Imaging of traumatic shoulder injuries - Understanding the surgeon's perspective.

Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon's perspective.

Risk factors for postoperative coronal decompensation in adult lumbar scoliosis after posterior correction with osteotomy.

INTRODUCTION: To determine potential risk factors for postoperative coronal imbalance following posterior osteotomy for adult scoliosis. MATERIALS AND METHODS: A total of 74 patients underwent osteotomy for rigid adult lumbar scoliosis. A group of 20 patients with postoperative coronal imbalance was identified. Clinical data and surgical strategies were compared to determine the risk factors, including age, gender, etiology, Cobb angle, preoperative coronal balance distance, direction of preoperative imbalance, T1 tilt, tilt of upper instrumented vertebra (UIV), UIV translation, location of UIV (T6 above or below), fusion to L5 or S1, lower instrumented vertebra (LIV) tilt, LIV rotation, screw density, osteotomy procedure (PSO or SPOs) and use of iliac screws. RESULTS: Comparison between patients with and without postoperative coronal imbalance showed that postoperative coronal imbalance occurred in older patients and those with degenerative scoliosis as the etiology, UIV above T6, preoperative LIV rotation, preoperative LIV tilt and preoperative coronal imbalance towards the convex side and who underwent Smith-Petersen osteotomy. All seven parameters were included in the logistic regression analysis. UIV above T6 (P = 0.010), LIV rotation (P = 0.012) and preoperative coronal imbalance towards the convex side (P = 0.005) were identified as risk factors for postoperative coronal imbalance after osteotomy. CONCLUSIONS: Patients with preoperative coronal imbalance towards the convex side (UIV above T6) and LIV rotation were more likely to develop coronal imbalance than those without risk factors. Older patients and those with degenerative scoliosis were also at a relatively higher risk of postoperative coronal imbalance.

A Case Report of a Successful Percutaneous Trial and Surgical Placement of a Spinal Cord Stimulator in a Patient With Severe Thoracolumbar Scoliosis.

Spinal cord stimulation has been demonstrated as a therapeutic option for patients with persistent lumbar radicular pain secondary to failed back surgery syndrome. This case report demonstrates a successful percutaneous spinal cord stimulator (SCS) trial followed by surgical placement of a permanent SCS to treat lumbar radicular pain and axial low back pain in a patient with severe thoracolumbar scoliosis status after laminectomy and spinal fusion surgery. Currently, there is a paucity of literature on this topic.

A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis.

BACKGROUND: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. METHODS: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. RESULTS: Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively. CONCLUSIONS: As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly. CLINICAL RELEVANCE: Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.

Resident Participation is Not Associated With Worse Outcomes After TKA.

BACKGROUND: Approximately one-half of all US surgical procedures, and one-third of orthopaedic procedures, are performed at teaching hospitals. However, the effect of resident participation and their level of training on patient care for TKA postoperative physical function, operative time, length of stay, and facility discharge are unclear. QUESTIONS/PURPOSES: (1) Are resident participation, postgraduate year (PGY) training level, and number of residents associated with absolute postoperative Patient-Reported Outcomes Measurement Information System (PROMIS®-10) global physical function score (PCS), and achieving minimum clinically important difference (MCID) PCS improvement, after TKA? (2) Are resident participation, PGY, and number of residents associated with increased TKA operative time? (3) Are resident participation, PGY, and number of residents associated with increased length of stay after TKA? (4) Are resident participation, PGY, and number of residents associated with higher odds of patients being discharged to another inpatient facility, rather than to their home (facility discharge)? METHODS: We performed a retrospective study using a longitudinally maintained institutional registry of TKAs that included 1626 patients at a single tertiary academic institution from April 2011 through July 2016. All patients who underwent primary, elective unilateral TKA were included with no exclusions. All patients were included in the operative time, length of stay, and facility discharge models. The PCS model required postoperative PCS score (n = 1417; 87%; mean, 46.4; SD, 8.5) and the MCID PCS model required pre- and postoperative PCS (n = 1333; 82%; 55% achieved MCID). Resident participation was defined as named residents being present in the operating room and documented in the operative notes, and resident PGY level was determined by the date of TKA and its duration since the resident entered the program and using the standard resident academic calendar (July - June). Multivariable regression was used to assess PCS scores, operative time, length of stay, and facility discharge in patients whose surgery was performed with and without intraoperative resident participation, accounting for PGY training level and number of residents. We defined the MCID PCS score improvement as 5 points on a 100-point scale. Adjusting variables included surgeon, academic year, age, sex, race-ethnicity, Charlson Comorbidity Index, preoperative PCS, and patient-reported mental function, BMI, tobacco use, alcohol use, and postoperative PCS time for the PCS models. We had postoperative PCS for 1417 (87%) surgeries. RESULTS: Compared with attending-only TKAs (5% of procedures), no postgraduate year or number of residents was associated with either postoperative PCS or MCID PCS improvement (PCS: PGY-1 = -0.98, 95% CI, -6.14 to 4.17, p = 0.708; PGY-2 = -0.26, 95% CI, -2.01to 1.49, p = 0.768; PGY-3 = -0.32, 95% CI, -2.16 to 1.51, p = 0.730; PGY-4 = -0.28, 95% CI, -1.99 to 1.43, p = 0.746; PGY-5 = -0.47, 95% CI, -2.13 to 1.18, p = 0.575; two residents = 0.28, 95% CI, -1.05 to 1.62, p = 0.677) (MCID PCS: PGY-1 = odds ratio [OR], 0.30, 95% CI, 0.07-1.30, p = 0.108; PGY-2 = OR, 0.86, 95% CI, 0.46-1.62, p = 0.641; PGY-3 = OR, 0.97, 95% CI, 0.49-1.89, p = 0.921; PGY-4 = OR, 0.73, 95% CI, 0.39-1.36, p = 0.325; PGY-5 = OR, 0.71, 95% CI, 0.39-1.29, p = 0.259; two residents = OR, 1.23, 95% CI, 0.80-1.89, p = 0.337). Longer operative times were associated with all PGY levels except for PGY-5 (attending surgeon only [reference] = 85.60 minutes, SD, 14.5 minutes; PGY-1 = 100. 13 minutes, SD, 21.22 minutes, +8.44 minutes, p = 0.015; PGY-2 = 103.40 minutes, SD, 23.01 minutes, +11.63 minutes, p < 0.001; PGY-3 = 97.82 minutes, SD, 18.24 minutes, +9.68 minutes, p < 0.001; PGY-4 = 96.39 minutes, SD, 18.94 minutes, +4.19 minutes, p = 0.011; PGY-5 = 88.91 minutes, SD, 19.81 minutes, -0.29 minutes, p = 0.853) or the presence of multiple residents (+4.39 minutes, p = 0.024). There were no associations with length of stay (PGY-1 = +0.04 days, 95% CI, -0.63 to 0.71 days, p = 0.912; PGY-2 = -0.08 days, 95% CI, -0.48 to 0.33 days, p = 0.711; PGY-3 = -0.29 days, 95% CI, -0.66 to 0.09 days, p = 0.131; PGY-4 = -0.30 days, 95% CI, -0.69 to 0.08 days, p = 0.120; PGY-5 = -0.28 days, 95% CI, -0.66 to 0.10 days, p = 0.145; two residents = -0.12 days, 95% CI, -0.29 to 0.06 days, p = 0.196) or facility discharge (PGY-1 = OR, 1.03, 95% CI, 0.26-4.08, p = 0.970; PGY-2 = OR, 0.61, 95% CI, 0.31-1.20, p = 0.154; PGY-3 = OR, 0.98, 95% CI, 0.48-2.02, p = 0.964; PGY-4 = OR, 0.83, 95% CI, 0.43-1.57, p = 0.599; PGY-5 = OR, 0.7, 95% CI, 0.41-1.40, p = 0.372; two residents = OR, 0.93, 95% CI, 0.56-1.54, p = 0.766) for any PGY or number of residents. CONCLUSIONS: Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety.Level of Evidence Level III, therapeutic study.

Symptomatic Lumbar Facet Synovial Cysts: Clinical Outcomes Following Percutaneous CT-Guided Cyst Rupture with Intra-articular Steroid Injection.

PURPOSE: To evaluate clinical outcomes following percutaneous rupture of symptomatic lumbar facet synovial cysts (LFSCs) with intra-articular steroid injection. MATERIALS AND METHODS: In this retrospective review, 44 consecutive patients with symptomatic LFSCs received primary treatment with CT-guided synovial cyst rupture with intra-articular steroid injection. Outcomes questionnaires were obtained before and 1, 4, 26, and 52 weeks after LFSC rupture. Assessment included pain medication use and numeric rating scale (NRS), Oswestry Disability Index (ODI), and 12-item short form health survey (SF-12) physical and mental composite scores (PCS and MCS). Clinical endpoint was 52-week survey response or surgery. RESULTS: LFSC rupture was technically successful in 84% (37/44) of cases. Clinical endpoint was reached in 68% (30/44) of patients with 82% overall 1-year follow-up. Lumbar spine surgery was performed in 25% (11/44) of patients within 1 year after procedure. Mean NRS, ODI, and SF-12 PCS demonstrated significant improvement at all follow-up time points (P < .001). At 52-week follow-up, NRS decreased from 8.1 to 3.7 (P < .001), ODI improved from 35 to 24 (P = .006), and SF-12 PCS improved from 31 to 42 (P < .001). Daily pain medication decreased from 71% (31/44) of patients before procedure to 29% (9/26) at 52-week follow-up (P = .012). History of prior lumbar intervention was associated with poorer LFSC rupture success (P = .025) and ODI (P = .047). CONCLUSIONS: NRS, ODI, and SF-12 PCS indices improved and pain medication use decreased significantly at all time points over 1-year follow-up after percutaneous rupture of symptomatic LFSCs with intra-articular steroid injection.

Do the disc degeneration and osteophyte contribute to the curve rigidity of degenerative scoliosis?

BACKGROUND: The factors associated with lateral curve flexibility in degenerative scoliosis have not been well documented. Disc degeneration could result in significant change in stiffness and range of motion in lateral bending films. The osteophytes could be commonly observed in degenerative spine but the relationship between osteophyte formation and curve flexibility remains controversial. The aim of the current study is to clarify if the disc degeneration and osteophyte formation were both associated with curve flexibility of degenerative scoliosis. METHODS: A total of 85 patients were retrospectively analyzed. The inclusion criteria were as follow: age greater than 45 years, diagnosed as degenerative scoliosis and coronal Cobb angle greater than 20°. Curve flexibility was calculated based on Cobb angle, and range of motion (ROM) was based on disc angle evaluation. Regional disc degeneration score (RDS) was obtained according to Pfirrmann classification and osteophyte formation score (OFS) was based on Nanthan classification. Spearman correlation was performed to analyze the relationship between curve flexibility and RDS as well as OFS. RESULTS: Moderate correlation was found between RDS and curve flexibility with a Spearman coefficient of -0.487 (P = 0.009). Similarly, moderate correlation was observed between curve flexibility and OFS with a Spearman coefficient of -0.429 (P = 0.012). Strong correlation was found between apical ROM and OFS compared to the relationship between curve flexibility and OFS with a Spearman coefficient of -0.627 (P < 0.001). CONCLUSIONS: Both disc degeneration and osteophytes formation correlated with curve rigidity. The pre-operative evaluation of both features may aid in the surgical decision-making in degenerative scoliosis patients.

Comparison of Surgical Outcome of Adolescent Idiopathic Scoliosis and Young Adult Idiopathic Scoliosis: A Match-Pair Analysis of 160 Patients.

STUDY DESIGN: Retrospective study. OBJECTIVE: To investigate if the surgical outcome of young adults was equivalent to adolescents for surgical correction of thoracic adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Despite numerous reports on the satisfactory surgical correction, some AIS patients or families still have the assumption that delay of surgery into young adulthood may be more beneficial. Hence, the strict paired analysis of clinical outcome between AIS and adult idiopathic scoliosis (AdIS) is required, which lacks report in the current literature. METHODS: This is a retrospective 1:1 matched cohort. A total of 80 pairs were recruited with the following inclusion criteria: (A) female Lenke Type 1A or 1B idiopathic scoliosis; (B) selective fusion; (C) adolescents aged 10 to 18 years and young adults aged 19 to 29 years; (D) one-stage posterior approach; (E) all-pedicle-screws instrumentations; (F) major Cobb angle 45° to 80°. AIS patients and AdIS patients were matched for apex, major thoracic curve magnitude (±5°), lumbar curve magnitude (±5°), time of surgery (±6 month), and follow-up (±6 month). RESULTS: The age at the time of surgery in AdIS patients averaged 22.21years, significantly larger than that of AIS patients (22.21 vs. 14.47 yr). AdIS patients had significant lower curve flexibility. Accordingly, lower correction rate and larger postoperative main Cobb angle were found in AdIS patients. Regarding quality of life, no significant difference was observed between the two groups during follow-up. CONCLUSION: The results may provide evidence for spine surgeons to communicate with AIS patients and their families regarding pros and cons of the delay of surgery into young adulthood. AIS patients would gain better radiographic curve correction compared with matched AdIS patients due to more flexibility. When considering potential curve progression, the radiographic outcome of AdIS may be even worse. Whereas delaying to adulthood may have similar health-related quality of life and reduce the risk of adding-on phenomenon. LEVEL OF EVIDENCE: 3.

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.

Halo-gravity traction combined with assisted ventilation: an effective pre-operative management for severe adult scoliosis complicated with respiratory dysfunction.

PURPOSE: To investigate the change of pulmonary function in adult scoliosis patients with respiratory dysfunction undergoing HGT combined with assisted ventilation. METHODS: 21 adult patients were retrospectively reviewed with a mean age of 26.2 years. Inclusion criteria were as follows: age over 18 years old; coronal Cobb angle greater than 100°; with respiratory failure; and duration of HGT more than 1 month. All patients underwent respiratory training. RESULTS: The Cobb angle averaged 131.21° and was reduced to 107.68° after HGT. Significantly increased mean forced vital capacity (FVC) was found after HGT (P = 0.003) with significantly improved percent-predicted values for FVC (P < 0.001). Meanwhile, significantly increased forced expiratory volume in 1 s (FEV1) was also observed (P < 0.001) with significantly improved percent-predicted values for FEV1 (P = 0.003) after HGT. CONCLUSION: The results of our study revealed that combined HGT and assisted ventilation would be beneficial to pulmonary function improvement in severe adult scoliosis cases, most of which were young adults.

Validation and Reliability Analysis of the Spinal Deformity Study Group Classification for L5-S1 Lumbar Spondylolisthesis.

STUDY DESIGN: An intra- and interobserver reliability study. OBJECTIVE: To assess the intra- and interobserver reliability of the Spinal Deformity Study Group (SDSG) system for classifying adolescent and adult L5-S1 spondylolisthesis. SUMMARY OF BACKGROUND DATA: Reliability of the SDSG classification has only been previously validated in adolescent patients as performed by the SDSG study group investigators. METHODS: A total of 80 patients with L5-S1 spondylolisthesis were included in this study. Only dysplastic and isthmic spondylolisthesis were included in this study. Long-cassette standing lateral radiographs of the spine and pelvis were obtained. All 80 cases were classified according to the SDSG classification by four observers. After a 2-week interval, the same classification was independently repeated by each observer with the cases in a different randomly assigned order. The Fleiss' κ coefficient was calculated to test the intra- and interobserver reliabilities of the SDSG classification. RESULTS: The present study included all six types of SDSG classification. Overall intra- and interobserver agreements were 86.6% (κ: 0.830) and 73.3% (κ: 0.648), respectively. The intra- and interobserver agreements and repeatability associated with slip grade were 89.7% (κ: 0.824) and 87.7% (κ: 0.721), respectively. Regarding sacropelvic and spinal balance, intra- and interobserver agreements and repeatability were 83.7% (κ: 0.735) and 77.5% (κ: 0.602) for low-grade slips, and 90.75% (κ: 0.883) and 90.4% (κ: 0.851) for high-grade slips, respectively. CONCLUSION: Substantial intra- and interobserver reliability was found for the SDSG classification in L5-S1 lumbar spondylolisthesis. SDSG classification system is a simple and clear classification scheme incorporating spinopelvic parameters, which provides significant clinical utility. LEVEL OF EVIDENCE: 3.

Scoliosis related information on the internet in China: can patients benefit from this information?

BACKGROUND: There has been an increasing popularity of searching health related information online in recent years. Despite that considerable amount of scoliosis patients have shown interest in obtaining scoliosis information through Internet, previous studies have demonstrated poor quality of online information. However, this conclusion may vary depending on region and culture. Since China has a restricted Internet access outside of its borders, the aim of this study is to evaluate the quality of scoliosis information available online using recognized scoring systems and to analyze the Internet as a source of health information in China. METHODS: A survey-based questionnaire was distributed to 280 respondents at outpatient clinics. Information on demographics and Internet use was collected. Binary logistic analysis was performed to identify possible predictors for the use of Internet. In addition, the top 60 scoliosis related websites assessed through 4 search engines were reviewed by a surgeon and the quality of online information was evaluated using DISCERN score and JAMA benchmark. RESULTS: Use of the Internet as a source for scoliosis related information was confirmed in 87.8% of the respondents. College education, Internet access at home and urban residence were identified as potential predictors for Internet use. However, the quality of online scoliosis related information was poor with an average DISCERN score of 27.9±11.7 and may be misleading for scoliosis patients. CONCLUSION: The study outlines the profile of scoliosis patients who use the Internet as a source of health information. It was shown that 87.8% of the scoliosis patients in outpatient clinics have searched for scoliosis related information on Internet. Urban patients, higher education and Internet access at home were identified as potential predictors for Internet search. However, the overall quality of online scoliosis related information was poor and confusing. Physician based websites seemed to contain more reliable information.

Prognostic implications of quantitative evaluation of baseline Q-wave width in ST-segment elevation myocardial infarction.

OBJECTIVES: To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Baseline Q-waves are useful in predicting clinical outcomes after MI. METHODS: 3589 STEMI patients were assessed from a multi-centre study. RESULTS: 1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p<0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥40ms for inferior and ≥20ms for lateral/apical MI in all patients (n=3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54-3.85), p<0.001) and the composite (HR: 2.32, 95% CI (1.70-3.16), p<0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p<0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02-0.29), p=0.027). CONCLUSIONS: The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥40ms in inferior and ≥20ms for lateral/apical MI enhances prognostic insight beyond current criteria.