Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded, placebo-controlled trial. OBJECTIVE: To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA: Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS: Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS: A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS: By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.

Tommy John: Elbow Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace.

Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.

The top 100 classic papers on adolescent idiopathic scoliosis in the past 25 years: a bibliometric analysis of the orthopaedic literature.

STUDY DESIGN: Bibliometric analysis. OBJECTIVES: To identify the 100 most cited orthopedic papers in adolescent idiopathic scoliosis (AIS) over the past 25 years and characterize them by study type, topic, and country and assess study quality (design, level of evidence, and impact factor) to provide an updated account of the most impactful AIS evidence. AIS represents a three-dimensional deformity that drives a significant number of investigations. Although available evidence continues to grow, recent impactful studies pertaining to AIS have not been identified; their quality has not been thoroughly assessed. METHODS: Web of Science was reviewed to identify the top 1000 cited AIS studies published from 1992 to 2017. Articles were organized by number of citations. Titles and abstracts were screened for inclusion/relevance, and the top 100 articles by citation count were identified, and study and publication characteristics were extracted. RESULTS: Among the top 100 articles, 42 were cited ≥ 100 times. Mean number of authors and citations of these studies was 5.6 and 118.3, respectively. Study types were predominantly retrospective (n = 53), followed by prospective (n = 18), cross-sectional (n = 13), and systematic review/meta-analysis (n = 7). Topics covered in these studies included clinical/patient outcomes (n = 47), methodology/validation (n = 22), basic science (n = 15), radiographic analyses (n = 12), and gait/biomechanics (n = 4). Most studies originated in the United States of America (n = 65) and were published in Spine (n = 76), with 8266 total citations. Most studies were of Level III (n = 55) or Level II (n = 23) evidence. Mean impact factor was 3.47. CONCLUSIONS: Despite recent studies' shorter time frames for impact, citations of AIS research have progressively increased during the past 25 years. The top 100 cited orthopedic studies were predominantly Level III, retrospective, nonrandomized studies, and therefore, were subject to biases. The low proportion of prospective studies (18%) reflects an area of future improvement, underscoring the need for higher-quality studies to support our practice. LEVEL OF EVIDENCE: N/A.

After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up.

BACKGROUND: In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO. OBJECTIVE: To investigate if performance of 3CO surgeries improves with years of practice. METHODS: Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis. RESULTS: Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001). CONCLUSION: Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.

Bone substitutes in adolescent idiopathic scoliosis surgery using sublaminar bands: is it useful? A case-control study.

INTRODUCTION: In order to avoid pseudarthrosis in adolescent idiopathic (AIS) patients, it is recommended to bring additional bone graft or substitute. Modern rigid instrumentations have been shown to provide less pseudarthroses even without bone substitutes. The aim of our study was to determine the impact of using bones substitutes on fusion rates in adolescent idiopathic scoliosis patients undergoing PSF with sublaminar bands. METHOD: AIS patients scheduled to undergo PSF with sublaminar bands were prospectively enrolled into this study and not given any bone substitutes (no-substitute group). Data were collected and analyzed in patients with at least two years of follow-up. Pseudarthrosis was diagnosed if at least one of the following was present: persistent back pain, hardware failure, loss of correction greater than 10°. The results were compared to a control group who received bone substitutes for the same surgical procedure. RESULTS: Eighty-eight patients were included. For the whole cohort, the mean age was 14.8 years old and the mean follow-up was 30.9 months. For the 'no-substitute' group (n = 44), the mean Cobb angle was 56° pre-operatively, 20.1° post-operatively, and 22° at final follow-up. The fusion rate was not statistically different between the two groups (97.7% vs 95.5%, p = 0.56). At last follow-up, one pseudarthrosis occurred in the 'no substitute' group and two in the control group. DISCUSSION: This is the first study to determine the impact of bone substitutes in AIS fusion using sublaminar bands. In our study, the use of local autologous bone graft alone resulted in a fusion rate of 97.7% despite the use of more flexible instrumentation. The high rate of fusion in AIS patients is more probably due to the healing potential of these young patients rather than to the type of instrumentation. CONCLUSION: The use of additional bone graft or bone substitutes may not be mandatory when managing AIS. LEVEL OF EVIDENCE: 4.

Mismatch Between Proximal Rod Contouring and Proximal Junctional Angle: A Predisposed Risk Factor for Proximal Junctional Kyphosis in Degenerative Scoliosis.

STUDY DESIGN: A retrospective study. OBJECTIVE: To investigate whether the mismatch between proximal junctional angle (PJA) and the proximal rod contouring contributed to the occurrence of postoperative proximal junctional kyphosis (PJK) in degenerative scoliosis. SUMMARY OF BACKGROUND DATA: PJK is one of the complications in the treatment of degenerative scoliosis, the postoperative PI-LL mismatch and the increased rod stiffness are supposed to be the etiology of PJK. However, the impact of rod contouring on PJK has not been fully illustrated. METHODS: A retrospective study was performed on 27 consecutive degenerative scoliosis patients (three males and 24 females) who underwent corrective surgery with more than 2-year follow-up. Radiographic parameters included proximal rod contouring angle (PRCA) and PJA at the three time-points. The subjects were divided into two groups: PJK group and non-PJK group with the definition of PJK as a PJA more than 10°. The mismatch between PRCA and post-op PJA, defined as the difference between PRCA and postop PJA of more than 5°, was then compared with PJK and non-PJK group. RESULTS: The patients' mean age was 60.48 ±â€Š6.47 years old with a mean Cobb angle of 40.89 ±â€Š14.33°. Twelve patients, with a mean PJA of 18.67 ±â€Š5.31° at the last followup, were stratified into the PJK group, while the remaining 15 patients, with a mean PJA of 5.33 ±â€Š2.47, were placed into the non-PJK group. A significant difference in the mismatch between post-op PJA and PRCA was observed between PJK and non-PJK group (8.83 ±â€Š5.07° vs. 4.07 ±â€Š2.91°, P = 0.005). Meanwhile the difference of mismatch between preop PJA and PRCA showed no statistical significance (5.16 ±â€Š4.24° vs. 3.00 ±â€Š2.48°, P = 0.109). CONCLUSION: Mismatch between rod contouring and postoperative proximal spinal curve may be a predisposed risk factor for PJK in degenerative scoliosis. LEVEL OF EVIDENCE: 4.

Sagittal alignment of the spine: What do you need to know?

Sagittal alignment, often misrepresented as sagittal balance, describes the ideal and "normal" alignment in the sagittal plane, resulting from the interplay between various organic factors. Any pathology that alters this equilibrium instigates sagittal malalignment and its compensatory mechanisms. As a result, sagittal malalignment is not limited to adult spinal deformity; its pervasiveness extends through most spinal disorders. While further research is developing, the literature reports clinically relevant radiographic parameters that have significant relationships with patient-reported outcomes. This article aims to provide a pragmatic review of sagittal plane analysis. At the end of this review, the reader should be able to analyze the sagittal plane of the spine, identify compensatory mechanisms, and choose patient-specific alignment targets.