Surgeon Learning Curve for the Sinus Tarsi Approach to Intra-articular Calcaneus Fractures - Improvement with Experience.

OBJECTIVE: To analyze the relationship between surgeon experience with the sinus tarsi approach (STA) and outcomes in the treatment of displaced intra-articular calcaneus fractures (DIACF). SETTING: Single level 1 trauma center. DESIGN: Retrospective.Patients/Participants: 103 consecutive DIACF (OTA/AO 82C; Sanders II-IV) treated operatively using STA from 2015 to 2021. INTERVENTION: Open management using the STA performed by two fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENT: Quality of anatomic reduction based on postoperative CT scans and standard radiographs. RESULTS: Sixty-six patients met inclusion criteria. Patients were primarily men (75.8%) with mean age 41 years (range 20-71 years), including 14 smokers (21.2%), 9 diabetics (13.6%), and 10 open fractures (15.2%). Sanders III fractures were most common (68.2% vs 28.5% and 6.1% Sanders II/IV respectively). Reduction quality was predominantly Good (59.1%, n=39) or Excellent (25.8%, n=17). Complications included wound necrosis (1), superficial infection (1), deep infection (1), and symptomatic posttraumatic arthritis requiring arthrodesis (3). There was a 29.3% reduction in likelihood of surgical complication with each year in surgeon experience with the STA and an 8.9% reduction per case (p<0.001). The likelihood of achieving a Good or Excellent reduction was 1.8 and 2.3 times greater than achieving a Fair reduction, respectively, for each year increase in surgeon experience with the STA (p=0.012 and 0.007, respectively). For each successive case, there was a 1.2 times greater likelihood of achieving a Good reduction (p=0.03). CONCLUSION: Surgeon experience plays a critical role in outcomes. We found that outcomes (reduction, complications) improve with each cumulative case and year of experience with the STA to treat DIACF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Augmented Reality-Assisted Spine Surgery: An Early Experience Demonstrating Safety and Accuracy with 218 Screws.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: In spine surgery, accurate screw guidance is critical to achieving satisfactory fixation. Augmented reality (AR) is a novel technology to assist in screw placement and has shown promising results in early studies. This study aims to provide our early experience evaluating safety and efficacy with an Food and Drug Administration-approved head-mounted (head-mounted device augmented reality (HMD-AR)) device. METHODS: Consecutive adult patients undergoing AR-assisted thoracolumbar fusion between October 2020 and August 2021 with 2 -week follow-up were included. Preoperative, intraoperative, and postoperative data were collected to include demographics, complications, revision surgeries, and AR performance. Intraoperative 3D imaging was used to assess screw accuracy using the Gertzbein-Robbins (G-R) grading scale. RESULTS: Thirty-two patients (40.6% male) were included with a total of 222 screws executed using HMD-AR. Intraoperatively, 4 (1.8%) were deemed misplaced and revised using AR or freehand. The remaining 218 (98.2%) screws were placed accurately. There were no intraoperative adverse events or complications, and AR was not abandoned in any case. Of the 208 AR-placed screws with 3D imaging confirmation, 97.1% were considered clinically accurate (91.8% Grade A, 5.3% Grade B). There were no early postoperative surgical complications or revision surgeries during the 2 -week follow-up. CONCLUSIONS: This early experience study reports an overall G-R accuracy of 97.1% across 218 AR-guided screws with no intra or early postoperative complications. This shows that HMD-AR-assisted spine surgery is a safe and accurate tool for pedicle, cortical, and pelvic fixation. Larger studies are needed to continue to support this compelling evolution in spine surgery.

Opioid use after elective spine surgery: Do spine surgery patients consume less than prescribed today?

Background: The opioid epidemic in the US has led prescribers to reevaluate postoperative pain control particularly in the field of spine surgery, where postoperative analgesia requirements and consumption have historically been high. There is a need to mitigate the quantity of unused pills after surgery by adjusting prescribing practices. Achieving the balance of pain control after surgery without overprescribing opioids may be accomplished by developing a modified approach to prescribing practices; however, there is a need to first understand the opioid requirements of the modern spine surgery patient with respect to their elective spine surgery. Therefore, the primary aim of this study was to determine the percentage of opioids not utilized at 90-days after elective spine surgery. Secondary aims were to identify differences in the percentage of unused opioids between surgical subgroups and preoperative opioid status, to determine factors associated with opioid utilization, and to estimate the distribution of opioids consumed to control pain up to the 90th percentile in each surgical subgroup. Methods: In this prospective, observational cohort study, adults undergoing elective spine surgery at a multi-surgeon, single center were prospectively enrolled and divided into subgroups: anterior cervical, lumbar decompression, and short-segment lumbar fusion. Prescribed MMEs were identified from prescriptions, consumed MMEs were obtained from pill counts, and the percent leftover was calculated. Distributions of MMEs consumed were analyzed to compare utilization between preoperative opioid users or non-users within each surgical subgroup. Results: Of 117 patients, 41.9% were preoperative opioid users. The percentage of unused opioids by surgical subgroup was: 45.4% cervical, 57.3% lumbar decompression, and 37.4% lumbar fusion (p=0.066). The percentage of unused opioids by preoperative opioid exposure was greater in the opioid non-users (58.0%) than users (28.4%, p<0.001)). Regression analysis showed that surgical subgroup and preoperative opioid exposure were associated with leftover opioids. Conclusions: At 90-days, the percentage of unused opioids was over 45% in this cohort of elective spine surgery patients and was nearly double in the group without preoperative opioid exposure. These results suggest the modern elective spine surgery patient is using less opioids than prescribed, supporting the conclusion that the number of MMEs prescribed can be reduced to minimize quantities of leftover pills available for diversion, without sacrificing the priority of appropriate postoperative pain control.

Low Back Pain, Disability, and Quality of Life One Year following Intradiscal Injection of Autologous Bone Marrow Aspirate Concentrate.

Introduction: Degenerative disc disease is a common cause of chronic low back pain. Surgical intervention is an invasive treatment associated with high costs. There is growing interest in regenerative medicine as a less invasive but direct disc treatment for chronic discogenic low back pain. Objective: To evaluate clinical improvement of primary discogenic low back pain with intradiscal injection of autologous bone marrow aspirate concentrate (BMAC). Study Design. Prospective cohort study. Setting. Single, multiphysician center. Patients. 32 adult patients undergoing intradiscal injection of autologous BMAC for the treatment of primary discogenic low back pain. Interventions. Intradiscal injection of autologous BMAC. Main Outcome Measures. Primary outcome measure is visual analog back pain scale (VAS back pain). Secondary outcome measures include ODI, VAS leg pain, and EQ-5D-5L scores. Outcomes were compared from baseline to 1 year. Results: Thirty-two patients (56.3% male) with a mean age of 45.9 years were enrolled, giving 92 treated levels. Mean VAS back and leg pain scores improved from 5.4 to 3.0 (p < 0.001) and 2.8 to 1.3 (p = 0.005), respectively. Mean ODI scores decreased from 33.5 to 21.1 (p < 0.001), and EQ-5D-5L scores improved from 0.69 to 0.78 (p = 0.001). Using established MCID values, 59.4% had clinically significant improvement in VAS back pain, 43.8% in VAS leg pain, and 56.3% in ODI scores. Conclusion: Intradiscal injection of autologous BMAC significantly improved low back pain, disability, and quality of life at one year. This study suggests that intradiscal BMAC has the potential to be an effective nonsurgical treatment for chronic discogenic low back pain.

Novel artificial intelligence algorithm: an accurate and independent measure of spinopelvic parameters.

OBJECTIVE: The analysis of sagittal alignment by measuring spinopelvic parameters has been widely adopted among spine surgeons globally, and sagittal imbalance is a well-documented cause of poor quality of life. These measurements are time-consuming but necessary to make, which creates a growing need for an automated analysis tool that measures spinopelvic parameters with speed, precision, and reproducibility without relying on user input. This study introduces and evaluates an algorithm based on artificial intelligence (AI) that fully automatically measures spinopelvic parameters. METHODS: Two hundred lateral lumbar radiographs (pre- and postoperative images from 100 patients undergoing lumbar fusion) were retrospectively analyzed by board-certified spine surgeons who digitally measured lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope. The novel AI algorithm was also used to measure the same parameters. To evaluate the agreement between human and AI-automated measurements, the mean error (95% CI, SD) was calculated and interrater reliability was assessed using the 2-way random single-measure intraclass correlation coefficient (ICC). ICC values larger than 0.75 were considered excellent. RESULTS: The AI algorithm determined all parameters in 98% of preoperative and in 95% of postoperative images with excellent ICC values (preoperative range 0.85-0.92, postoperative range 0.81-0.87). The mean errors were smallest for pelvic incidence both pre- and postoperatively (preoperatively -0.5° [95% CI -1.5° to 0.6°] and postoperatively 0.0° [95% CI -1.1° to 1.2°]) and largest preoperatively for sacral slope (-2.2° [95% CI -3.0° to -1.5°]) and postoperatively for lumbar lordosis (3.8° [95% CI 2.5° to 5.0°]). CONCLUSIONS: Advancements in AI translate to the arena of medical imaging analysis. This method of measuring spinopelvic parameters on spine radiographs has excellent reliability comparable to expert human raters. This application allows users to accurately obtain critical spinopelvic measurements automatically, which can be applied to clinical practice. This solution can assist physicians by saving time in routine work and by avoiding error-prone manual measurements.

Adoption of enhanced surgical recovery (ESR) protocol for adult spinal deformity (ASD) surgery decreases in-hospital and 90-day post-operative opioid consumption.

PURPOSE: Retrospective observational cohort study of primary adult spinal deformity (ASD) surgery during the transitional period prior to and after the implementation of Enhanced Surgical Recovery (ESR) at a single center. We sought to determine if ESR reduces in-hospital and 90-day post-operative opioid consumption for ASD surgery. METHODS: We evaluated patients undergoing primary ASD surgery in the transition period prior to (N = 29) and after (N = 56) adoption of ESR, comparing in-hospital and 90-day post-operative opioid consumption. Regression analysis was used to control for confounders including age, number of surgical levels, surgical approach, staged vs same-day surgery, insurance type and pre-op opioid use. RESULTS: Mean age of the cohort was 53 years with 57 (60%) females. Regression analysis showed that pre-operative opioid use and number of levels fused were associated with higher in-hospital and 90-day post-operative opioid consumption, while use of ESR was associated with lower in-hospital and 90-day post-operative opioid consumption. Secondary analysis showed that patients on ESR ambulated earlier (0.6 days vs 1.1, p = 0.028) and had their urinary catheter removed earlier (2.7 days vs 3.9, p = 0.006) compared to non-ESR patients. CONCLUSIONS: ESR was associated with a significantly decreased in-hospital and 90-day post-operative opioid consumption and earlier mobilization with earlier urinary catheter removal in patients undergoing primary ASD surgery. These results demonstrate ESR's potential to improve outcomes in ASD perioperative care. LEVEL OF EVIDENCE: 3.

Robotic-guidance allows for accurate S2AI screw placement without complications.

The study design is retrospective, multi-surgeon, single-center review. The objective is to evaluate complication rates, revision rates, and accuracy grading for robotic-guided S2 alar-iliac (S2AI) screws. Sixty-five consecutive patients underwent S2AI fixation (118 screws) as part of a posterior spine fusion using robotic-guidance. Screws were placed percutaneously in 14 cases and 51 were placed in an open fashion by three board-certified spine surgeons using the Mazor core technology robotic systems (Mazor X, n = 42; Mazor XSE, n = 23). Medical charts were retrospectively reviewed for revisions and complications. All patients were followed for 90 days or greater. Postoperative CT scans were obtained in 22 of the 51 patients, allowing for 46 screws to be reviewed by an independent neuroradiologist who graded the screws for accuracy. There were no intraoperative or postoperative complications associated with S2AI screw placement. There were no revisions found to be related to the S2AI screw placement. All 46 screws evaluated with postoperative CT scans were reported as being at the highest level of accuracy, grade A, with a breach distance of 0 mm (no breach). The robotic-guided technique for S2AI screw placement is a reliable method to achieving pelvic fixation with low complication and revision rates. In addition, a high degree of accuracy can be achieved without relying on visible and tactile landmarks needed for the freehand technique or the additional radiation associated with fluoroscopic-guidance.

Influence of preoperative factors on timing for bilateral shoulder arthroplasty.

INTRODUCTION: In bilateral shoulder arthroplasty patients, it is unclear what features are responsible for the timing of their contralateral shoulder arthroplasty. This study hypothesized that patient factors (age, gender, and hand dominance), disease factors (diagnosis and radiographic severity of contralateral shoulder), and surgical factors (type of arthroplasty) impact the timing to contralateral surgery. METHODS: A retrospective review of 332 patients treated with bilateral anatomic (TSA) or reverse (RSA) shoulder arthroplasty (172 TSA/TSA, 107 RSA/RSA, or 53 TSA/RSA) were divided into groups depending on the interval timing between arthroplasty surgeries: group 1, n = 142 (≤1 year); group 2, n = 62 (1-2 years); and group 3, n = 128 (≥2 years). Preoperative factors were analyzed to determine associations between different time groups, including age, gender, hand dominance, diagnosis, radiographic severity of contralateral shoulder, and type of surgery. Bilateral diagnoses included 211 osteoarthritis (OA), 36 cuff tear arthropathy (CTA), 13 inflammatory arthritis, 12 massive cuff tears without OA, and 4 avascular necrosis. RESULTS: OA patients had their contralateral shoulder arthroplasty sooner than CTA patients (P = .035). OA patients with arthritic changes on contralateral radiographs before the first arthroplasty had their contralateral arthroplasty sooner than those without contralateral radiographs (P < .0001). Patients who had TSA first had their contralateral arthroplasty sooner than patients who had RSA first (P = .037). DISCUSSION: This study confirmed our hypothesis identifying preoperative variables associated with different time intervals between arthroplasties. The preoperative factors associated with the highest likelihood of having contralateral shoulder arthroplasty within 1 year included OA, radiographic bilateral shoulder disease, and TSA for the first surgery.