Evaluating the Readability of Patient Education Materials for Anterior Vertebral Body Tethering, Distraction-Based Methods, and Posterior Spinal Fusion for the Treatment of Pediatric Spinal Deformity.

BACKGROUND: The Internet is an important source of information for patients, but its effectiveness relies on the readability of its content. Patient education materials (PEMs) should be written at or below a sixth-grade reading level as outlined by agencies such as the American Medical Association. This study assessed PEMs' readability for the novel anterior vertebral body tethering (AVBT), distraction-based methods, and posterior spinal fusion (PSF) in treating pediatric spinal deformity. METHODS: An online search identified PEMs using the terms "anterior vertebral body tethering," "growing rods scoliosis," and "posterior spinal fusion pediatric scoliosis." We selected the first 20 general medical websites (GMWs) and 10 academic health institution websites (AHIWs) discussing each treatment (90 websites total). Readability tests for each webpage were conducted using Readability Studio software. Reading grade levels (RGLs), which correspond to the US grade at which one is expected to comprehend the text, were calculated for sources and independent t tests compared with RGLs between treatment types. RESULTS: The mean RGL was 12.1 ± 2.0. No articles were below a sixth-grade reading level, with only 2.2% at the sixth-grade reading level. AVBT articles had a higher RGL than distraction-based methods (12.7 ± 1.6 vs 11.9 ± 1.9, P = 0.082) and PSF (12.7 ± 1.6 vs 11.6 ± 2.3, P = 0.032). Materials for distraction-based methods and PSF were comparable (11.9 ± 1.9 vs 11.6 ± 2.3, P = 0.566). Among GMWs, AVBT materials had a higher RGL than distraction-based methods (12.9 ± 1.4 vs 12.1 ± 1.8, P = 0.133) and PSF (12.9 ± 1.4 vs 11.4 ± 2.4, P = 0.016). CLINICAL RELEVANCE: Patients' health literacy is important for shared decision-making. Assessing the readability of scoliosis treatment PEMs guides physicians when sharing resources and discussing treatment with patients. CONCLUSION: Both GMWs and AHIWs exceed recommended RGLs, which may limit patient and parent understanding. Within GMWs, AVBT materials are written at a higher RGL than other treatments, which may hinder informed decision-making and patient outcomes. Efforts should be made to create online resources at the appropriate RGL. At the very least, patients and parents may be directed toward AHIWs; RGLs are more consistent.

Evaluating consensus and uncertainty among treatment options for early-onset scoliosis: new generation and international perspectives.

PURPOSE: It is currently unknown how treatment preferences differ between a senior group of U.S. spinal surgeons, a new generation of U.S. surgeons, and non-U.S. surgeons with regard to the treatment of early-onset scoliosis (EOS). The purpose of this study was to evaluate clinical consensus and uncertainty among treatment options for patients with EOS to understand how they compare between these three cohorts. METHODS: 11 senior pediatric spinal deformity surgeons in the U.S., 12 "junior" surgeons in the U.S., and 7 surgeons practicing in non-U.S. countries were invited to complete a survey of 315 idiopathic and neuromuscular EOS case scenarios. Treatment options included: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Chi-squared and multiple regression analyses were performed to evaluate the associations between case characteristics and consensus for different treatments. RESULTS: Although all 3 cohorts of surgeons chose conservative management most frequently, the non-U.S. cohort of surgeons chose distraction-based methods more often, particularly for neuromuscular cases. In both U.S. surgeon cohorts, there was consensus for conservative management in idiopathic patients aged 3 or younger regardless of other factors, whereas non-U.S. surgeons selected distraction-based methods for some of these patients. CONCLUSION: Just as research studies are being conducted to find approaches to optimally manage the EOS population, future research efforts should focus on identifying the reasoning behind treatment preferences in different cohort of surgeons, as this will allow the interexchange of information which can ultimately improve EOS care. LEVEL OF EVIDENCE: V.

Operative choices matter: the role of UIV and sagittal balance in the development of proximal junctional kyphosis following posterior instrumentation for Scheuermann's kyphosis.

PURPOSE: This study sought to investigate associations between upper instrumented vertebra (UIV) location and the risk of proximal junctional kyphosis (PJK) at 2 years following posterior spinal fusion (PSF) for Scheuermann's kyphosis (SK). METHODS: In this retrospective cohort study, SK patients who underwent PSF and reached 2 years postop were identified in a multicenter international registry, excluding those with anterior release, prior spine surgery, neuromuscular comorbidity, post-traumatic kyphosis, or kyphosis apex below T11-T12. Location of UIV as well as the number of levels between UIV and preoperative kyphosis apex was determined. Additionally, the degree of kyphosis correction was evaluated. PJK was defined as a proximal junctional angle ≥ 10° that is ≥ 10° greater than the preoperative measurement. RESULTS: 90 patients (16.5 ± 1.9 yo, 65.6% male) were included. Preoperative and 2-year postoperative major kyphosis was 74.6 ± 11.6° and 45.9 ± 10.5°, respectively. Twenty-two (24.4%) patients developed PJK at 2 years. Patients with UIV below T2 had a 2.09 times increased risk of PJK when compared to those with UIV at or above T2, adjusting for distance between UIV and preoperative kyphosis apex [95% Confidence Interval (CI) 0.94; 4.63, p = 0.070]. Patients with UIV ≤ 4.5 vertebrae from the apex had a 1.57 times increased risk of PJK, adjusting for UIV relative to T2 [95% CI 0.64; 3.87, p = 0.326]. CONCLUSION: SK patients with UIV below T2 had an increased risk of developing PJK at 2 years following PSF. This association supports consideration of UIV location during preoperative planning. LEVEL OF EVIDENCE: Prognostic Level II.

Younger age at spinal cord detethering is potentially associated with a reduced risk of curve progression in children with early onset scoliosis.

PURPOSE: In children with early onset scoliosis (EOS) who have tethered spinal cord (TSC), spinal cord detethering is commonly performed prior to spinal deformity correction (SDC). The purpose of this study was to investigate whether age or curve magnitude at the time of detethering is associated with curve progression at a follow-up of at least 2 years. It was hypothesized that patients who undergo detethering at a younger age, or those with a smaller curve magnitude, would experience a reduced rate of curve progression when compared with those who are older or with larger curves. METHODS: Patients with EOS who underwent detethering at least 2 years prior to SDC were identified in a multicenter international registry. Radiographs were assessed just prior to the detethering procedure (pre-detether) and at the most recent visit prior to SDC (most recent post-detether). The rate of curve progression > 10° was examined. Owing to unequal follow-up in individual patients, Cox regression was used to investigate associations between primary variables (age and magnitude of major coronal curve) and rate of curve progression. RESULTS: 37 patients met inclusion criteria and 18 (mean age: 3.7 ± 2.9 years, 66.7% female, mean follow-up: 3.4 ± 1.3 years) had radiographic data available for analysis. Pre-detether and most recent post-detether major coronal curves were 44.8° ± 18.5° and 47.6° ± 23.9°, respectively. 5 (27.8%) patients had curve progression > 10° at a follow-up of 3.2 ± 1.2 years. Patients with progression > 10° were older at the time of detethering when compared with those without (5.6 ± 2.8 vs. 3 ± 2.7 years, p = 0.084). Regression analysis demonstrated that as age at detethering increased by 1 year, the rate of curve progression > 10° increased by 28.6% [95% confidence interval (CI) 0.899; 1.839, p = 0.169]. There was no evidence of an association between pre-detethering curve magnitude and rate of curve progression > 10° [HR: 1.027, 95% CI 0.977; 1.079, p = 0.297]. CONCLUSION: In a small multicenter cohort of EOS patients with TSC, younger age, but not curve size, at the time of detethering was associated with a lower rate of scoliosis progression. Although these results indicate a potential role for early spinal cord detethering in the EOS population, they require further prospective investigation with a larger number of patients. LEVEL OF EVIDENCE: Level II.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis.

PURPOSE: Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons. METHODS: Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement. RESULTS: 11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement . CONCLUSION: The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes. LEVEL OF EVIDENCE: Level V.

Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update.

PURPOSE: Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago. METHODS: 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described. RESULTS: Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves. CONCLUSION: Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population. LEVEL OF EVIDENCE: Level V.

Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis.

PURPOSE: In patients with early onset scoliosis (EOS) and intraspinal anomalies, surgery may be necessary for both the tethered spinal cord (TSC) and spinal deformity. The purpose of this study was to determine if there is a difference in complications when TSC release and surgery for spinal deformity correction (SDC) are performed separately compared simultaneously. METHODS: EOS patients with TSC who underwent detethering and SDC surgeries were identified through a multicenter registry. Patients were stratified into two groups. The simultaneous cohort consisted of patients receiving both detethering and SDC surgeries in a single anesthetic event on the same day, and the staged cohort consisted of patients undergoing detethering and SDC on two separate occasions. Postoperative complications up to 180 days for either surgery were assessed. RESULTS: Twenty five (65.8%) patients were staged and 13 (34.2%) underwent a simultaneous approach. Percent curve correction following SDC surgery did not significantly differ between the groups (p = 0.36). Within 90 days postoperatively, 16 complications in 11 patients (44.0%) occurred in the staged group, whereas no complications occurred in the simultaneous cohort (p = 0.006). From 90-days to 180-days postoperatively, 4 additional complications in 3 patients (12.0%) occurred in the staged group, with no complications reported in the same timeframe for the simultaneous cohort. CONCLUSION: To our knowledge, this is the largest multicenter comparative study to date, and it suggests that a simultaneous approach can be performed safely for EOS patients undergoing detethering and SDC surgeries, with a potentially lower risk profile than the traditional staged approach to these pathologies. LEVEL OF EVIDENCE: Level III.

Development and Validation of a Health-Related Quality-of-Life Measure in Older Children and Adolescents with Early-Onset Scoliosis: Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF).

BACKGROUND: The 24-question Early-Onset Scoliosis Questionnaire (EOSQ-24) is a proxy measure assessing health-related quality of life (HRQoL) among patients with early-onset scoliosis (EOS). There exists an increasing need to assess HRQoL through a child's own perspective, particularly for older children and adolescents with EOS. The purpose of this study was to develop and validate a self-reported questionnaire, the Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF), to assess HRQoL in older children and adolescents with EOS. METHODS: A literature review, an expert focus group, and patient interviews were used to generate a preliminary survey of appropriate domains and question items. This survey was provided to English-speaking patients with EOS who were 8 to 18 years of age and capable of answering survey questions. Content validity was assessed for clarity and relevance of questions. Confirmatory factors analysis was performed to reduce the number of items and determine domains that fit items. Reliability was evaluated by measuring the internal consistency of items and test-retest reliability. Construct validity was evaluated by convergent, discriminant, and known-group validity. RESULTS: The literature review, expert focus group, and patient interviews identified 59 questions in 14 domains. Psychometric analysis reduced these to 30 questions across 12 domains: General Health, Pain/Discomfort, Pulmonary Function, Transfer, Physical Function/Daily Living, Participation, Fatigue/Energy Level, Sleep, Appearance, Relationships, Emotion, and Satisfaction. The final questionnaire was found to have good content and construct validity and adequate reliability. CONCLUSIONS: The EOSQ-SELF is a valid and reliable instrument for measuring self-reported HRQoL among older children and adolescents with EOS (ages 8 to 18 years). This will serve as an important research outcome measure and enhance clinical care by providing a better understanding of HRQoL for these patients. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Malpractice litigation following orthopaedic surgery of the hip: Frequency, reasons for lawsuit, and outcomes.

Medical malpractice litigation in the United States has resulted in the widespread adoption of defensive medicine practices. Orthopaedic surgery is among the specialties most likely to face a malpractice lawsuit, and hip-related surgeries are commonly involved. This study aimed to analyse malpractice litigation as it relates to hip surgery in the United States. The purpose of this study was to seek answers to the following questions: Has there been an increase or a decrease in the number of hip surgery malpractice cases in recent years? What are the most common reasons for a patient to pursue litigation? Which surgical complications are most likely to result in a lawsuit? What trends do we see in terms of outcomes? The Westlaw legal database was queried for all relevant cases from 2008 to 2018. A retrospective review of cases was conducted and descriptive analyses were performed in order to identify factors associated with hip surgery malpractice litigation. A total of 82 cases were analysed. There was a downtrend in the number of cases per year. Total hip arthroplasty (47 cases, 57.3%) was the procedure most often involved. Procedural error was noted as a reason for litigation in 71 (86.6%) cases. Neurological injury (22 cases, 26.8%), malpositioned hardware (15 cases, 18.3%) and leg length discrepancy (8 cases, 9.8%) were the most common complications listed. The majority of cases resulted in a verdict in favour of the defendant orthopaedic surgeon (48 cases, 58.5%). The mean payout for a plaintiff verdict (20 cases, 24.4%) was $1,647,981 (range, $1,852-$7,000,000) and the mean payout for a settlement (13 cases, 15.9%) was $657,823 (range, $49,000-$3,000,000) (p = 0.063). The study concluded that, within the 10-year period, there was a significant downtrend in hip surgery malpractice cases filed per year. Orthopaedic surgeons were found liable in the minority of cases. As expected, verdicts in favour of plaintiffs resulted in seemingly higher payouts than settlements.

Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery.

PURPOSE: To expand on previously described intraoperative aids by developing consensus-based best practice guidelines to optimize the approach to intraoperative neuromonitoring (IONM) events associated with "high-risk" spinal deformity surgery. METHODS: Consensus was established among a group of experienced spinal deformity surgeons by way of the Delphi method. Through a series of iterative surveys and a final virtual consensus meeting, participants expressed their agreement (strongly agree, agree, disagree, and strongly disagree) with various items. Consensus was defined as ≥ 80% agreement ("strongly agree" or "agree"). Near-consensus was defined as ≥ 60% but < 80%. Equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. RESULTS: 15 out of 15 (100%) invited surgeons agreed to participate. Final consensus supported inclusion of 105 items (53 in Response Algorithm, 13 in Ongoing Consideration of Etiology, 31 in Real-Time Data Scenarios, 8 in Patterns of IONM Loss), which were organized into a final set of best practice guidelines. CONCLUSION: Detailed consensus-based best practice guidelines and aids were successfully created with the intention to help organize and direct the surgical team in exploring and responding to neurological complications during high-risk spinal deformity surgery. LEVEL OF EVIDENCE: Level V.

Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery.

PURPOSE: To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits. METHODS: Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. RESULTS: Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines. CONCLUSION: A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients. LEVEL OF EVIDENCE: Level V.

Uncorrected Pelvic Obliquity Is Associated With Worse Health-related Quality of Life (HRQoL) in Children and Their Caregivers at the End of Surgical Treatment for Early Onset Scoliosis (EOS).

BACKGROUND: While largely of concern in nonambulatory patients, pelvic obliquity (PO) can be found in many patients with early onset scoliosis (EOS) and may remain following surgery. However, its association with health-related quality of life (HRQoL) in children and their caregivers at the end of treatment is not well understood. The purpose of this study was to investigate the association between residual PO and HRQoL in children and their caregivers at the end of surgical treatment in ambulatory patients with EOS. METHODS: In this retrospective cohort study, a multicenter EOS registry was queried to identify ambulatory patients who underwent definitive posterior spinal fusion (PSF) from 2012 to 2019. Patients with fusions extending to the pelvis were excluded. PO was measured at least 1 year following PSF. HRQoL, Parental Burden, Financial Burden, and Satisfaction were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) also at a minimum of 1 year following PSF. RESULTS: A total of 155 patients (12.5±2.1 y, 73.5% female) were included. Etiology distribution was 30.3% congenital, 12.9% neuromuscular, 21.3% syndromic, and 35.5% idiopathic. In congenital patients, those with residual PO >8 degrees had worse Satisfaction by 23.2 points compared with those with PO ≤8 degrees. In neuromuscular patients, those with residual PO >7 degrees had worse HRQoL by 16.1 points and Parental Burden by 22.3 points compared with their counterparts. In syndromic patients, those with residual PO >8 degrees had worse HRQoL by 14.8 points, Parental Burden by 16.4 points, and Satisfaction by 21.2 points compared with their counterparts. In idiopathic patients, those with >9 degrees of residual PO had worse HRQoL by 15.0 points and Financial Burden by 26.8 points compared with their counterparts. CONCLUSIONS: Remaining PO at the end of surgical treatment is associated with worse HRQoL in ambulatory children and their caregivers. These results suggest that correction of PO should remain a primary goal of treatment in patients with EOS undergoing surgery. LEVEL OF EVIDENCE: Level II-multicenter retrospective cohort study investigating prognosis.

The Impact of Unplanned Return to the Operating Room on Health-related Quality of Life at the End of Growth-friendly Surgical Treatment for Early-onset Scoliosis.

BACKGROUND: Limiting complications, especially unplanned return to the operating room (UPROR), is a major focus in the surgical management of early-onset scoliosis (EOS). Although UPROR remains common in this population, its effect on long-term health-related quality of life (HRQoL) remains unclear. The purpose of this study was to investigate the association between UPROR and end-of-treatment HRQoL in EOS patients treated with growth-friendly instrumentation. METHODS: Patients with EOS who underwent growth-friendly instrumentation at age less than 10 years from 1993 to 2018, and completed treatment, were identified in a multicenter EOS registry. UPROR events were recorded, and end-of-treatment (defined as skeletal maturity and/or definitive spinal fusion) HRQoL was assessed via the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24). RESULTS: A total of 825 patients were identified, and 325 patients (age at surgery: 6.4 y, follow-up: 8.1 y) had end-of-treatment HRQoL data necessary for our investigation. Overall, 129/325 (39.7%) patients experienced 264 UPROR events; the majority (54.2%) were implant-related. Aside from age and etiology, no other variables were determined to be confounders or effect modifiers. Congenital patients with UPROR had worse pain/discomfort by 10.4 points (P=0.057) and worse pulmonary function by 7.8 points (P=0.102) compared with non-UPROR patients adjusting for age. Neuromuscular patients with UPROR had worse pulmonary function by 10.1 points compared with non-UPROR patients adjusting for age (P=0.037). Idiopathic and syndromic patients with UPROR reported consistently worse domain scores than their non-UPROR counterparts, but smaller (<5-point) differences were seen. CONCLUSIONS: UPROR during growth-friendly surgical treatment for EOS is associated with worse HRQoL in all patients, but particularly in those with neuromuscular or congenital etiologies. Ongoing efforts to avoid UPROR are critical. LEVEL OF EVIDENCE: Level II. This is a multicenter retrospective cohort study investigating the effect of UPROR on HRQoL (prognostic study).

Distal adding-on in adolescent idiopathic scoliosis results in diminished health-related quality of life at 10 years following posterior spinal fusion.

PURPOSE: The purpose of this study was to investigate associations between the various definitions of adding-on identified in the literature and HRQoL at 10 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) to identify a clinically relevant definition. METHODS: In this retrospective cohort study, patients with Lenke type 1 or 2 AIS with 10-year follow-up after PSF were identified in a multicenter registry. Adding-on was identified independently using 5 published definitions and expert spine surgeons' visual confirmation. Worsening of HRQoL was defined as a preoperative to 10-year postoperative decrease in SRS-22 domain score ≥ the minimal clinically important difference (MCID). RESULTS: One hundred fifty patients were included, and 118 had HRQoL data available for the main analysis. Worsening pain was noted in 49 (41.5%) patients, appearance in 1 (0.8%), and activity in 70 (59.3%) from preoperative to postoperative. 4 of the 5 definitions of adding-on demonstrated no evidence of association with worsening HRQoL. By Cho's definition (either 1. ≥ 5° increase in Cobb angle AND increase in number of vertebrae in curve distally, or 2. ≥ 5° increase in angulation of 1st disc below LIV), adding-on (27 patients, 22.9%) was associated with an increased risk of worsening pain (59.3% vs. 36.3%, p = 0.033) and activity (77.8% vs. 53.8%, p = 0.026). There was no evidence of association with changes in appearance. Risk of worsening pain and activity was increased by 1.75 and 1.51 times (p = 0.023 and p = 0.002), respectively. CONCLUSION: Cho's definition of adding-on was associated with worsening HRQoL at 10 years following PSF for Lenke type 1 and 2 AIS. Consistent use of this definition will allow us to compare studies and obtain meaningful information in this population. LEVEL OF EVIDENCE: Level II.

Mortality in Neuromuscular Early Onset Scoliosis Following Spinal Deformity Surgery.

BACKGROUND: The purpose of this study was to report mortality and associated risk factors in neuromuscular early onset scoliosis following spinal deformity surgery. METHODS: This is a multicenter retrospective cohort study of patients with cerebral palsy (CP), spinal muscular atrophy, myelodysplasia, muscular dystrophy, or myopathy undergoing index spine surgery from 1994 to 2020. Mortality risk was calculated up to 10 years postoperatively. Proportional hazard modeling was utilized to investigate associations between risk factors and mortality rate. RESULTS: A total of 808 patients [mean age 7.7 y; 439 (54.3%) female] were identified. Postoperative 30-day, 90-day, and 120-day mortality was 0%, 0.001%, and 0.01%, respectively. 1-year, 2-year, 5-year, and 10-year mortality was 0.5%, 1.1%, 5.4%, and 17.4%, respectively. Factors associated with increased mortality rate: CP diagnosis [hazard ratio (HR): 3.14, 95% confidence interval (CI): 1.71; 5.79, P<0.001]; nonambulatory status (HR: 3.01, 95% CI: 1.06; 8.5, P=0.04)]; need for respiratory assistance (HR: 2.17, 95% CI: 1.00; 4.69, P=0.05). CONCLUSIONS: In neuromuscular patients with early onset scoliosis, mortality risk at 10 years following spine surgery was 17.4%. As mortality was 1.1% at 2 years, premature death was unlikely a direct result of spine surgery. Diagnosis (CP) and markers of disease severity (nonambulatory status, respiratory assistance) were associated with increased mortality rate. LEVEL OF EVIDENCE: Prognostic level II.

A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures.

INTRODUCTION: Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations. METHODS: A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period. RESULTS: For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except "other musculoskeletal (MSK)," resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and "other MSK" cases have accounted for less. CONCLUSIONS: The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.

Shoulder balance in patients with Lenke type 1 and 2 idiopathic scoliosis appears satisfactory at 2 years following anterior vertebral body tethering of the spine.

BACKGROUND: Shoulder balance is an important factor for patient satisfaction following surgery for idiopathic scoliosis (IS). There is no literature reporting the effect of anterior vertebral body tethering (AVBT) on shoulder balance. The purpose of this study was to report the prevalence of postoperative shoulder imbalance in patients undergoing AVBT for IS. METHODS: In this retrospective case series, patients enrolled in a multicenter scoliosis registry who underwent AVBT from 2013 to 2017 in two Canadian centers were identified. The primary outcome was shoulder imbalance, defined as an absolute radiographic shoulder height of > 2 cm, at 2 years postoperatively (follow-up range: 22-30 months). Clavicular angle and T1 tilt angle were also investigated. RESULTS: Of the 50 patients identified (92% female; preoperative age: 11.9 ± 1.4 years), there were 43 (86%) patients with Lenke 1 and 7 (14%) patients with Lenke 2 curves. The mean Cobb angles of the proximal thoracic and main thoracic curves were 22.8° ± 8.8° and 49.4° ± 8.5° preoperatively and 13.1° ± 7.5° and 24.9° ± 9.5° at a mean follow-up time of 2.1 years. Absolute clavicular angle and T1 tilt angle were 2.8° ± 2.2° and 4.8° ± 3.5° preoperatively and 2.2° ± 1.7° and 4.7° ± 4.2° at 2-year follow-up. Preoperatively, absolute shoulder height averaged 15.6 ± 10.4 mm, and 15 (30%) patients had shoulder imbalance. At 2-year follow-up, absolute shoulder height averaged 11.2 ± 8.3 mm, and 8 (16%) patients had shoulder imbalance. Of the patients who had acceptable shoulder balance preoperatively, 4 (11.4%) became imbalanced at 2 years postoperatively. CONCLUSION: Postoperative shoulder imbalance in this early group of patients with IS undergoing AVBT was seen in 16% of patients, a reduction from 30% preoperatively. These results likely reflect the potential of the proximal thoracic curve to correct spontaneously following AVBT. LEVEL OF EVIDENCE: Level III.

YouTube as a Patient Education Resource for Male Hypogonadism and Testosterone Therapy.

INTRODUCTION: YouTube is an unregulated platform that patients are using to learn about treatment options. AIM: To assess the reliability of YouTube videos (YTVs) related to male hypogonadism and testosterone therapy. METHODS: Searching on YouTube by relevance and view count, we analyzed the top 10 videos (80 videos total) for the following search terms: low testosterone, testosterone replacement therapy, AndroGel, and hypogonadism. MAIN OUTCOME MEASURE: We recorded the number of views for each video, evaluated videos using the DISCERN score (DS) criterion, and compared the DS for videos including board-certified physicians and videos without. A second comparison was made between videos with board-certified physicians in urology, endocrinology, other MD, and those without any physician. RESULTS: The YTVs analyzed received a total of 38,549,090 views, a median of 25,201 and 17.30 views/day. Videos that featured physicians had significantly fewer views/day than videos that did not (39.48 CI 9,72 vs 1,731 CI 330, 3,132; P = .019). Most YTVs studied were unreliable. The median DS across all videos was 2. However, most videos created by physicians were found to be reliable with a median DS of 4. In addition, YTVs that did not feature a physician were found to be significantly less reliable than videos that featured a physician (3.22 CI 3.06, 4.09 vs 1.87 CI 1.56, 2.18; P < .001). There was no significant difference in the reliability or viewership of YTVs stratified by physician type. CONCLUSION: Most YTVs related to male hypogonadism/testosterone therapy were unreliable, but there are reliable YTVs available. Reliable videos usually feature a physician and receive fewer views than unreliable YTVs. Physicians and academic societies should work to provide verified videos to provide patients with reliable information about male hypogonadism and testosterone therapy. CJ Warren, J Wisener, B Ward, et al. YouTube as a Patient Education Resource for Male Hypogonadism and Testosterone Therapy. Sex Med 2021;9:100324.