients. CONCLUSION: Patients undergoing double lung isolation required greater ventilatory support and had more evidence of acute lung injury, as evidenced by a higher postoperative alveolar to arterial oxygen gradient; however, these healthy adolescents tolerated the procedure well and only differed in the hospital length of stay by a day.

Predicting academic productivity among American Shoulder and Elbow Surgeons fellowship faculty from publications acquired before and during surgical training.

BACKGROUND: Orthopedic residency and fellowship applicants with a strong research record are highly valued for their potential in continuing academic excellence. Despite this, the association between research productivity during training and future academic productivity as an attending orthopedic surgeon is not well-established. We assess the effects of research output during different periods of surgical training as well as residency location on long-term academic productivity as an attending shoulder and elbow surgeon. METHODS: A search of the 2022-2023 American Shoulder and Elbow Surgeons Fellowship Directory was conducted to identify a list of orthopedic shoulder and elbow fellowship faculty members. Each surgeon's residency, fellowship and current institution of practice were determined and stratified by geographic location. Total publication counts acquired before residency, during residency, during fellowship, and after fellowship were collected for each faculty member. Attending publication rates and H-indices were calculated. A multivariate linear regression model was created, and significance was set at a P value <.05. RESULTS: A total of 149 shoulder and elbow fellowship faculty members representing 34 fellowship programs were identified. The average number of total publications per surgeon was 88.8 ± 102. The average attending publication rate was 5.29 ± 6.89 publications per year. The average H-index for included surgeons was 27.8 ± 24.4. The number of publications acquired before residency (ß = 0.293; P < .001), during residency (ß = 0.110; P = .025) and during fellowship (ß = 0.593; P < .001) were significantly associated with an increased attending publication rate, but no association was observed with the H-index [before residency (ß = -0.221; P = .574), during residency (ß = 0.045; P = .866), during fellowship (ß = 0.198; P = .678)]. There were no significant differences in total publication count (P = .397), attending publication rate (P = .237), or H-index (P = .364) based on location of residency training. DISCUSSION: Research output before and during surgical training is predictive of continued academic productivity as a shoulder and elbow surgeon. In particular, greater productivity during surgical fellowship was most predictive of academic output as an attending. While long-term academic productivity does not seem to be influenced by the geographic location of residency training, attending surgeons practicing in the Midwest had significantly greater total publication counts and H-indices but similar annual publication rates.

Multiple Serial Casting for Recurrent Clubfoot in Arthrogryposis Corrects Deformity With Diminishing Returns.

PURPOSE: Arthrogryposis multiplex congenita (AMC) consists of more than 400 conditions involving severe joint contractures of at least two or more body regions. Management of clubfoot in patients with AMC is notoriously challenging, with a higher likelihood of recurrence than idiopathic clubfoot, which can be treated using the Ponseti technique to avoid or delay more invasive procedures. The purpose of this study is to determine the utility of multiple serial casting as a treatment of clubfoot in AMC using Pirani scores as an objective measure of deformity. METHODS: Pirani scores were retrospectively collected from 17 AMC patients with a total of 30 clubfeet and two years follow-up from initiation of treatment. Patients with a minimum of three casting series were included. Pre-treatment and post-treatment deformity scores were examined across casting series using analysis of variance (ANOVA) statistical analysis. RESULTS: The first series pre-treatment Pirani score improved from 4.80±1.54 to 1.68±1.48 (p<0.001). The second series improved from 4.23±1.03 to 2.72±0.916 (p<0.001). The third series had the smallest improvement from 3.87±1.07 to 2.82±1.02 (p<0.001). Change in Pirani scores showed a significant decrease from the first series to the second (p=0.001) and third (p<0.001). In addition, the number of casting days was found to significantly affect the change in scores during the third series (p=0.038). CONCLUSIONS: The Ponseti technique can improve clubfoot in AMC as measured by the Pirani score. Data shows that early intervention yields better results, with a diminished yet effective ability to elicit change over time.

Autofusion With Magnetically Controlled Growing Rods: A Case Report.

Magnetically controlled growing rods (MCGRs) are an effective alternative to traditional growing rods (TGRs) in the treatment of early-onset scoliosis (EOS), with comparable deformity correction despite fewer planned reoperations. This case report presents a unique case of autofusion in a patient with tetraplegic cerebral palsy, thoracic myelomeningocele, and EOS who was treated with dual MCGR instrumentation and underwent serial lengthening procedures for four years. We detail the operative and radiographic findings in a novel case of autofusion encountered after MCGR placement to treat EOS. An eight-year-old female with tetraplegic cerebral palsy causing a 94° right thoracic neuromuscular scoliosis was treated with dual MCGRs; she then underwent serial lengthenings every four months. At 12 years of age, during MCGR explantation and posterior spinal fusion, dense heterotopic autofusion was encountered around the MCGR instrumentation, limiting further deformity correction. The benefits of MCGRs make them an appealing alternative to TGRs for the treatment of EOS. Although the theoretical risk of autofusion in MCGRs is low, recent case reports propose autofusion as a possible reason for MCGRs' failure to lengthen.

Metabolic Bone Disorders Are Predictors for 2-year Adverse Outcomes in Patients Undergoing 2-3 Level Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy or Myelopathy.

STUDY DESIGN: Retrospective cohort study utilizing the New York statewide planning and research cooperative system. STUDY OBJECTIVE: To investigate postoperative complications of patients with metabolic bone disorders (MBDs) who undergo 2-3 levels of anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: MBDs and cervical degenerative pathologies, including cervical radiculopathy (CR) and cervical myelopathy (CM), are prevalent in the aging population. Complications with ACDF procedures can lead to increased hospitalization times, more expensive overhead, and worse patient outcomes. METHOD: Patients with CM/CR who underwent an ACDF of 2-3 vertebrae from 2009 to 2011 with a minimum 2-year follow-up were identified. Patients diagnosed with 1 or more MBD at baseline were compared with a control cohort without any MBD diagnosis. Cohorts were compared for demographics, hospital-related parameters, and 2-year medical, surgical, and overall complications. Binary multivariate logistic regression was used to identify independent predictors. RESULTS: A total of 22,276 patients were identified (MBD: 214; no-MBD: 22,062). Among MBD patients, the majority had vitamin D deficiency (n = 194, 90.7%). MBD patients were older (53.0 vs 49.7 y, P < 0.001), and with higher Deyo index (1.0 vs 0.5, P < 0.001). MBD patients had higher rates of medical complications, including anemia (6.1% vs 2.3%), pneumonia (4.7% vs 2.1%), hematoma (3.3% vs 0.7%), infection (2.8% vs 0.9%), and sepsis (3.7% vs 0.9%), as well as overall medical complications (23.8% vs 9.6%) (all, P ≤0.033). MBD patients also experienced higher surgical complications, including implant-related (5.7% vs 1.9%), wound infection (4.2% vs 1.2%), and wound disruption (0.9% vs 0.2%), and overall surgical complications (9.8% vs 3.2%) (all, P ≤0.039). Regression analysis revealed that a baseline diagnosis of MBD was independently associated with an increased risk of 2-year surgical complications (odds ratio = 2.10, P < 0.001) and medical complications (odds ratio = 1.84, P = 0.001). CONCLUSIONS: MBD as a comorbidity was associated with an increased risk of 2-year postoperative complications after 2-3 level ACDF for CR or CM.

The Impact of Osteoporosis on 2-Year Outcomes in Patients Undergoing Long Cervical Fusion.

INTRODUCTION: Osteoporosis affects nearly 200 million individuals worldwide. Given this notable disease burden, there have been increased efforts to investigate complications in patients with osteoporosis undergoing cervical fusion (CF). However, there are limited data regarding long-term outcomes in osteoporotic patients in the setting of ≥4-level cervical fusion. METHODS: The New York State Statewide Planning and Research Cooperative System database was used to identify patients who underwent posterior or combined anterior-posterior ≥4-level CF for cervical radiculopathy or myelopathy from 2009 to 2011, with a minimum follow-up surveillance of 2 years. The following were compared between patients with and without osteoporosis: demographics, hospital-related parameters, medical/surgical complications, readmissions, and revisions. Binary multivariate stepwise logistic regression was used to identify independent predictors of outcomes. RESULTS: A total of 2,604 patients were included (osteoporosis: n = 136 (5.2%); nonosteoporosis: n = 2,468). Patients with osteoporosis were older (66.9 ± 11.2 vs. 60.0 ± 11.4 years, P < 0.001), more often female (75.7% vs. 36.2%, P < 0.001), and White (80.0% vs. 65.3%, P = 0.007). Both cohorts had comparable comorbidity burdens (Charlson/Deyo: 1.1 ± 1.2 vs. 1.0 ± 1.3, P = 0.262), total hospital charges ($100,953 ± 94,933 vs. $91,618 ± 78,327, P = 0.181), and length of stay (9.7 ± 10.4 vs. 8.4 ± 9.6 days, P = 0.109). Patients with osteoporosis incurred higher rates of overall medical complication rates (41.9% vs. 29.4%, P = 0.002) and individual surgical complications, such as nonunion (2.9% vs. 0.7%, P = 0.006). Osteoporosis was associated with medical complications (OR = 1.57, P = 0.021), surgical complications (OR = 1.52, P = 0.030), and readmissions (OR = 1.86, P = 0.003) at 2 years. DISCUSSION: Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. These data indicate that preoperative screening and management of osteoporosis may be important for optimizing long-term outcomes in patients who require multilevel CF. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: The data used in this study are available for public use at https://www.health.ny.gov/statistics/sparcs/.

The Impact of Perceived Upper Extremity Severity and Prior Surgery on Patient-Reported Outcomes.

Background: The recently validated Hand Questionnaire (HAND-Q) is a multifaceted patient-reported outcome measure (PROM) for hand/upper extremity (UE) pathology and treatment. Here, we conduct a pilot study utilising data collected as a participating site for the Phase II HAND-Q Pilot Multicenter International Validation Study. We hypothesised that self-reported hand functionality, symptom/disease severity, hand appearance, emotional dissatisfaction and treatment satisfaction would be worse in patients who perceived their disease severity to be more severe but would not differ between patients based on prior surgical history. Methods: Patients were prospectively enrolled for HAND-Q participation from September 2018 to August 2019. Patients were included in this analysis if they responded to the following scales of HAND-Q: Hand Functionality Satisfaction, Symptom Severity, Hand Appearance Satisfaction, Emotional Dissatisfaction and Treatment Satisfaction. Composite scores (CS) were created for each section. Surgical versus non-surgical CS and mild versus moderate/severe CS were compared with t-tests. Bi-variate comparisons of responses were performed between surgical and non-surgical groups, and between mild and moderate/severe groups. Results: HAND-Q individual question analysis revealed significant differences in functionality and symptom severity for patients with prior surgery (p < 0.047). CS analysis confirmed greater overall impairment in surgical patients, but no overall impact on symptom severity. Regarding disease severity HAND-Q individual question analysis, moderate/severe patients reported worse outcomes for specific aesthetic qualities and symptoms for almost all items (p < 0.05). CS analysis revealed significantly worse overall hand appearance satisfaction, hand functionality, emotional satisfaction and symptom severity for patients with moderate/severe hand conditions. Conclusions: HAND-Q revealed worsened outcomes for UE patients with self-reported moderate/severe conditions or previous surgical history. Understanding how previous surgery and disease severity may impact clinical outcomes is important for crafting appropriate treatment. Level of Evidence: Level II (Prognostic Study).

Sexual Dissatisfaction after Hand Surgery.

Using the hand questionnaire (HAND-Q) patient-reported outcome measure, the effects of upper extremity surgery on patients' perception of their sex life were explored. The hand is a uniquely sexual organ, and we hypothesized that self-reported measures of disease severity, quality of life, and emotional impact would correlate with sexual dissatisfaction among patients receiving treatment for hand/upper extremity conditions. Methods: Patients were prospectively enrolled for hand questionnaire participation. Patients with valid responses to the following questions were included: functionality, hand appearance satisfaction, symptom severity, emotional dissatisfaction, sexual dissatisfaction, and treatment satisfaction. Composite scores were created and scored. Sexual dissatisfaction composite scores were compared through Spearman correlation coefficient analysis to quality of life, emotional dissatisfaction, hand appearance, symptom severity, and hand functionality. Results: High levels of diminished quality of life correlated with sexual dissatisfaction (rs = 0.748, P < 0.001). Increased emotional dissatisfaction correlated with sexual dissatisfaction (rs = 0.827, P < 0.001). Increased satisfaction with hand appearance negatively correlated with sexual dissatisfaction (rs = -0.648, P = 0.001). Increased levels of dissatisfaction with hand functionality correlated with sexual dissatisfaction (rs = 0.526, P = 0.005). Conclusions: The correlation between sex life and quality of life may allow surgeons to improve patient satisfaction when treating hand/upper extremity issues. The relationship between sex life and emotional dissatisfaction emphasizes the impact that sexual dissatisfaction has on patients' lives. Evaluating the relationship between hand appearance and sexual dissatisfaction may indicate that patient self-perception of hand attractiveness plays a role in sex life.

The Impact of Osteoporosis on Adverse Outcomes After Short Fusion for Degenerative Lumbar Disease.

INTRODUCTION: Osteoporosis affects nearly 200 million individuals worldwide. There are little available data regarding outcomes in patients with osteoporosis who undergo short-segment lumbar fusion for degenerative disk disease (DDD). We sought to identify a relationship between osteoporosis and risk of adverse outcomes in patients with DDD undergoing short-segment lumbar fusion. METHODS: Using the New York State Statewide Planning and Research Cooperative System, all patients with DDD who underwent 2- to 3-level lumbar fusion from 2009 through 2011 were identified. Patients with bone mineralization disorders and other systemic and endocrine disorders and surgical indications of trauma, systemic disease(s), and infection were excluded. Patients were stratified by the presence or absence of osteoporosis and compared for demographics, hospital-related parameters, and 2-year complications and revision surgeries. Multivariate binary logistic regression models were used to identify notable predictors of complications. RESULTS: A total of 29,028 patients (osteoporosis = 1,353 [4.7%], nonosteoporosis = 27,675 [95.3%]) were included. Patients with osteoporosis were older (66.9 vs 52.6 years), more often female (85.1% vs 48.4%), and White (82.8% vs 73.5%) (all P < 0.001). The Charlson/Deyo comorbidity index did not significantly differ between groups. Hospital lengths of stay and total charges were higher for patients with osteoporosis (4.9 vs 4.1 days; $74,484 vs $73,724; both P < 0.001). Medical complication rates were higher in patients with osteoporosis, including acute renal failure and deep-vein thrombosis (both P < 0.01). This cohort also had higher rates of implant-related (3.4% vs 1.9%) and wound (9.8% vs 5.9%) complications (both P < 0.01). Preoperative osteoporosis was strongly associated with 2-year medical and surgical complications (odds ratios, 1.6 and 1.7) as well as greater odds of revision surgeries (odds ratio, 1.3) (all P < 0.001). CONCLUSION: Patients with osteoporosis undergoing 2- to 3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, especially implant-related and wound complications. These findings highlight the importance of rigorous preoperative metabolic workup and patients' optimization before spinal surgery.

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Combined adult neurogenesis and BDNF mimic exercise effects on cognition in an Alzheimer's mouse model.

Adult hippocampal neurogenesis (AHN) is impaired before the onset of Alzheimer's disease (AD) pathology. We found that exercise provided cognitive benefit to 5×FAD mice, a mouse model of AD, by inducing AHN and elevating levels of brain-derived neurotrophic factor (BDNF). Neither stimulation of AHN alone, nor exercise, in the absence of increased AHN, ameliorated cognition. We successfully mimicked the beneficial effects of exercise on AD mice by genetically and pharmacologically inducing AHN in combination with elevating BDNF levels. Suppressing AHN later led to worsened cognitive performance and loss of preexisting dentate neurons. Thus, pharmacological mimetics of exercise, enhancing AHN and elevating BDNF levels, may improve cognition in AD. Furthermore, applied at early stages of AD, these mimetics may protect against subsequent neuronal cell death.

BACE1 Regulates Proliferation and Neuronal Differentiation of Newborn Cells in the Adult Hippocampus in Mice.

ß-Site amyloid precursor protein cleaving enzyme 1 (BACE1) is required for the production of ß-amyloid (Aß), one of the major pathogenic molecules of Alzheimer's disease (AD), and is therefore being actively pursued as a drug target for AD. Adult hippocampal neurogenesis (AHN) is a lifelong process that is known to be important for learning and memory and may have the potential to regenerate damaged neural tissue. In this study, we examined whether BACE1 regulates AHN, which holds important implications for its suitability as a drug target in AD. Cohorts of 2-month-old wild-type (BACE1+/+), heterozygous, and homozygous BACE1 knockout mice (BACE1+/- and BACE1-/-, respectively) were injected with 5-bromo-2'-deoxyuridine (BrdU) and sacrificed 1 day later to examine the impact of loss of BACE1 on neural precursor cell (NPC) proliferation in the adult brain. Parallel cohorts of mice were sacrificed 4 weeks after BrdU injection to determine the effects of BACE1 on survival and differentiation of newborn NPCs. We found that NPC proliferation was increased in BACE1-/- mice compared to BACE1+/+ mice, while no difference was observed in NPC survival across genotypes. Differentiation of NPCs to neuronal lineage was impaired in BACE1-/- mice. However, no differences were observed in astrogenesis, the proportion of immature neurons, or the production of oligodendrocytes across genotypes. Importantly, corresponding with a decrease in neuronal differentiation in the absence of a complementary increase in an alternate cell fate, BACE1-/- mice were found to have a pool of undifferentiated NPCs in the hippocampus compared to BACE1+/+ and BACE1+/- mice.