Do ChatGPT and Google differ in answers to commonly asked patient questions regarding total shoulder and total elbow arthroplasty?

BACKGROUND: Artificial intelligence (AI) and large language models (LLMs) offer a new potential resource for patient education. The answers by Chat Generative Pre-Trained Transformer (ChatGPT), a LLM AI text bot, to frequently asked questions (FAQs) were compared to answers provided by a contemporary Google search to determine the reliability of information provided by these sources for patient education in upper extremity arthroplasty. METHODS: "Total shoulder arthroplasty" (TSA) and "total elbow arthroplasty" (TEA) were entered into Google Search and ChatGPT 3.0 to determine the ten most FAQs. On Google, the FAQs were obtained through the "people also ask" section, while ChatGPT was asked to provide the ten most FAQs. Each question, answer, and reference(s) cited were recorded. A modified version of the Rothwell system was used to categorize questions into 10 subtopics: special activities, timeline of recovery, restrictions, technical details, cost, indications/management, risks and complications, pain, longevity, and evaluation of surgery. Each reference was categorized into the following groups: commercial, academic, medical practice, single surgeon personal, or social media. Questions for TSA and TEA were combined for analysis and compared between Google and ChatGPT with a 2 sample Z-test for proportions. RESULTS: Overall, most questions were related to procedural indications or management (17.5%). There were no significant differences between Google and ChatGPT between question categories. The majority of references were from academic websites (65%). ChatGPT produced a greater number of academic references compared to Google (80% vs. 50%; P = .047), while Google more commonly provided medical practice references (25% vs. 0%; P = .017). CONCLUSION: In conjunction with patient-physician discussions, AI LLMs may provide a reliable resource for patients. By providing information based on academic references, these tools have the potential to improve health literacy and improved shared decision making for patients searching for information about TSA and TEA. CLINICAL SIGNIFICANCE: With the rising prevalence of AI programs, it is essential to understand how these applications affect patient education in medicine.

Single Long-Incision Minimally Invasive Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study is to determine differences in outcomes in patients with adolescent idiopathic scoliosis undergoing spinal deformity correction surgery using a posterior spinal fusion (PSF) approach versus single and triple-incision minimally invasive surgery (MIS). SUMMARY OF BACKGROUND DATA: MIS increased in popularity as surgeons' focus moved towards soft tissue preservation, but it carries technical demands and increased surgical time compared with PSF. PATIENTS AND METHODS: Surgeries performed from 2016 to 2020 were included. Cohorts were formed based on surgical approach: PSF versus single long-incision MIS (SLIM) versus traditional MIS [3-incision MIS (3MIS)]. There were a total of 7 subanalyses. Demographic, radiographic, and perioperative data were collected for the 3 groups. Kruskal-Wallis and χ 2 tests were used for continuous and categorical variables, respectively. RESULTS: Five hundred thirty-two patients met our inclusion criteria, 294 PSF, 179 3MIS, and 59 SLIM.Estimated blood loss (mL) ( P < 0.00001) and length of stay (LOS) ( P < 0.00001) was significantly higher in PSF than in SLIM and 3MIS. Surgical time was significantly higher in 3MIS than in PSF and SLIM ( P = 0.0012).Patients who underwent PSF had significantly lower postoperative T5 to T12 kyphosis ( P < 0.00001) and percentage kyphosis change ( P < 0.00001). Morphine equivalence was significantly higher in the PSF group during total hospital stay ( P = 0.0042).Patients who underwent SLIM and 3MIS were more likely to return to noncontact ( P = 0.0096) and contact sports ( P = 0.0095) within 6 months and reported lower pain scores ( P < 0.001) at 6 months postoperation. CONCLUSION: SLIM has a similar operative time to PSF and is technically similar to PSF while maintaining the surgical and postoperative outcome advantages of 3MIS.

A Newer Way of Determining LIV in AIS Patients: Rotation of the Touched Vertebrae.

STUDY DESIGN: A retrospective review. OBJECTIVE: The objective of this study was to determine whether fusing to touched vertebra (TV) on prone x-rays (XRs) with minimal rotation (Gd 0/1) allow for shorter fusion with optimal correction. SUMMARY OF BACKGROUND: Previous studies have shown risk of "adding on" when TV is not selected as lowest instrumented vertebra (LIV). Fusion proximal to TV leads to suboptimal results but fusing to TV on standing XRs can result in longer fusions. On lying down XRs, TV moves proximally, and its rotation decreases by a grade. METHODS: TV patients with minimal rotation were selected on prone (TVP) or standing XRs (TVS). Patients fused to rotated (Gd 2+) TV on standing or prone XRs were considered touched vertebra rotated (TVR). In the non-TV (NTV) group, LIV was fused proximal to TV. Disk wedging ≥5° determined risk of "adding-on." To compare patients fused to minimally rotated TV, to those that were not, patients in group A (TVP + TVS) were compared with group B (TVR + NTV).In part II: TVP, TVS, TVR, and NTV patients were compared. Subanalysis compared levels saved as the difference between predicted and real LIV in TVP and TVS patients. Another subanalysis was carried out for Lenke 1+2 and Lenke 3, 4, 5.In part III: XRs of nonoperative adolescents idiopathic scoliosis patients with Cobb <30 and Risser 4/5 were analyzed to determine "acceptable" end vertebra tilt and disc wedging and served as controls. RESULTS: There were a significantly greater number of patients in group B patients(TVR + NTV) with final disk wedging ≥5°, final LIV translation ≥1 and ≥2 cm ( P <0.001).Utilizing prone XRs in TVP saved average 1 level, and 1.2 levels in TVS patients. TVP patients also had similar LIV tilt, disk wedging and coronal balance( P >0.05) to controls. CONCLUSION: Choosing minimally rotated (Gd 0/1) TV on prone XR saves levels without sacrificing radiographic outcomes.

In Scheuermann's kyphosis, a proximal UIV and postop kyphosis value close to patients' PI decreases the risk of PJK.

PURPOSE: Prevalence of proximal junctional kyphosis (PJK) in Scheuermann's kyphosis (SK) varies between 24 and 40%. Multiple factors have been implicated, including kyphosis overcorrection, failure to include proximal end vertebra, and implant choice. This study aimed to determine the goal correction parameters based upon patients' pelvic incidence, and UIV to decrease PJK in Scheuermann's kyphosis. METHODS: X-ray and chart review of SK patients operated with all pedicle screw (PS), hybrid fixation (HF), and anterior/posterior fusions with hybrid fixation (AP). T1/T2 were grouped together as proximal fusion groups compared to T3 and distal groups. RESULTS: 96 total patients: PS (n = 41), HF (n = 24), and AP (n = 31). Overall, at early postop 12 (12.5%) patients had PJK. At final follow-up, 33 (34.4%) had PJK. There was no significant difference between groups at early postop (p = 0.86) or final follow-up (p = 0.67). When correcting kyphosis-PI to > - 10.0° and UIV was chosen to be T1 or T2, PJK developed in 6.1% of patients at final follow-up; when fusing to T1/T2 but with kyphosis-PI < - 10.0°, 38.9% of patients developed PJK. With kyphosis-PI > - 10.0° and UIV at T3 or below, 37.0% of patients developed PJK at final follow-up. When fusing to T3 or below but failing to correct kyphosis-PI to > - 10.0°, 77.8% of patients developed PJK. CONCLUSION: Selecting proximal UIV and avoiding kyphosis-PI mismatch can significantly decrease the prevalence of PJK rather than surgical technique or implant choice. Surgeons treating SK should, therefore, aim to correct kyphosis closer to the patient's pelvic incidence and choose T2/T1 as UIV.

The Incidence of Subsequent Cervical Spine Surgery after Cervical Disc Arthroplasty, a Minimum Two-year Follow-up.

To identify the risk factors and incidence of subsequent cervical spine surgery in patients undergoing primary cervical disc arthroplasty (CDA). We analyzed the 2005-2015 NYS SPARCS database. Patients were longitudinally followed to determine the incidence of re-operation. Univariate and Multivariate analyses were used to identify demographic risk factors. Eight-hundred and thirty-five CDA patients had a cervical spine re-operation rate of 7.5%; 4.4% re-operation rate at two-year follow-up. The most common cervical re-operation was a primary anterior cervical discectomy and fusion (ACDF) (76.2%). Patients who underwent re-operation were more likely to be younger (p = 0.034) and female (p = 0.007). Logistic regression analysis found only female sex to have increased odds of re-operation (odds ration = 2.10, 95% confidence interval 1.21-3.63). There was a 4.4% rate of subsequent cervical spine surgery following CDA at 2 years and a 7.5% rate of subsequent cervical spine surgery. The most common cervical spine procedure following CDA was ACDF. Female sex was the only patient demographic factor to significantly influence the odds of cervical spine re-operation. (Journal of Surgical Orthopaedic Advances 31(1):007-011, 2022).

Ambulatory Neuromuscular Scoliosis Patients Have Superior Perioperative Results Than Nonambulatory Neuromuscular Scoliosis Patients and Can Approach Adolescent Idiopathic Scoliosis Outcomes After Posterior Spinal Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aims to identify differences in perioperative outcomes between ambulatory patients with neuromuscular scoliosis (ANMS) and adolescent idiopathic scoliosis (AIS) following spinal fusion. SUMMARY OF BACKGROUND DATA: NMS patients have severe curves with more comorbidities and procedural complexity. These patients require extensive fusion levels, increased blood loss, and suffer increased periop complications. However, NMS patients have a variable severity spectrum, including ambulation status. METHODS: Chart and radiographic review of NMS and AIS patients undergoing PSF from 2005 to 2018. NNMS included NMS patients who were completely dependent (GMFCS IV-V). ANMS consisted of community ambulators without significant reliance on wheeled assistive devices (GMFCS I-III). Subanalysis matched by age, sex, levels fused and preoperative Cobb angle was conducted as well. Wilcoxon Rank-Sum, Kruskal-Wallis, χ2, and Fisher exact tests were performed. RESULTS: There were 120 patients in the NNMS group, 54 in ANMS and 158 in the AIS group. EBL was significantly lower for ANMS and AIS patients (P < 0.001). Complications within 30 days were similar between ANMS and AIS (P = 1.0), but significantly higher for NNMS (P < 0.001). Two (1.3%) AIS patients, (1.7%) nonambulatory NMS patients, and one (1.9%) ANMS patient required revision surgery (P = 1.0). However, all NMS patients had increased fusion levels, fixation points, and surgery time (P < 0.05). NNMS had significantly longer ICU (P < 0.001), hospital stay (P < 0.001), intraoperative transfusions (P < 0.001), and fewer patients extubated in the OR (P < 0.001) than ANMS and AIS patients. In the subanalysis, ANMS had similar radiographic measurements, EBL, transfusion, surgery time, extubation rate, and complication rate (P > 0.05) to AIS. CONCLUSION: Our data show radiographic outcomes, infections, revisions, and overall complications for ANMS were similar to the AIS population. This suggests that NMS patients who ambulate primarily without assistance can expect surgical outcomes comparable to AIS patients with further room for improvement in length of ICU and hospital stay.Level of Evidence: 4.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA). SUMMARY OF BACKGROUND DATA: Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication. METHODS: AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared. RESULTS: There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation. CONCLUSION: This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Scoliosis Surgery Normalizes Cardiac Function in Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Single-center retrospective chart review with minimum 2-year follow up. OBJECTIVE: To determine incidence of pulmonary hypertension in adolescent idiopathic scoliosis patients and to determine the effect of scoliosis surgery on pulmonary hypertension. SUMMARY OF BACKGROUND DATA: Spinal deformity in adolescent idiopathic scoliosis can increase right atrial and ventricular pressures secondary to restrictive lung disease. Pulmonary hypertension leading to cor pulmonale is the most feared outcome, however mild pulmonary hypertension in adolescent idiopathic scoliosis (AIS) patients has been reported. No study has previously examined changes in the improvement of right heart function following scoliosis surgery. METHODS: Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), pulmonary function tests (PFTs), arterial blood gas (ABG), and patient demographics reviewed. Right ventricular systolic pressure (RVSP) estimated using Bernoulli equation (4[TRV]2) and right atrial pressure. RVSP ≥36 mmHg is a surrogate marker for pulmonary hypertension. All echocardiograms were read by board certified Pediatric Cardiologists. Logistic regression used to assess for differences in TRV between groups. RESULTS: Mean preoperative RVSP was significantly elevated in AIS patients (26.9 ±â€Š0.49; P < 0.001) compared with controls (17.25 + 0.88). Only 47 (21%) Group 1 patients had elevated preoperative TRV (≥2.8 m/s) versus none in Group 2 (P < 0.001). Additionally, logistic regression showed AIS patients have odds ratio of 3.29 for elevated TRV (P = 0.007)-an indirect measure of pulmonary hypertension. In all Group 3 patients, the cardiac function normalized postoperatively (mean TRV = 2.09 + 0.23; P < 0.001). No association found between Cobb angle, aortic root parameters, or pulmonary function tests. CONCLUSION: This study found 13.9% of patients with adolescent idiopathic scoliosis had elevated TRV while controls had no TRV abnormalities. Additionally, RVSP measurements demonstrated mild pulmonary hypertension in AIS patients. These abnormal values normalized postoperatively, indicating the benefits of scoliosis surgery on cardiac function in adolescent idiopathic scoliosis.Level of Evidence: 3.

Effects of Fellowship Training on Pediatric Anterior Cruciate Ligament Reconstruction Techniques and Outcomes.

The purpose of this study is to examine differences in pediatric anterior cruciate ligament reconstruction (ACLR) between surgeons with either pediatric or sports medicine fellowship training. Patients were divided into two groups, those performed by either a pediatric or sports medicine fellowship-trained surgeon. One hundred and forty-one patients were identified: 91 (64.5%) by pediatric trained surgeons and 50 (35.4%) by sports medicine trained surgeons. Patients that had ACLR by a pediatric trained surgeon were younger (p = 0.02), had larger body mass index (BMI) (p = 0.027), and more likely to have government assisted insurance (p = 0.006). Pediatric trained surgeons had longer procedure time (p < 0.001), used smaller graft sizes (p = 0.016), used soft tissue grafts (p < 0.001) and used button fixation at both the femur and tibia (p < 0.001). There were no differences regarding meniscus surgery, surgical technique (transphyseal versus physeal sparing), arthrofibrosis, graft failure, and intraoperative complications (p > 0.05). This study shows favorable and comparable results after ACLRs with either pediatric or sports medicine fellowship training. (Journal of Surgical Orthopaedic Advances 30(3):161-165, 2021).

Minimally Invasive Versus Standard Surgery in Idiopathic Scoliosis Patients: A Comparative Study.

STUDY DESIGN: Retrospective review of prospective case-control study. OBJECTIVE: To compare minimally invasive scoliosis surgery (MIS) and posterior spinal fusion (PSF) in a large group of patients. SUMMARY OF BACKGROUND DATA: MIS, has been shown to have benefits over standard PSF in adolescent idiopathic scoliosis (AIS). METHODS: Radiographic, clinical, and operative review of a multi-institutional prospective database from 2013 to 2018. MIS patients with minimum 2-year XR follow up were compared with open PSF technique patients. RESULTS: Four hundred eighty five patients were included; 192 MIS and 293 PSF. Preoperative Cobb (P = 0.231) and kyphosis were similar (P = 0.501). Cobb correction was comparable (P = 0.46), however percent improvement in thoracic kyphosis was significantly higher in MIS (P < 0.001). MIS had significantly lower blood loss (P < 0.001), transfusions (P < 0.001), fixation points (P < 0.001), opioid consumption (P = 0.001), and hospital stay (P < 0.001). Operative time was shorter (P = 0.001) and 30-day complications rate was similar (P = 0.81). CONCLUSION: This is the largest study comparing the surgical outcomes of MIS and PSF. MIS patients benefit from increased kyphosis, fewer transfusion, lower opioid consumption, and shorter hospital stay with similar Cobb correction. Increased postoperative kyphosis is likely from muscle sparing dissection in MIS.Level of Evidence: 3.

A Global Perspective of Mentorship in Medical Schools: Systematic Review from 2014 to 2019.

Formal mentorship programs afford medical students research involvement, career guidance, and personal and professional development. We reviewed a total of 36 studies on mentorship in medical schools, 17 of which are from the United States (US) and 19 from outside the US. This descriptive study has determined the most common mentorship models used in medical schools both in the United States and internationally. Despite variance between programs, medical students in the US and worldwide prefer highly invested mentors with strong interpersonal skills. We concluded that both US and international mentorship provide crucial professional development for students; however, US-based mentorship is more focused on providing experience within individual specialties. More studies on current mentorship practices in medical schools are required to ensure that the diverse international medical education community is better represented.

Patient Satisfaction After Lower Extremity Total Joint Arthroplasty: An Analysis of Medical Comorbidities and Patient Demographics.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey has received increased attention to determine which demographics may influence patient satisfaction after Total Hip and Knee Arthroplasty. The purpose of this study was to evaluate the various effects that patient-specific factors, medical comorbidities, and demographics had on patient satisfaction. Two thousand and ninety-two patients underwent lower extremity total joint arthroplasty at our institution between 2014 and 2018. Nine hundred twenty-three of these patients responded to their HCAHPS survey (44%). Most patients (609, 66%) underwent primary total knee arthroplasty followed by 244 (26.4%) total hip arthroplasties, 35 (3.8%) revision total knee arthroplasties, 28 (3.0%) bilateral total knee arthroplasties, and 7 (0.8%) revision total hip arthroplasties. Increasing age and length of stay were associated with a decrease in patient satisfaction whereas patients who were married reported higher satisfaction. Patients discharged to a rehabilitation facility had a 12% decrease in top-box response rate compared to those discharged home. Contrary to our hypothesis, specific procedure type and the presence of comorbidities failed to predict patient satisfaction. The results of this study shed light on the intricate relationship between patient satisfaction and patient-specific factors. Furthermore, health care workers can counsel patients on expected satisfaction when considering total hip and knee arthroplasty.

Seatbelts Save Lives, and Spines, in Motor Vehicle Accidents: A Review of the National Trauma Data Bank in the Pediatric Population.

STUDY DESIGN: Database study. OBJECTIVE: The purpose of this study was to use a large, nationwide database to determine prevalence of pediatric spine fractures in the United States, associated injuries, mechanisms of injury (MOI), use of safety devices, and mortality rates. SUMMARY OF BACKGROUND DATA: Spinal fractures account for 1% to 2% of pediatric injuries. However, they are associated with significant comorbidities and complications. Motor vehicle accidents (MVAs) are most responsible for increased incidence observed. METHODS: Retrospective review of National Trauma Data Bank between 2009 and 2014 (analysis in 2019) for all vertebral fractures in patients under 18 years of age. Subanalysis included those in MVAs where protective device use data were available. Patient demographics, MOI, geographical and anatomical region of injury, concomitant musculoskeletal/organ injury, protective device usage, hospital length of stay, surgical procedures, and mortality were all analyzed. RESULTS: A total of 34,563 patients with 45,430 fractured vertebrae included. Median age was 15 years. Most fractures (63.1%) occurred in patients aged 15 to 17 years, most frequent MOI was MVA (66.8%), and most common geographic location was the South (38%). Males sustained more spine fractures than females, overall (58.4% vs. 41.6%; P < 0.001) and in MVAs (54.4% vs. 45.6%; P < 0.001). Those in MVAs wearing seatbelts had lower odds of cranial (29.6% vs. 70.4%; odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.82-0.89; P < 0.001) and thoracic (30.1% vs. 69.9%; OR = 0.88, 95% CI: 0.84-0.91; P < 0.001) organ injury, multivertebral (30% vs. 70%; OR = 0.78, 95% CI: 0.73-0.83; P < 0.001) and concomitant nonvertebral fractures (30.9% vs. 69.1%; OR = 0.89, 95% CI:0.73-0.83; P < 0.001), and 21% lower odds of mortality (29.3% vs. 70.7%; OR = 0.79, 95% CI: 0.66-0.94; P = 0.009). Over 70% of drivers were not restrained during MVA, with majority of seatbelt violations incurred by males, ages 15 to 17, in the South. CONCLUSION: Over 60% of pediatric spinal fractures occur in children aged 15 to 17 years, coinciding with the beginning of legal driving. MVA is the most common cause and has significant association with morbidity/mortality. Nearly two- thirds pediatric spinal fractures sustained in MVAs occurred without seatbelts. Absence of seatbelts associated with >20% greater odds of mortality. Ensuring new drivers wear protective devices can greatly reduce morbidity/ mortality associated with MVA.Level of Evidence: 3.

Predicting Autologous Hamstring Graft Diameter in the Pediatric Population Using Preoperative Magnetic Resonance Imaging and Demographic Data.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction before 18 years of age has been linked with an increased risk for failure when the graft diameter is <8 mm. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether autologous hamstring graft size can be reliably predicted with the use of preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that the average of multiple axial cross-sectional area MRI measurements for the semitendinosus tendon and gracilis tendon would alone accurately predict graft diameter. Additionally, factoring in specific demographic data to the MRI cross-sectional areas would provide a synergistic effect to the accuracy of graft diameter predictions. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We retrospectively reviewed 51 pediatric patients undergoing ACL reconstructions (age <18 years) performed using either a quadruple-strand semitendinosus tendon or combined double-bundle semitendinosus tendon-gracilis tendon autograft. Preoperative axial MRI scans at multiple points along the craniocaudal axis-specifically, at the level of the joint line, 3 cm cephalad to the medial tibial plateau, and 5 cm cephalad to the medial tibial plateau-were used to determine the combined cross-sectional area of the semitendinosus and gracilis tendons. The MRI measurements were analyzed using Pearson correlation as well as regression analysis to evaluate strength of correlation between measurements. Binomial linear regression was used to analyze the same predictive variables assessed by multiple regression. RESULTS: The predicted graft diameter was within 0.5 mm of the intraoperative graft size in 37 of 51 (72.5%) patients and within 1 mm of the intraoperative graft size in 49 of 51 (96.1%). With the addition of demographics, the accuracy of predictions increased to 78.4% within 0.5 mm and 98% within 1 mm of the actual graft size. Additionally, 38 of 42 patients whose true graft diameter was ≥8 mm were correctly classified, giving a sensitivity of 90.4%. For those whose true graft diameter was <8 mm, 8 of 9 patients were correctly classified; therefore, the specificity was 88.9%. CONCLUSION: The results of our study suggest that taking the average of multiple preoperative MRI measurements can be used to accurately predict autologous hamstring graft size when approaching pediatric patients undergoing ACL reconstruction.

Are All Hardware Removals Equal?

The objective of this study is to report operative time and associated complications of six types of implants and to determine if surgeons are adequately compensated. Hardware removals were analyzed from 2014-2019. Implants were flexible nails, intramedullary rigid nails, long plates, screw(s), single guided-growth plates, and multiple guided-growth plates. Patient demographics, operative time, blood loss, complications, and relative value units (RVU)/min were collected. RVU/min was used to maximize rate. In total, 392 patients were analyzed. Long plate removals took significantly longer than screw removal, therefore RVU/min was significantly lower (p < 0.001). Long plate removals also took significantly longer, and RVU/min was significantly lower compared to guided-growth plate removal (p < 0.001). Intramedullary nails took significantly longer compared to flexible nails, nearly double the RVU/min (p = 0.02). The results from this study indicate that the RVU/ minute for these six different types of implant removals are not equal. Surgeons can use this data to set up their schedule to ensure maximum utilization. (Journal of Surgical Orthopaedic Advances 30(1):020-023, 2021).

Demographic Analysis of Pedicle Diameter, and Estimated Pedicle Screw Length of the Lumbar Spine in a Diverse Population.

BACKGROUND: Recent literature confirms the importance of understanding the variability in pedicle morphology among races. These studies suggest that more detailed and reliable measurements of pedicles should be undertaken. However, there is limited data on average pedicle diameters (PDs) or estimated pedicle screw lengths (EPSLs) between diverse racial populations. We sought to determine the differences in PD and EPSL in the lumbar spine between various races: "Asian," "Black," "White," and "Hispanic" to aid in perioperative planning during instrumented spinal fusion. METHODS: Axial cuts of 404 patients were inspected to obtain their transverse outer cortical PD as measured through the isthmus, and EPSL by measuring the posterior entry point at the longest distance, which perpendicularly transected the measured isthmic diameter, to the anterior vertebral cortex from L1 to L5. We examined the average PD and PD range at each level for each race. To determine the significance, we used a mixed analysis of variance and a post hoc analysis. RESULTS: In this retrospective chart review the races were found to be significantly different in PD and EPSL (P < .001). Post hoc analysis using Dunn-Bonferroni correction showed that Asians had significantly smaller PDs than Blacks and Whites (P < .002 and P < .014, respectively). The White and Hispanic population had significantly longer EPSLs when compared to Blacks and Asians from L1 to L5 (P < .01). CONCLUSIONS: This study demonstrates that there are significant differences in pedicle morphology among races that must be taken into consideration when inserting pedicle screws during lumbar spinal fusion. Knowledge of these differences is of the utmost importance in order to limit complications while improving fixation. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Pedicle morphology is variable between races and understanding these differences is important for the safe placement of pedicle screws.

Factors Predicting Hemodynamic Interventions During Inpatient Admission After Shoulder Arthroplasty.

BACKGROUND: We sought to identify the influence of shoulder arthroplasty (SA) type (primary anatomic, primary reverse, revision) and indication (fracture, arthritis) on the risk of postoperative packed red blood cell transfusion (pRBCT) and intravenous fluid bolus (IVFB). METHODS: Patients who underwent SA from 2013 through 2016 at our institution were categorized into four groups: primary anatomic (pTSA; N = 298), primary reverse (pRTSA; N = 292), revision (RevSA; N = 133), and shoulder arthroplasty for fracture (SAF; N = 58). Basic demographics, intraoperative metrics, preoperative lab values, and postoperative interventions (pRBCT and IVFB) were retrieved from electronic records. RESULTS: There were 781 SAs, of which 176 cases involved at least one postoperative intervention: pRBCT (6.3%) or IVFB (18.8%). Compared to pTSA, the odds of pRBCT in pRTSA, revSA, and SAF were: 3.0 (95% CI 0.9-10.0), 3.4 (95% CI 0.9-2.7), and 8.6 (95% CI 2.2-32.9), respectively. Independent risk factors for pRBCT included increasing age (p = 0.003), underweight body mass index (p = 0.019), Charlson Comorbidity Index ≥ 3 (p = 0.002), inpatient discharge to higher level of care (p = 0.011), estimated blood loss (p = 0.003), and preoperative hemoglobin (p ≤ 0.001). Also, compared to pTSA, the odds for IVFB in pRTSA, revSA, and SAF were: 2.8 (95% CI 1.7-4.6), 2.2 (95% CI 1.2-4.0), and 4.7 (95% CI 2.2-9.9), respectively. Other independent risk factors for IVFB included female sex (0.002), CCI ≥ 3 (p = 0.017), and operative time (p = 0.047). CONCLUSION: Shoulder arthroplasty for fracture is an independent risk factor for higher risk of postoperative pRBCT and IVFB.

Surgeon volume affects short- and long-term surgical outcomes in idiopathic scoliosis.

STUDY DESIGN: Retrospective review of New York Statewide Planning and Research Cooperative System (SPARCS) Inpatient Database. OBJECTIVE: To identify the differences in short- and long-term complications, following long-segment pediatric spinal fusion in idiopathic scoliosis surgery, between surgeons with low versus high annual surgical volume. Spinal deformity surgery is complex and requires significant training and repetition to master. Surgeon and hospital volume have been shown to correlate with outcomes following cervical and lumbar spine surgery. However, there is limited literature regarding the impact of surgeon volume on long-term outcomes following pediatric idiopathic spinal deformity correction. METHODS: This is a retrospective review of the SPARCS inpatient database from 2004 to 2013 of pediatric patients who underwent idiopathic scoliosis surgery. Surgeons were stratified into high (> 15 cases/year)- and low (≤ 15 cases/year)-volume cohorts by aggregating all cases completed over the study period until 50% of the total cases were captured above and below an average case per-year threshold. This threshold occurred at 15 cases/year. Short-term and long-term readmission and medical/surgical complications were collected. Multivariate logistic regression models assessed the risk of short- and long-term complications between cohorts. RESULTS: 3910 pediatric patients underwent a primary arthrodesis from a total of 223 surgeons. More high-volume surgeons operated at academic teaching hospitals (p < 0.001), used a combined AP surgical approach (p < 0.001), and fewer utilized rhBMP (p < 0.001). High-volume surgeons had shorter lengths of stay (p < 0.001). Low-volume surgeons had increased odds of inpatient surgical complications (OR 1.55, 95% CI 1.00-2.45). Low-volume surgeons had increased odds of revision at 5 and 10 years (5 years. OR 1.56, 95% CI 1.05-2.31; 10 years. OR 1.59, 95% CI 1.09-2.31). Low-volume surgeons had increased odds of implant malfunction at 10 years (OR 1.81, 95% CI 1.15-2.86). CONCLUSIONS: High-volume surgeons had decreased odds of short- and long-term complications compared to low volume when performing primary spinal arthrodesis in idiopathic scoliosis. Low-volume surgeons experienced significantly greater odds of inpatient surgical complications, as well as increased risk of revision during long-term follow-up with a significantly increased risk of implant malfunction at 10 years post-operatively. LEVEL OF EVIDENCE: Level III.

The Screw-Aorta Dilemma: Changing Patient Position in Computed Tomography Scan Is Critical in Documenting Aortic Mobility.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To determine if obtaining a prone computed tomography (CT)-scan can better delineate a questionable screw-aorta relationship. SUMMARY OF BACKGROUND DATA: Pedicle screw misplacement rate is reported between 6% and 15%. Studies looking at misplacements on a per patient basis show up to 14% of patients have screws at risk (impinging vital structures). A screw abutting the aorta is a management challenge and often requires vascular surgery intervention. However, CT scans routinely done in supine position may overestimate screw-aorta relationship. Change in patient position may allow the aorta to roll away and, in most cases, reveal an uncompromised aorta. This will allow safe removal of pedicle screws without any vascular intervention. METHODS: One hundred eleven spinal deformity patients who underwent Posterior spinal fusion from 2004 to 2009 were evaluated. Patients with concerning screw-aorta relationship underwent additional prone CT scan. Mobility of the aorta was determined and distance was compared using prone and supine CT scans. RESULTS: Two thousand two hundred ninety five screws were reviewed, 36 screws in 18 patients were in proximity to the aorta. Fourteen screws (nine patients) appeared to be impinging the aorta. On prone CT, 13 out of the 14 instances the aorta moved away from the screw. The average distance at the screw level was 13.6 ±â€Š4.8 mm in supine position and 8.9 ±â€Š5.4 mm in prone position (P = 0.001). In one instance the relationship was unchanged on prone CT. No screw was noted to violate the lumen or distort the aorta. CONCLUSION: Supine CT scan alone is not entirely accurate in determining screw-aorta relationship. Prone-CT scan provides additional information for better delineation. This additional diagnostic step can change the treatment option by limiting the need for vascular intervention. When in doubt, the additional use of an arteriogram can allow for improved visualization. LEVEL OF EVIDENCE: 3.