Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures.

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

Review of Enhanced Handheld Surgical Drills.

The handheld drill has been used as a conventional surgical tool for centuries. Alongside the recent successes of surgical robots, the development of new and enhanced medical drills has improved surgeon ability without requiring the high cost and consuming setup times that plague medical robot systems. This work provides an overview of enhanced handheld surgical drill research focusing on systems that include some form of image guidance and do not require additional hardware that physically supports or guides drilling. Drilling is reviewed by main contribution divided into audio-, visual-, or hardware-enhanced drills. A vision for future work to enhance handheld drilling systems is also discussed.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population.

Background Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

Immunotherapy during the Immediate Perioperative Period: A Promising Approach against Metastatic Disease.

Tumor excision is a necessary life-saving procedure in most solid cancers. However, surgery and the days before and following it, known as the immediate perioperative period (IPP), entail numerous prometastatic processes, including the suppression of antimetastatic immunity and direct stimulation of minimal residual disease (MRD). Thus, the IPP is pivotal in determining long-term cancer outcomes, presenting a short window of opportunity to circumvent perioperative risk factors by employing several therapeutic approaches, including immunotherapy. Nevertheless, immunotherapy is rarely examined or implemented during this short timeframe, due to both established and hypothetical contraindications to surgery. Herein, we analyze how various aspects of the IPP promote immunosuppression and progression of MRD, and how potential IPP application of immunotherapy may interact with these deleterious processes. We discuss the feasibility and safety of different immunotherapies during the IPP with a focus on the latest approaches of immune checkpoint inhibition. Last, we address the few past and ongoing clinical trials that exploit the IPP timeframe for anticancer immunotherapy. Accordingly, we suggest that several specific immunotherapies can be safely and successfully applied during the IPP, alone or with supporting interventions, which may improve patients' resistance to MRD and overall survival.

The Effect of Intra-articular Corticosteroid Injections on Vaccine Efficacy: A Current Concepts Review.

Orthopedic surgeons commonly perform corticosteroid injections. These injections have systemic side effects, including suppression of the hypothalamic-pituitary adrenal axis. Due to this suppression, there is a theoretical risk of corticosteroid injections affecting the efficacy of the novel COVID-19 vaccines. This potential interaction led the American Academy of Orthopedic Surgeons to recommend, "avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID vaccine administration." This review examines the literature underlying this recommendation. An extensive literature review was performed through PubMed, MEDLINE, and Google Scholar from database inception to May 2022. Keywords searched were COVID, coronavirus, vaccine, vaccination, steroids, and corticosteroids. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles. There is no definitive evidence that corticosteroid injections affect COVID-19 vaccine efficacy or increase the risk of contracting COVID. The authors recommend orthopedic surgeons follow the AAOS guidelines, which recommend avoiding injections two weeks before and one week following COVID vaccine administration. Additional research is needed to better define this theoretical risk, especially since there is good evidence that injections suppress the hypothalamic-pituitary-adrenal-axis.

Compression Screw Fixation for Pediatric Olecranon Fractures.

BACKGROUND: Pediatric olecranon fractures can be treated with several methods of fixation. Though postoperative outcomes of various fixation techniques, including cannulated intramedullary screws, have been described in adults, functional and radiographic outcomes of screw fixation in pediatric patients are unclear. In this study, we assessed clinical, radiographic, functional, and patient-reported outcomes of pediatric olecranon fractures treated with compression screw fixation. METHODS: We retrospectively identified 37 patients aged 16 years or younger with a total of 40 olecranon fractures treated with screw fixation at our level-1 trauma center between April 2005 and April 2022. From medical records, we extracted data on demographic characteristics, time to radiographic union, range of elbow motion at final follow-up, and complications during the follow-up period. Patient-reported outcomes were evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Pediatric Upper Extremity Short Form 8a measures. RESULTS: There were no malunions or nonunions at the final mean follow-up of 140 days (range, 26 to 614 d). Four patients had implant failure (11%), of whom 3 experienced fracture union with no loss of fixation or need for revision surgery. One patient underwent a revision for fracture malreduction. Screw prominence was documented in 1 patient. Instrumentation was removed at our institution for 33 of 40 fractures. Mean time to radiographic union was 53 days (range, 20 to 168 d). Postoperative range of motion at the most recent follow-up visit showed a mean extension deficit of 6 degrees (range, 0-30 degrees) and mean flexion of 134 degrees (range, 60-150 degrees). At the final follow-up, the mean (±SD) Quick Disabilities of the Arm, Shoulder, and Hand score was 4.2±8.0, and the mean Patient-Reported Outcomes Measurement Information System score was 37±1.5, indicating good function and patient satisfaction. CONCLUSIONS: All 37 patients in our series had excellent radiographic, functional, and patient-reported outcomes after screw fixation. We observed no cases of nonunion or malunion, growth disturbance, or refracture. These results suggest that screw fixation is a safe and effective option for pediatric olecranon fractures. LEVEL OF EVIDENCE: Level IV, case series.

Partial Resection of First Dorsal Compartment Extensor Retinaculum in De Quervain's Stenosing Tendovaginitis Release.

Various surgical techniques exist to treat de Quervain's stenosing tendovaginitis. Specific surgical techniques for de Quervain's are designed to avoid complications including injury to branches of the superficial branch of the radial nerve, inadequate decompression, reflex sympathetic dystrophy, and palmar subluxation of the released tendons. A simple dorsal incision through the extensor retinaculum is advocated by many as a means to release the compartment while preventing postoperative subluxation. A single incision through the retinaculum limits exposure of the compartment and could lead to reannealing of the retinaculum and recurrent symptoms. Partial resection of the extensor retinaculum provides a more complete release and has not been found to lead to palmar tendon subluxation.

Using Predictive Modeling and Supervised Machine Learning to Identify Patients at Risk for Venous Thromboembolism Following Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology. METHODS: Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic. RESULTS: 13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.001), and comparable to that of the XGBoost algorithm (P > 0.05). CONCLUSION: Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.

Rate of Tibiotalocalcaneal (TTC) Fusion Using the Surgical Implant Generation Network (SIGN) Intramedullary Nail in Developing Countries.

Outcomes of the Surgical Implant Generation Network (SIGN) nail have been reported for femur and tibial fractures, but its use in tibiotalocalcaneal arthrodesis (TTCA) is not well studied. Radiographic and clinical outcomes of TTCA using the SIGN database in patients with > 6 months of radiographic follow up were analyzed. Rates of tibiotalar (TT) fusion and subtalar (ST) fusion at final follow up were assessed by two independent reviewers. Of the 62 patients identified, use of the SIGN nail for TCCA resulted in 53% rate of fusion in the TT joint and 20% in the ST joint. Thirty-seven patients (60%) demonstrated painless weight bearing at final follow up. There were no differences in incidence of painless weight bearing between consensus fused and not fused cohorts for TT and ST joints (p > 0.05). There were five implant failures, no cases of infection, and seven cases of reoperation. (Journal of Surgical Orthopaedic Advances 32(3):187-192, 2023).

Financial Burden of Pediatric Anterior Cruciate Ligament Reconstruction.

BACKGROUND: High costs and lack of price transparency for common pediatric orthopaedic procedures create financial burden for patients. We assessed (1) how patient medical debt after anterior cruciate ligament reconstruction (ACLR) correlates with health insurance type; and (2) factors associated with patient financial burden and worry after ACLR. METHODS: We reviewed records of 122 patients aged below 18 years who underwent ACLR at our US academic hospital from 2016 to 2020. Patients were grouped by health insurance type: private (n=80) or public (n=42). A telephone survey about ACLR-related financial burden and worry was administered to patients' parents (45% response rate). Primary outcomes were patient medical debt and patient-reported financial burden measured by the financial burden composite score (0 to 6, with 6 representing highest burden) and dichotomized worry score (1 to 3, low worry; 4 to 5, high worry). We used univariate analyses to compare financial outcomes and multivariable regressions to determine factors associated with reported financial burden (alpha=0.05). RESULTS: Debt after ACLR was reported by 10 of 122 patients (8%), all of whom had private insurance ( P =0.045). Of 55 survey respondents, treatment-related financial burden was reported by 32 (58%). Mean±SD financial burden composite scores were higher for privately insured (1.8±2.0) versus publicly insured patients (0.74±1.2) ( P =0.02), but rates of high financial worry were similar (private, 8% vs. public, 21%) ( P =0.22). A higher proportion of patients with private insurance (31%) reported having to use savings after ACLR compared with publicly insured patients (5%) ( P =0.04). The most frequently cited reason for financial burden was the cost of postoperative physical therapy (PT) (n=21). Number of PT visits was independently associated with financial burden composite scores ( P =0.02). Insurance type was not independently associated with financial burden ( P >0.05). CONCLUSION: Although a small proportion of patients generated medical debt after ACLR (greater for those privately vs. publicly insured), the majority reported treatment-related financial burden primarily driven by PT costs. LEVEL OF EVIDENCE: Level III.

Height Gain After Spinal Fusion for Idiopathic Scoliosis: Which Model Fits Best?

BACKGROUND: Patients will often inquire about the magnitude of height gain after scoliosis surgery. Several published models have attempted to predict height gain using preoperative variables. Many of these models reported good internal validity but have not been validated against an external cohort. We attempted to test the validity of 5 published models against an external cohort from our institution. Models included were Hwang, Van Popta, Spencer, Watanabe, and Sarlak models. METHODS: We retrospectively queried our institution's records from 2006 to 2019 for patients with adolescent idiopathic scoliosis treated with posterior spinal fusion. We recorded preoperative and postoperative variables including clinical height measurements. We also performed radiographic measurements on preoperative and postoperative radiographic studies. We then tested the ability of the models to predict height gain by evaluating Pearson correlation coefficient, root mean square error, Akaike Information Criterion for each model. RESULTS: A total of 387 patients were included. Mean clinical height gain was 3.1 (±1.7) cm.All models demonstrated a moderate positive Pearson correlation coefficient, except the Hwang model, which demonstrated a weak correlation. The Spencer model was the only model with acceptable root mean square error (≤0.5) and was also the best fitting with the lowest Akaike Information Criterion (-308). The mean differences in height gain predictions between all models except the Hwang model was ≤1 cm. CONCLUSIONS: Four of the 5 models demonstrated moderate correlation and had good external validity compared with their development cohorts. Although the Spencer model was the best fitting, the clinical significance of the difference in height predictions compared with other models was low. The Watanabe model was the second best fitting and had the simplest formula, making it the most convenient to use in a clinical setting. We offer a simplified equation to use in a preoperative clinical setting based on this data-ΔHeight (mm)=0.77*(preoperative coronal angle-postoperative coronal angle). LEVEL OF EVIDENCE: Not Applicable.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database.

BACKGROUND: Early initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending. METHODS: Using the Truven MarketScan database, we identified nearly 980,000 US adults ages 18-64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05. RESULTS: At 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40-0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47-0.51), emergency department visits (OR = 0.51, 95% CI = 0.49-0.54), advanced imaging (OR = 0.57, 95% CI = 0.56-0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66-0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65-0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4-25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to -$410; P < 0.001). CONCLUSION: Early PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state. LEVEL OF EVIDENCE: IV.

Pelvic Osteotomy in Patients With Previous Sacral-Alar-Iliac (SAI) Fixation.

INTRODUCTION: Patients with neuromuscular disease are at high risk for developing hip dysplasia and scoliosis. The purpose of this study was to investigate the technical challenges and outcomes of pelvic osteotomy in patients with prior sacral-alar-iliac (SAI) fixation. METHODS: We reviewed clinical and radiographic records of patients aged 18 years and below who underwent pelvic osteotomy after SAI fixation. We recorded technical challenges during the osteotomy, time from SAI fixation to osteotomy, type of osteotomy, migration index, and distance from the SAI screw to the acetabulum. A 2-sample Wilcoxon rank-sum test was used to assess the data. RESULTS: Nineteen patients were included. Technical challenges were defined as having greater intraoperative fluoroscopy times and noted difficult osteotomy in the operative report. The mean time from SAI fixation to pelvic osteotomy was 2.2±1.5 years. For all 12 Chiari osteotomies, the ilium could not be laterally displaced; however, medial displacement of the distal segment of the osteotomy allowed adequate coverage. All 7 Dega osteotomies were performed by cutting the cortex at the tip of the SAI screw. The screw improved proximal leverage and provided a strong buttress for bone graft. The mean migration index before pelvic osteotomy was 59±19%, and at most recent follow-up was 13±4%. Twelve patients, who had a noted complicated osteotomy, had SAI screws that were ≤1.87 cm ( P <0.01) from the acetabulum and significantly increased intraoperative fluoroscopy time (1.76 vs. 1.18 min, P <0.01). CONCLUSIONS: The presence of SAI screws may cause iliac osteotomies to be technically challenging if the tip of the SAI screw is ≤1.87 cm to the acetabulum. When initially implanting SAI screws in neuromuscular patients, surgeons should attempt to place screw tips ∼2 cm from the acetabulum in the event these patients require subsequent pelvic osteotomy. LEVEL OF EVIDENCE: Level IV.

Sacral-Alar-Iliac (SAI) Fixation in Patients With Previous Pelvic Osteotomy.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The purpose of this study was to investigate the technical challenges and outcomes of sacral-alar-iliac (SAI) fixation for scoliosis in patients who had previously undergone a pelvic osteotomy for hip dysplasia. SUMMARY OF BACKGROUND DATA: Patients with neuromuscular disease are at high risk for developing hip dislocation and scoliosis. Surgical correction of one may affect the other. METHODS: We reviewed the records of patients aged 18 years and below who underwent spinal fusion using SAI screws after having undergone a pelvic osteotomy, with ≥2-year follow-up. We recorded the SAI screw dimensions, time from osteotomy to SAI fixation, type of osteotomy, and any complications performing SAI fixation due to the pelvic osteotomy. Bivariate statistics were used to analyze the data with statistical significance defined as P -value <0.05. RESULTS: Thirty-two patients were included. The average age was 10.3±3.2 years at pelvic osteotomy and 13.5±3.4 years at SAI fixation. Most patients had cerebral palsy (87.5%) and a unilateral Dega osteotomy (78.1%). Average screw dimensions were significantly shorter on the side of the osteotomy (66 vs. 72 mm, P <0.05). SAI screw placement was technically challenging in 8 patients (25%), due to pelvic distortion from the pelvic osteotomy. The use of a curved awl helped to find the intracortical channel. No patients had complications due to the SAI screw, and there were no significant differences in pelvic obliquity and major coronal curve correction. Two patients (6.3%) had screw lucency >2 mm around the SAI screw on the side of the pelvic osteotomy but no clinical symptoms. CONCLUSIONS: SAI fixation in patients with previous pelvic osteotomy is technically challenging due to pelvic morphology and prior implants. Often, a shorter SAI screw is required on the side of the osteotomy. However, outcomes in this patient population are satisfactory, with no significant complications at a 2-year follow-up. LEVEL OF EVIDENCE: Level IV.

Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up.

INTRODUCTION: Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up. METHODS: We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections. RESULTS: Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications. CONCLUSIONS: SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time. LEVEL OF EVIDENCE: Level IV.

Evaluation of a Slipped Capital Femoral Epiphysis Virtual Reality Surgical Simulation for the Orthopaedic Trainee.

OBJECTIVE: The purpose of this study was to compare outcomes between orthopaedic trainees using various preoperative training platforms (physical simulation [PS], virtual reality [VR], and reading/videos) in a slipped capital femoral epiphysis model. METHODS: Participants were randomly assigned to one of the three groups: (1) reading/video control group (n = 7), (2) VR group (n = 7), or (3) PS group (n = 7). Participants in the VR group completed a VR slipped capital femoral epiphysis module while participants in the PS group practiced the placement of a screw in the physical module before evaluation of percutaneous screw placement in the PS model. Outcomes evaluated included overall surgical time, amount of fluoroscopy, Global Rating Scale score, radiographic screw position, physical screw accuracy, presence of breeching of the articular surface or femoral neck, and overall platform rating (0 to 10). RESULTS: No difference was observed in surgical time, Global Rating Scale score, radiographic or physical accuracy of screw position, or articular surface breaching between the groups. Subjectively, there was a difference in utility of platform rating between the groups (PS: 10 ± 0, VR: 7 ± 2, and control: 6 ± 1, P = 0.001). CONCLUSION: Training with VR was subjectively rated higher in value compared with reading/video methods and had similar performance outcomes compared with training with PS.

Development and Validation of SCFE Percutaneous Pinning Surgical Simulation.

BACKGROUND: In situ screw fixation with a single percutaneously placed femoral screw remains widely accepted for femoral head fixation in adolescent patients with slipped capital femoral epiphysis (SCFE). Given the potential risks involved with this procedure, a simulation whereby surgical skills could be refined before entering the operating room may be of benefit to orthopaedic trainees. METHODS: We developed a synthetic model for the simulated treatment of SCFE. Five orthopaedic attendings and twenty trainees were recorded performing an in situ percutaneous fixation on the SCFE model. Time, radiation exposure, and final anteroposterior and lateral radiographs of the SCFE model were recorded. After completion, the attendings and trainees answered a Likert-based questionnaire regarding the realism and utility of the simulation, respectively. Two blinded orthopaedic surgeons rated each participant's skill level based on previously described assessment tools, including a Global Rating Scale (GRS) of technical proficiency and radiographic grading index for screw placement. Performance metrics and survey responses were evaluated for construct validity, face validity, and interrater reliability. RESULTS: The attendings demonstrated superior technical proficiency compared with trainees in terms of higher GRS scores (27.9±1.9 vs. 14.7±5.0, P<0.001) and better radiographic grading of screw placement on lateral views (P=0.019). Similarly, compared with the trainees, the orthopaedic attendings demonstrated shorter operative times (11.0±4.1 vs. 14.7±6.2 min, P=0.035) and less radiation exposure (3.7±1.7 vs. 9.5±5.7 mGy, P=0.037). The interrater reliability was excellent for both the GRS scoring (intraclass correlation coefficient=0.973) and radiographic grading (weighted κ=1.000). The attendings and trainees rated the realism and teaching utility of the simulation as "very good," respectively. CONCLUSION: Our surgical simulation for in situ percutaneous fixation of SCFE represents a valid and reliable measure of technical competency and demonstrates much promise for potential use as a formative educational tool for orthopaedic residency programs. LEVEL OF EVIDENCE: Level II.

Is there an increased risk for subtrochanteric stress fracture with the Femoral Neck System versus multiple cannulated screws fixation?

Purpose: This study sought to compare the risk of subtrochanteric stress-riser fractures and biomechanical stability of the Femoral Neck System (FNS) versus multiple screw fixation (MSF). Methods: Eight paired cadaveric femurs were randomly assigned to FNS or MSF. Physiologic load mimicking single leg stance at the subtrochanteric region was applied to the constructs. Results: No constructs failed in the subtrochanteric region during loading. There was no significant difference in force (P = 0.364) or loading cycles (P = 0.348) between groups. Conclusion: FNS constructs were not associated with an increased incidence of iatrogenic subtrochanteric fractures or biomechanical stability versus MSF.

Late spinal infections are more common after pediatric than after adult spinal deformity surgery.

PURPOSE: To compare the incidence, timing, and microbiologic factors associated with late spinal infection (onset ≥ 6 months after index operation) in pediatric versus adult spinal deformity patients who underwent instrumented posterior spinal fusion (PSF). METHODS: We retrospectively queried our institutional database for pediatric (aged ≤ 21 years) and adult patients who underwent instrumented PSF from 2000 to 2015. Inclusion criteria were > 12-month follow-up, spinal arthrodesis spanning 4 or more levels, and idiopathic or degenerative spinal deformity. We included 1260 patients (755 pediatric, 505 adult). Incidence, timing, and microbiologic and operative parameters of late spinal infections were compared using chi-squared and Fisher exact tests. Alpha = 0.05. RESULTS: Late spinal infection occurred in 28 (3.7%) pediatric and 2 (0.39%) adult patients (p = 0.009). Mean onset of infection was 4.2 years (range 0.7-12) in pediatric patients and 4.0 years (range 0.7-7.3) in adults (p = 0.93). Pediatric patients underwent arthrodesis spanning more levels (mean ± standard deviation, 10 ± 2.0) compared with adults (8.4 ± 3.3) (p < 0.001). Adults experienced greater intraoperative blood loss (2085 ± 1491 mL) compared with pediatric patients (796 ± 452 mL) (p < 0.001). Culture samples yielded positive growth in 11 pediatric and 2 adult cases. Propionibacterium and coagulase-negative staphylococci were the most commonly detected microorganisms in both cohorts. CONCLUSION: Late spinal infections were significantly more common in pediatric patients than in adults after instrumented PSF for spinal deformity. Skin and indolent microorganisms were the primary identifiable causative bacteria in both cohorts. LEVEL OF EVIDENCE: III.

Evaluating the sagittal spinal and pelvic parameters in Marfan syndrome patients affected by scoliosis.

INTRODUCTION: Spinal deformities present a common finding in patients affected with Marfan syndrome (MFS). More specifically, sagittal spine imbalances reflect the typical finding of such deformities. Observing spino-pelvic radiographs, we focused on eliciting any correlation between the pelvic incidence (PI), sacral slope (SS) and thoracolumbar kyphosis measurements, and categorising them according to a sagittal spinal classification system. MATERIALS AND METHODS: One hundred seventy patient records were found over a 6 year period, and further refined to incorporate a total of 44 patients. 25 males and 19 females with an average age of 20 years at imaging. Electronic and hard copies of radiographs were used and measurements were made with virtual Cobb meters, rulers and protractors. RESULTS: The mean PI was significantly different between type-I (46°) and type-II spines (35°) (p = 0.04), and the values for each class were as follows: type IA-53°, type IB-44°, type IC-36°, type IIA-42°, and type IIB-34°. Type II spines had a lower PI compared to type IA spines (p = 0.037) and to that of an unaffected population. Statistically significant differences were noted in SS between groups (t test; p < 0.001), and ANOVA demonstrated that the largest differences between spinal classes were found in SS. CONCLUSION: In our study, PI values were much higher in type I compared to type II spines. Type II spines had PI values as expected, however, had higher than expected SS values. SS followed a down trending pattern across all spinal classes. Type IIA spines had a much greater preponderance for male patients. Overall, we wish to highlight in particular that type II spines were associated with a much lower PI and SS, and report these differences in pelvic morphology and sagittal spine patterns seen in MFS patients. The pelvic tilt and sacral slope parameters observed in our Type II spines may further reflect and characterize the deformity.