Quality of ChatGPT Responses to Frequently Asked Questions in Carpal Tunnel Release Surgery.

Background: Although demonstrating remarkable promise in other fields, the impact of artificial intelligence (including ChatGPT in hand surgery and medical practice) remains largely undetermined. In this study, we asked ChatGPT frequently asked patient-focused questions surgeons may receive in clinic from patients who have carpel tunnel syndrome (CTS) and evaluated the quality of its output. Methods: Using ChatGPT, we asked 10 frequently asked questions that hand surgeons may receive in the clinic before carpel tunnel release (CTR) surgery. Included questions were generated from the authors' own experiences regarding conservative and operative treatment of CTS. Results: Responses from the following 10 questions were included: (1) What is CTS and what are its signs and symptoms? (2) What are the nonsurgical options for CTS? (3) Should I get surgery for CTS? (4) What is a CTR and how is it preformed? (5) What are the differences between open and endoscopic CTR? (6) What are the risks associated with CTR and how frequently do they occur? (7) Does CTR cure CTS? (8) How much improvement in my symptoms can I expect after CTR? (9) How long is the recovery after CTR? (10) Can CTS recur after surgery? Conclusions: Overall, the chatbot provided accurate and comprehensive information in response to most common and nuanced questions regarding CTS and CTR surgery, all in a way that would be easily understood by many patients. Importantly, the chatbot did not provide patient-specific advice and consistently advocated for consultation with a healthcare provider.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anatomical front and back reconstruction sustains radiographic alignment: a comparison to three-ligament tenodesis.

Multiple techniques exist to reconstruct the scapholunate interosseous ligament, though none have demonstrated superiority. This study compares 1-year radiographic outcomes of the three-ligament tenodesis and the anatomical front and back reconstruction. All patients who underwent reconstruction of their scapholunate interosseous ligament at one institution with either anatomical front and back reconstruction or three-ligament tenodesis between 2011 and 2020 were retrospectively reviewed. At 52-week follow-up, anatomical front and back reconstruction maintained a statistically significant improvement in scapholunate gap, corrected radiolunate angle and dorsal scaphoid translation, while three-ligament tenodesis demonstrated no sustained improvement in any parameter. The improvement in dorsal scaphoid translation was significantly greater for patients undergoing anatomical front and back reconstruction compared with three-ligament tenodesis at the 16-weeks postoperative timepoint (-1.0 mm, -0.3 mm). Anatomical front and back reconstruction demonstrates sustained improvement in radiographic outcomes at 1 year when compared with three-ligament tenodesis. By addressing both volar and dorsal critical ligament restraints, adoption of anatomical front and back reconstruction for advanced stage scapholunate interosseous ligament injuries should be considered.Level of evidence: IV.

Referral Patterns Associated With Delayed Care for Traumatic Brachial Plexus Injuries.

PURPOSE: Traumatic brachial plexus injuries (BPI) are devastating, time-sensitive conditions that often require definitive treatment at academic tertiary care centers. Delays to presentation and surgery have been associated with inferior outcomes. In this study, we evaluate referral patterns associated with delayed presentation and late surgery in traumatic BPI patients. METHODS: Patients diagnosed with a traumatic BPI at our institution from 2000 to 2020 were identified. Medical charts were reviewed for demographic characteristics, prereferral work-up, and referring provider characteristics. Delayed presentation was defined as greater than 3 months from date of injury to initial evaluation by our brachial plexus specialists. Late surgery was defined as greater than 6 months from date of injury. Multivariable logistic regression was used to identify factors associated with delayed presentation or surgery. RESULTS: A total of 99 patients were included, 71 of whom underwent surgery. Sixty-two patients presented delayed (62.6%), with 26 receiving late surgery (36.6%). There were similar rates of delayed presentation or late surgery by referring provider specialty. Patients whose initial diagnostic EMG was ordered by the referring provider prior to initial presentation at our institution were more likely to have a delayed presentation (76.2% vs 31.3%) and undergo late surgery (44.9% vs 10.0%). CONCLUSIONS: Delayed presentation and late surgery in traumatic BPI patients were associated with initial diagnostic EMG ordered by the referring provider. CLINICAL RELEVANCE: Delayed presentation and surgery have been associated with inferior outcomes in traumatic BPI patients. We recommend that providers direct patients with clinical concern of traumatic BPI directly to a brachial plexus center without further work-up before referral and encourage referral centers to accept these patients.

Pediatric injuries related to electric scooter use: a national database review.

Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of <0.05 was considered significant. Nine hundred and two pediatric patients were treated for an e-scooter injury at an emergency department (ED) between 2015 and 2019. Among those admitted (n = 47), 72.3% were men, and the average age at injury was 11.3 years. Among all injuries (n = 56), the most common diagnosis was fracture (24/56, 42.9%). The 19% (9/47) of patients that experienced polytrauma were significantly older than those with single injuries (P < 0.001). ED admissions grew by 616% from 2017 to 2018. Children experience a greater rate of fractures and polytrauma from e-scooters compared to adults, but fewer facial injuries despite a similar rate of head trauma. The incidence of pediatric head injuries indicates a lack of helmet use similar to adults. Lawmakers should consider bolstering e-scooter regulations to decrease pediatric injuries.

Inter-rater and Intrarater Reliabilities of the Identification of a "Gothic Arch" in the Acetabulum of Children With Cerebral Palsy.

BACKGROUND: Progressive hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage (MP) on anteroposterior (AP) pelvis radiographs. Accurate measurement of MP requires the lateral margin of the ossified acetabulum to be identified for the placement of Perkin's line. It has been suggested that when there is an erosion of the acetabular rim, described as a gothic arch, the midpoint of the arch be used for the placement of Perkin's line. However, this requires that there be agreement on what constitutes a gothic arch. The purpose of this study was to evaluate the inter-rater and intrarater reliabilities of identifying a gothic arch on pelvis radiographs. METHODS: An online survey with 100 AP pelvis images (200 hips) of children with CP was sent to international experts. Participants were asked to identify which hip(s) had a gothic arch (left, right, both, and neither). The Fleiss κ statistic for inter-rater reliability was calculated. Eight weeks later, the images were shuffled and redistributed to calculate intrarater reliability. RESULTS: The initial survey was completed by 10 participants with 9 participants completing the second survey. The average inter-rater κ value was 0.18 [95% confidence interval (CI), 0.14-0.23] and 0.19 (95% CI, 0.14-0.24) for the 2 surveys, respectively. Among the pediatric orthopaedic surgeons subgroup, the κ values were 0.06 (95% CI, 0.02-0.1) and 0.08 (95% CI, 0.03-0.13). The average intrarater reliability κ value was 0.61 (95% CI, 0.2-1), ranging from 0.32 to 0.86. CONCLUSIONS: There were poor inter-rater and moderate intrarater reliabilities in identifying a gothic arch on AP pelvis radiographs in children with CP. Further characterization and clarification of what constitutes a gothic arch are required. The lack of agreement on the identification of a gothic arch may negatively impact the measurement of MP and referrals to a pediatric orthopaedic surgeon.

Articular Cartilage Repair in the Knee: Postoperative Imaging.

Diagnostic and therapeutic advancements have improved clinical outcomes for patients with focal chondral injuries of the knee. An increased number and complexity of surgical treatment options have, in turn, resulted in a commensurate proliferation of patients requiring postoperative evaluation and management. In addition to patient-reported clinical outcomes, magnetic resonance imaging (MRI) offers clinicians with noninvasive, objective data to assist with postoperative clinical decision making. However, successful MRI interpretation in this setting is clinically challenging; it relies upon an understanding of the evolving and procedure-specific nature of normal postoperative imaging. Moreover, further research is required to better elucidate the correlation between MRI findings and long-term clinical outcomes. This article focuses on how specific morphologic features identified on MRI can be utilized to evaluate patients following the most commonly performed cartilage repair surgeries of the knee.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND: With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients. METHODS: Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized. RESULTS: This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048). CONCLUSION: Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Occipital Plate Fixation in the Pediatric Population.

BACKGROUND: Occipital plate fixation has been shown to improve outcomes in cervical spine fusion. There is a paucity of literature describing occipital plate fixation, especially in the pediatric population. The authors reviewed a case series of 34 patients at a pediatric hospital who underwent cervical spine fusion with occipital plate fixation between 2003 and 2016. This study describes how occipital plates aid the cervical spine union in a case series of diverse, complex pediatric patients. METHODS: Our orthopaedic database at our institution was queried for patients undergoing an instrumented cervical spine procedure between 2003 and 2016. Medical records were used to collect diagnoses, fusion levels, surgical technique, and length of hospitalization, neurophysiological monitoring, complications, and revision procedures. RESULTS: Thirty-four patients met the inclusion criteria. The mean age was 10.9 years (range, 3-21 y). Indications for surgery included cervical instability, basilar invagination, and os odontoideum. These indications were often secondary to a variety of diagnoses, including trisomy 21, Klippel-Feil syndrome, and rheumatoid arthritis. The mean length of hospitalization was 10 days (range, 2 to 80 d). There were no cases of intraoperative dural leak, venous sinus bleeding from occipital screw placement, or implant-related complications. Postoperative complications included 2 cases of nonunion. Eight patients (24%) had follow-up surgery, only 3 (9%) of which were instrumentation revisions. Both patients with nonunion had repeat occipitocervical fixation procedures and achieved union with revision. CONCLUSIONS: Occipital plate fixation was successful for pediatric cervical spine fusion in this diverse cohort. The only procedure-related complication demonstrated was delayed union or nonunion and implant loosening (4/34, 12%) and there were no plate-related complications. This novel case series shows that occipital plate fixation is safe and effective for pediatric patients with complex diagnoses. LEVEL OF EVIDENCE: Level IV-case series.

Use of recombinant human bone morphogenetic protein for revision cervical spine fusion in children with Down syndrome: a case series.

OBJECTIVE: Patients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a TGF-ß growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion. METHODS: A retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors' institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded. RESULTS: Eight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3-19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1-2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph. CONCLUSIONS: This is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2-related postoperative complications occurred.

Surgical Fixation Using Screw-Rod Construct Instrumentation for Upper Cervical Instability in Pediatric Down Syndrome Patients.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To describe the indications and outcomes of cervical fixation using modern instrumentation in a case series of pediatric Down syndrome (DS) patients. SUMMARY OF BACKGROUND DATA: Cervical instability is the major cervical spine concern in children with DS. Although fixation techniques have advanced over the past quarter-century, the outcome of fixation with modern instrumentation for upper cervical instability in DS patients has not been thoroughly investigated. METHODS: We searched the orthopedic database at our institution for patients with a diagnosis of DS who had undergone a cervical spine fusion between 2006 and 2017. Patient demographics, diagnoses, surgical indications, surgical details, and complications were recorded. Preoperative imaging was reviewed to determine atlanto-dens intervals and spinal cord signal changes. Postoperative radiographs or CT scans were reviewed to determine union. RESULTS: Twelve DS patients met our inclusion criteria. The mean age at surgery was 9.3 years (range 3.8-18.8 years). Patients with secondary causes of instability included 7 patients with os odontoideum and 1 patient with a pars fracture. Three patients (25%) were identified on asymptomatic screening, with none of these having cord signal changes on magnetic resonance imaging (MRI). Modern implants (screws, plates, cages) were used in every patient in our series. The mean number of levels fused was 1.9 (range 1-5). The overall complication rate was 41.7% (5/12). Four patients required repeat surgery for nonunion. All patients with adequate radiographic follow-up demonstrated union (11/11, 100%). One patient was lost to follow-up. CONCLUSIONS: Fixation for cervical instability is a critical component of the management of DS. A minority of patients receiving surgery were identified through asymptomatic screening. There was a high complication risk associated with surgery in our study; however, the addition of rigid fixation has lessened the complication rate compared with previous studies. LEVEL OF EVIDENCE: Level IV.

Outcomes of Meniscus Repair in Children and Adolescents.

PURPOSE OF REVIEW: The purpose of this study was to review the clinical and functional outcomes of meniscus repair in children and adolescents. RECENT FINDINGS: The sequel of meniscal tears and the outcome of meniscus repair have been well studied in adults. However, these topics have received less attention in the pediatric population despite the high prevalence and potentially critical effect on long-term knee function in children. Meniscus repair has a healing rate ranging from 33 to 100% with less than 40% reoperation rate. Several factors have been suggested to play a role in healing, such as concomitant ACL reconstruction and complexity of the tear. There is a lack of standardization among the utilization of functional outcome and activity level questionnaires across studies; however, most report improved function postoperatively. Other important considerations include bucket handle tears, the discoid meniscus, rehabilitation and return to sports, and alternatives after failed meniscus repair. Based on the favorable outcomes reported, meniscus repair should be attempted in most meniscus tears in children.

Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy.

BACKGROUND: There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety. OBJECTIVE: We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety. METHODS: In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study. RESULTS: During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784). CONCLUSIONS: Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.

Prevalence of Cozen's Phenomenon of the Proximal Tibia.

BACKGROUND: There has been little investigation into the epidemiology of Cozen's phenomenon, genu valgum as a complication of proximal tibial metaphysis fractures. In this study, we present a large case series of proximal tibia fractures in children to describe the prevalence, epidemiology, and characteristics associated with Cozen's phenomenon following proximal tibial fracture in children. METHODS: We searched the orthopedic database at our institution for all patients aged 1 to 8 years old with proximal tibia fractures presenting for initial fracture management between January 1, 2014 and December 31, 2017. Demographic data, mechanism of injury, fracture characteristics, and the presence of a concurrent fibula fracture were determined from the medical records. Initial and follow-up valgus angulation was measured as the angle between a line perpendicular to the proximal tibial physis and a line drawn along the axis of the tibia. Differences in the rate of valgus angulation by mechanism of injury and fracture type were compared. RESULTS: In total, 181 fractures in 181 patients were included in our study (98 male, 83 female). The average age at injury was 4.55 years (range, 1.02 to 7.95 y); 140 patients (77.3%, 140/181) had initial valgus angulation of <4 degrees; 20 of these patients (14.3%, 20/140) developed angulation of at least 4 degrees at some point during follow-up at an average of 0.8 months (range, 0.2 to 1.9 mo); 4 patients (20.0%, 4/20) with <4 degrees of initial angulation had persistent valgus angulation of 5 degrees at latest follow-up. Two of these patients were not scheduled to return because the provider did not determine the valgus angulation to be clinically meaningful. The 2 other patients were asymptomatic and continued to receive nonoperative management. No patients in our series required surgical correction of valgus deformity. CONCLUSIONS: Cozen's phenomenon is an uncommon complication of proximal tibial metaphysis fractures. Eliminating unnecessary radiographs and clinical visits for our pediatric trauma patients will improve the quality and value of care delivery. LEVEL OF EVIDENCE: Level IV.

A Dedicated Satellite Trauma Orthopaedic Program Operating Room Safely Increases Capacity.

BACKGROUND: Providing high-value care for urgent orthopaedic trauma patients requires effective and timely treatment. Herein, we describe the implementation of an innovative program utilizing the operating room (OR) capacity of a satellite campus to decrease stress on a pediatric tertiary care center without jeopardizing patient safety. METHODS: In addition to the daily emergency surgical room on the main campus, a dedicated orthopaedic trauma surgery OR was established in a satellite hospital location for 3 days per week in the summer and for 2 days per week for the rest of the year. Nonemergency, non-multitrauma operative fracture cases presenting to our tertiary care facility emergency department or orthopaedic clinic were considered for satellite referral. Eligible patients required clearance for transfer via orthopaedic, emergency department, and anesthesia checklists. An opt-out policy was established for provider judgment or patient family concern to overrule transfer decisions. Selected patients were discharged home with satellite OR scheduling or approved for same-day satellite location admission. Short elective cases were performed when openings existed in the schedule. RESULTS: From June 1, 2016, through June 30, 2017, 480 cases (372 trauma, 108 elective) were completed in our satellite OR. The most common trauma cases that were treated in the satellite OR were type-II supracondylar humeral fractures (n = 76). Summer months averaged 41.75 trauma cases and 11.25 elective cases per month, with 3.15 trauma cases and 0.85 elective cases per day. Nonsummer months averaged 22.78 trauma cases and 7.00 elective cases per month, with 2.93 trauma and 0.90 elective cases per day. Of the 17 postoperative issues, the greatest number (n = 7 [41%]) involved symptomatic hardware. The remaining complications were not surgeon or geographic-site-specific. There were no intraoperative complications, compartment syndrome episodes, or patients who required transfer back to our tertiary care facility for unexpected or serious medical issues. CONCLUSIONS: With the proper screening protocols in place for appropriate patient selection, the use of a dedicated satellite orthopaedic trauma OR can increase capacity without compromising patient safety.

C2 Translaminar Screw Fixation in Children.

BACKGROUND: Axis (C2) screw fixation has been shown to be effective in treating disorders that necessitate cervical stabilization. Although translaminar C2 screws have demonstrated clinical efficacy in adults, this technique has not yet been thoroughly investigated in children. This study describes the indications, technique, and results of translaminar C2 screw fixation in a case series of pediatric cervical spine disorders. METHODS: We searched the orthopaedic database at our institution for patients who had undergone a cervical spinal fusion that encompassed C2 between 2007 and 2017. Operative records were reviewed to determine if C2 screw fixation was performed and, if so, the type of C2 screw fixation. Clinical data with regard to patient age at surgery, diagnosis, procedure details, intraoperative complications, and postoperative complications were recorded. Preoperative and postoperative computer tomographic scans were reviewed to determine laminar measurements and containment, respectively. RESULTS: In total, 39 C2 translaminar screws were placed in 23 patients that met our inclusion criteria. The mean age was 12.6 years (range, 5.2 to 17.8 y) with a mean of 2 levels fused (range, 1 to 6). Diagnoses included 7 patients with instability related to skeletal dysplasia, 6 os odontoideum, 4 congenital deformities, 3 basilar invaginations, 2 cervical spine tumors, and 1 fracture. Indications for C2 translaminar screws included 14 cases with distorted anatomy favoring C2 translaminar screws, 6 cases without explicit reasoning for translaminar screw usage in the patient records, and 3 cases with intraoperative vertebral artery injury (1 sacrificed secondary to tumor load and 2 others injured during exposure because of anomalous anatomy). The vertebral artery injuries were not due to placement of any instrumentation. There were no screw-related intraoperative or postoperative complications and no neurological injuries. All patients demonstrated clinical union or healing on follow-up with no episodes of nonunion. CONCLUSIONS: Translaminar C2 screw fixation can be reliably used in the pediatric population. Our series contained no screw-related complications, no neurological injuries, and all patients demonstrated clinical union or healing. LEVEL OF EVIDENCE: Level IV-Case series.

Adult Tethered Cord Syndrome Following Chiari Decompression.

BACKGROUND: Adult tethered cord syndrome is a rare neurologic disorder that classically presents with back or leg pain, weakness, and urinary dysfunction. Spinal cord tethering has been associated with acquired Chiari malformations. Whereas the effects of tethered cord release on Chiari malformation symptoms have been described previously, we report an unusual case of acquired tethered cord syndrome following Chiari decompression. CASE DESCRIPTION: We report a 68-year-old man with a history of distant T12-level spinal cord injury and 2 weeks of progressive bilateral lower extremity weakness. The patient underwent a T12-L1 laminectomy in 1977, complicated by arachnoiditis and syringomyelia, with eventual placement of a syringopleural shunt. He remained neurologically stable until 2012, when he underwent a suboccipital craniectomy for Chiari decompression for new-onset headache and dysphagia. Ten days later, the patient noted progressive leg weakness and radiographic evidence of spinal cord tethering at the T11-T12 level. A T10-L1 laminectomy and medical facetectomy was undertaken for detethering with postoperative recovery of ambulatory function with assistance. CONCLUSIONS: Our patient exhibited an unusual acquisition of tethered cord syndrome. The tethering of the spinal cord may have been triggered by arachnoid adhesions from initial lumbar surgery 35 years before presentation and subsequently exacerbated by alterations of cerebrospinal fluid dynamics after Chiari decompression. Given the potentially devastating sequelae of tethered cord syndrome, investigation of cerebrospinal fluid flow dynamics may be beneficial before operative intervention in patients with risk factors for a tethered cord who exhibit adult-onset Chiari malformation.

Orthopaedic Device Approval Through the Premarket Approval Process: A Financial Feasibility Analysis for a Single Center.

The 2 main routes of medical device approval through the U.S. Food and Drug Administration are the premarket approval (PMA) process, which requires clinical trials, and the 510(k) premarket notification, which exempts devices from clinical trials if they are substantially equivalent to an existing device. Recently, there has been growing concern regarding the safety of devices approved through the 510(k) premarket notification. The PMA process decreases the potential for device recall; however, it is substantially more costly and time-consuming. Investors and medical device companies are only willing to invest in devices if they can expect to recoup their investment within a timeline of roughly 7 years. Our study utilizes financial modeling to assess the financial feasibility of approving various orthopaedic medical devices through the 510(k) and PMA processes. The expected time to recoup investment through the 510(k) process ranged from 0.585 years to 7.715 years, with an average time of 2.4 years; the expected time to recoup investment through the PMA route ranged from 2.9 years to 24.5 years, with an average time of 8.5 years. Six of the 13 orthopaedic device systems that we analyzed would require longer than our 7-year benchmark to recoup the investment costs of the PMA process. With the 510(k) premarket notification, only 1 device system would take longer than 7 years to recoup its investment costs. Although the 510(k) premarket notification has demonstrated safety concerns, broad requirements for PMA authorization may limit device innovation for less-prevalent orthopaedic conditions. As a result, new approval frameworks may be beneficial. Our report demonstrates how current regulatory policies can potentially influence orthopaedic device innovation.

A systematic review of spinal research conducted using the National Surgical Quality Improvement Program.

BACKGROUND CONTEXT: Over the course of the last decade, interest in the use of large data repositories for clinical research in orthopedic and spine surgery has grown substantially. Detractors maintain that the clinical relevance of research conducted using large registries is limited, and that the academic influence of such studies is minimal. Such contentions have not been empirically evaluated. PURPOSE: This study sought to perform a systematic review of spinal research conducted using the National Surgical Quality Improvement Program (NSQIP). STUDY DESIGN: This is a systematic review. OUTCOME MEASURES: Impact factor (IF) of the journal of publication and number of citations of published articles conducted using the NSQIP. METHODS: Orthopedic and spine-specific NSQIP articles published from January 1, 2007 to July 31, 2015, were identified through a query of PubMed or Medline, Embase, Web of Science, and Scopus. Articles were classified by journal of publication, year of publication, study topic, study purpose, and method of statistical analysis. Spine surgical publications were compared with other orthopedic research conducted using the NSQIP. The primary dependent variables for the purposes of statistical testing were IF of the journal in which the article was published and the number of citations for each publication. Negative binomial regression was used to evaluate the characteristics of papers associated with increased IF and number of citations. RESULTS: Of the 1,525 articles identified in the initial search, 114 studies were considered eligible for inclusion in the systematic review. The average IF for the journals publishing orthopedic NSQIP articles was 2.75 (standard deviation [SD] 1.22, range 0-5.28), whereas it was 2.52 (SD 0.81, range 1.38-5.28) for spinal research. The average number of citations per article was 6.08 (SD 10.9, range 0-69) and 6.4 (SD 12.0, range 0-69) for spine-specific studies. Following negative binomial regression, only IF (regression coefficients [RC] 0.31; 95% confidence intervals [CI] 0.08, 0.55) and the year of publication (RC -1.29; 9% CI -1.64, -0.95) were found to have a statistically significant association with number of citations. Among spine-specific research articles, only the year of publication was found to influence the number of citations (RC -1.29; 95% CI -1.94, -0.64). CONCLUSIONS: Our findings indicate that the academic impact of orthopedic and spine surgical research conducted using NSQIP is highly variable, with most publications found to have relatively low impact. As our evaluation of study characteristics associated with high-impact publications and increased citations were unable to uncover factors that are likely translatable, we suggest following research design guidelines that highlight best practices when using large datasets for orthopedic research.

Musculoskeletal Workforce Needs: Are Physician Assistants and Nurse Practitioners the Solution? AOA Critical Issues.

Growth estimates and demographic shifts of the population of the United States foreshadow a future heightened demand for musculoskeletal care. Although many articles have discussed this growing demand on the musculoskeletal workforce, few address the inevitable need for more musculoskeletal care providers. As we are unable to increase the number of orthopaedic surgeons because of restrictions on graduate medical education slots, physician assistants (PAs) and nurse practitioners (NPs) represent one potential solution to the impending musculoskeletal care supply shortage. This American Orthopaedic Association (AOA) symposium report investigates models for advanced practice provider integration, considers key issues affecting PAs and NPs, and proposes guidelines to help to assess the logistical and educational possibilities of further incorporating NPs and PAs into the orthopaedic workforce in order to address future musculoskeletal care needs.