Depression State Correlates with Functional Recovery Following Elective Lumbar Spine Fusion.

STUDY DESIGN: Retrospective review of single-institution cohort. OBJECTIVE: To determine how depression state impacts postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores and achievement of minimum clinically important difference (MCID) following lumbar fusion. Depression has been shown to negatively impact outcomes following numerous orthopedic surgeries. Situational and major clinical depression can differentially affect postoperative outcomes. METHODS: Adult patients undergoing elective 1-3 level lumbar fusion were reviewed. Patients with a formal diagnosis of major depression were classified as "clinically depressed" whereas patients with at least "mild" PROMIS Depression scores in the absence of formal depression diagnosis were deemed "situationally depressed." ANOVA testing was used to assess differences within and between groups. Multivariate regression was used to identify features associated with the achievement of MCID. RESULTS: 200 patients were included. The average age was 65.9 ± 12.2 years. 75 patients (37.5%) were non-depressed, 66 patients (33.0%) were clinically depressed, and 59 patients (29.5%) were situationally depressed. Situationally depressed patients had worse preoperative PF and PI scores and were more likely to have severe symptoms (P=0.001, P=0.001). All groups improved significantly from preoperative baseline scores. All groups met MCID PF at different rates, with highest proportion of situationally depressed reaching this metric (P = 0.03). Rates of achieving MCID PI were not significantly different between groups (P=0.47). Situational depression was predictive of achieving MCID PF (P=0.002) but not MCID PI. CONCLUSIONS: Our study investigated the relationship between depression and postoperative PROMIS scores and identified situationally depressed patients as having the worst preoperative impairment. Despite this, the situationally depressed cohort had the highest likelihood of achieving MCID PF, suggestive of a bidirectional relationship between lumbar degenerative disease and subclinical, situational depression. These findings may help guide preoperative counseling on expectations, and patient selection.

The rowing spine: A review of biomechanics, injury, and treatment.

STUDY DESIGN: Systematic literature review OBJECTIVES: Describe spinal biomechanics and injury patterns in rowing METHODS: A Google and PubMed literature search for "rowing," "biomechanics," and "spine" was undertaken. RESULTS: Relevant articles were reviewed and synthesized to describe biomechanics, injury patterns, treatment options, and techniques for injury prevention. CONCLUSIONS: Rowing grows ever more popular in the United States. Up-to-date knowledge of rowing biomechanics and spinal injury patterns is necessary for prompt diagnosis and appropriate treatment of the injured rowing athlete.

Prevalence, Characteristics, and Trends in Retracted Spine Literature: 2000 - 2023.

BACKGROUND: Retraction of scientific publications is an important check on scientific misconduct and serves to maintain the integrity of the scientific literature. The present study aims to examine the prevalence, trends, and characteristics of retracted spine literature across basic science and clinical spine literature. METHODS: Multiple databases were queried for retracted papers relating to spine or spine surgery, between January 2000 and May 2023. Of 112,668 publications initially identified, 125 were ultimately included in the present study following screening by two independent reviewers. Journal of origin, reasons for retraction, date of publication, date of retraction, impact factor of journal, countries of research origin, and study design were collected for each included publication. RESULTS: Clinical studies were the most frequent type of retracted publication (n=70). The most common reason for retraction was fraud (n=58), followed by plagiarism (n=22) and peer review process manipulation (n=16). Impact factors ranged from 0.3 to 11.1 with a median of 3.75. Average months from publication to retraction across all studies was 37.5 months. The higher the journal impact factor, the longer the amount of time between publication and retraction (p = 0.01). China (n=63) was the country of origin of more than half of all retracted spine publications. CONCLUSIONS: The rate of retractions has been increasing over the past 23 years, and clinical studies have been the most frequently retracted publication type. Clinicians treating disorders of the spine should be aware of these trends when relying on the clinical literature to inform their practice.

Patient-Reported Outcomes for Spine Oncology: A Narrative Review.

Spine tumors, both primary and metastatic, impose significant morbidity and mortality on patients and physicians. Patient-reported outcomes are valuable tools to assess a patient's impression of their health status and enhance communication between physicians and patients. Various spine generic patient-reported outcome tools have traditionally been used but have not been validated in the spine tumor patient population. The Spine Oncology Study Group Outcome Questionnaire, which is disease-specific for the metastatic spine patient population, has been shown to have strong validity, even across multiple languages. Patient-Reported Outcomes Measurement Information System, which has recently been developed, employs computerized adaptive testing to assess multiple health domains. It has been shown to capture information in both generic and specific questionnaires and has the potential to be used as a universal tool in the spine oncology patient population. Further long-term studies, as well as, cross-cultural adaptations, are needed to validate Patient-Reported Outcomes Measurement Information System's applicability and effectiveness.

Exploring the Impact of TLR-2 Signaling on miRNA Dysregulation in Intervertebral Disc Degeneration.

Toll-like receptors (TLRs) are key mediators of inflammation in intervertebral disc (IVD) degeneration. TLR-2 activation contributes to the degenerative process by increasing the expression of extracellular matrix-degrading enzymes, pro-inflammatory cytokines, and neurotrophins. As potent post-transcriptional regulators, microRNAs can modulate intracellular mechanisms, and their dysregulation is known to contribute to numerous pathologies. This study aims to investigate the impact of TLR-2 signaling on miRNA dysregulation in the context of IVD degeneration. Small-RNA sequencing of degenerated IVD cells shows the dysregulation of ten miRNAs following TLR-2 activation by PAM2CSK4. The miR-155-5p is most significantly upregulated in degenerated and non-degenerated annulus fibrosus and nucleus pulposus cells. Sequence-based target and pathway prediction shows the involvement of miR-155-5p in inflammation- and cell fate-related pathways and TLR-2-induced miR-155-5p expression leads to the downregulation of its target c-FOS. Furthermore, changes specific to the activation of TLR-2 through fragmented fibronectin are seen in miR-484 and miR-487. Lastly, miR-100-3p, miR-320b, and miR-181a-3p expression exhibit degeneration-dependent changes. These results show that TLR-2 signaling leads to the dysregulation of miRNAs in IVD cells as well as their possible downstream effects on inflammation and degeneration. The identified miRNAs provide important opportunities as potential therapeutic targets for IVD degeneration and low back pain.

Socioeconomic disadvantage is correlated with worse PROMIS outcomes following lumbar fusion.

BACKGROUND CONTEXT: Socioeconomic status (SES) has been associated with differential healthcare outcomes and may be proxied using the area-deprivation index (ADI). Few studies to date have investigated the role of ADI on patient-reported outcomes and clinically meaningful improvement following lumbar spine fusion surgery. PURPOSE: The purpose of this study is to investigate the role of SES on lumbar fusion outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. STUDY DESIGN/SETTING: Retrospective review of a single institution cohort. PATIENT SAMPLE: About 205 patients who underwent elective one-to-three level posterior lumbar spine fusion. OUTCOME MEASURES: Change in PROMIS scores and achievement of minimum clinically important difference (MCID). METHODS: Patients 18 years or older undergoing elective one-to-three level lumbar spine fusion secondary to spinal degeneration from January 2015 to September 2021 with minimum one year follow-up were reviewed. ADI was calculated using patient-supplied addresses and patients were grouped into quartiles. Higher ADI values represent worse deprivation. Minimum clinically important difference (MCID) thresholds were calculated using distribution-based methods. Analysis of variance testing was used to assess differences within and between the quartile cohorts. Multivariable regression was used to identify features associated with the achievement of MCID. RESULTS: About 205 patients met inclusion and exclusion criteria. The average age of our cohort was 66±12 years. The average time to final follow-up was 23±8 months (range 12-36 months). No differences were observed between preoperative baseline scores amongst the four quartiles. All ADI cohorts showed significant improvement for pain interference (PI) at final follow-up (p<.05), with patients who had the lowest socioeconomic status having the lowest absolute improvement from preoperative baseline physical function (PF) and PI (p=.01). Only those patients who were in the lowest socioeconomic quartile failed to significantly improve for PF at final follow-up (p=.19). There was a significant negative correlation between socioeconomic level and the absolute proportion of patients reaching MCID for PI (p=.04) and PF (p=.03). However, while ADI was a significant predictor of achieving MCID for PI (p=.02), it was nonsignificant for achieving MCID for PF. CONCLUSIONS: Our study investigated the influence of ADI on postoperative PROMIS scores and identified a negative correlation between ADI quartile and the proportion of patients reaching MCID. Patients in the worse ADI quartile had lower chances of reaching clinically meaningful improvement in PI. Policies focused on alleviating geographical deprivation may augment clinical outcomes following lumbar surgery.

Perioperative Complications and Radiographic Outcomes Following Cervical Laminoplasty: A Review of 105 Cases from a Single Academic Center.

OBJECTIVE: To assess complications and to compare preoperative and postoperative radiographic measures in patients who underwent cervical laminoplasty. METHODS: We evaluated patients undergoing cervical laminoplasty between 2011 and 2022 at an academic medical center. Patient demographics, intraoperative and postoperative complications, and preoperative and postoperative radiographic parameters were recorded. RESULTS: Of 150 patients undergoing cervical laminoplasty during 2011-2022, 105 met the inclusion criteria. We identified 22 (21.0%) adverse events in 20 patients: 4 intraoperative (3.8%), 10 perioperative (9.5%), and 8 delayed postoperative (7.6%). Among adverse events, 13 (12.4%) were judged to be minor and 9 (8.6%) were judged to be major complications. Revision surgery was required in 6 (5.7%) patients. Both preoperative and postoperative cervical spine radiographic imaging was available in 47 (44.8%) of the 105 patients. Mean preoperative and postoperative C2-7 Cobb angles were 14.7° and 12.3°, respectively (P = 0.04). Mean preoperative and postoperative sagittal vertical axis measurements were 29.2 mm and 33.3 mm, respectively (P = 0.07). Mean preoperative and postoperative T1 slopes were 32.3° and 30.2°, respectively (P = 0.07). CONCLUSIONS: Cervical laminoplasty carries a significant risk of adverse events, the majority of which are minor, and has a low rate of reoperation (5.7%). The procedure does not result in significant changes in sagittal vertical axis or T1 slope. Cervical laminoplasty remains a valuable surgical option for selected patients with cervical myelopathy.

Spinal fusion for postlaminectomy kyphosis following intramedullary spinal cord tumor resection: A 34-year follow-up.

Background: Resection of intramedullary spinal cord tumors (IMSCTs) in pediatric patients results in a high incidence of spinal deformity (i.e., kyphoscoliosis often requiring fusion). Here, a 6-year-old male underwent a spinal fusion to correct postlaminectomy thoracic kyphosis following resection of an IMSCT. Case Description: A 6-year-old male initially underwent multilevel thoracic laminectomies for resection of an IMSCT. Six months later, he presented with the onset of kyphoscoliosis. During adolescence he became increasingly paraparetic due to a thoracic kyphosis that had now progressed to 118°. He underwent a 360 decompression/fusion that included a T1-T9 laminectomy, a T5 to T11 anterior interbody arthrodesis/rib autograft, and posterolateral T2-T12 fusion/iliac crest autograft with Harrington rods placed from T5 to T12. Postoperative radiographs showed the thoracic kyphosis improved to 62°. However, 4.5 years later, X-rays showed the thoracic kyphosis newly progressed to 90° (i.e., from T3 to T12). Thirty-four years after this corrective surgery, he remained neurologically intact with only mild complaints of balance changes, and bladder/bowel urgency while radiographs confirmed continued stability. Further, the thoracic magnetic resonance imaging showed only chronic thoracic spine/cord changes. Conclusion: A 6-year-old child originally underwent a thoracic laminectomy for an IMSCT. As an adolescent, due to progressive postlaminectomy kyphosis, he underwent a successful secondary thoracic 360° decompression/ fusion. Notably, 34 years later, he did not require any surgical revision.

Clinical Improvement After Lumbar Fusion: Using PROMIS to Assess Recovery Kinetics.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: The goal of this study is to identify features that predict delayed achievement of minimum clinically important difference (MCID) following elective lumbar spine fusion using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. SUMMARYOF BACKGROUND DATA: Preoperative prediction of delayed recovery following lumbar spine fusion surgery is challenging. While many studies have examined factors impacting the achievement of MCID for patient-reported outcomes in similar cohorts, few studies have assessed predictors of early functional improvement. METHODS: We retrospectively reviewed patients undergoing elective one-level posterior lumbar fusion for degenerative pathology. Patients were subdivided into two groups based on achievement of MCID for each respective PROMIS domain either before six months ("early responders") or after six months ("late responders") following surgical intervention. Multivariable logistic regression analysis was used to determine features associated with odds of achieving distribution-based MCID before or after six months follow up. RESULTS: 147 patients were included. The average age was 64.3±13.0 years. At final follow-up, 57.1% of patients attained MCID for PI and 72.8% for PF. However, 42 patients (49.4%) reached MCID for PI by six months, compared to 44 patients (41.1%) for PF. Patients with severe symptoms had the highest probability of attaining MCID for PI (OR 10.3; P=0.001) and PF (OR 10.4; P=0.001) Preoperative PROMIS symptomology did not predict early achievement of MCID for PI or PF. Patients who received concomitant iliac crest autograft during their lumbar fusion had increased odds of achieving MCID for PI (OR 8.56; P=0.001) before six months. CONCLUSION: Our study demonstrated that the majority of patients achieved MCID following elective one-level lumbar spine fusion at long-term follow-up, although less than half achieved this clinical benchmark for each PROMIS metric by six months. We also found that preoperative impairment was not associated with when patients would achieve MCID. Further prospective investigations are warranted to characterize the trajectory of clinical improvement and identify the risk factors associated with poor outcomes more accurately.

Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score.

PURPOSE: Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease. METHODS: Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05. RESULTS: Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76. CONCLUSIONS: The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis. LEVEL OF EVIDENCE: Prognostic level III.

Improvement of postural stability and gait velocity after cervical decompression surgery in patients with cervical spondylotic myelopathy.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to significant neurological deficits, including gait instability. Biomechanical alterations of gait and its various components are poorly understood. The goal of the current study was to determine how spatiotemporal gait parameters, as well as postural and dynamic stability, change after surgery in CSM patients. METHODS: A total of 47 subjects were included, with 23 test subjects and 24 controls. Baseline measurements were made for both cohorts. In the CSM cohort, repeat measurements were made at 3 and 6 months postoperatively. To record spatiotemporal and dynamic stability parameters, subjects performed walking trials over force plates on a 15-m runway. To assess postural stability, standing balance trials were conducted on a floor-mounted force plate. Three-dimensional motion analysis cameras and gait modeling software were used to quantify and visually represent results. Statistical analysis was completed using repeated-measures ANOVA and paired t-tests. Significance was set at p < 0.05. RESULTS: CSM patients had significantly increased gait velocity at the 6-month follow-up (mean 0.948 ± 0.248 m/sec/leg length) versus baseline (mean 0.852 ± 0.257 m/sec/leg length) (p = 0.039). The tilted ellipse area was significantly decreased at the 6-month follow-up compared with baseline (mean 979.8 ± 856.7 mm2 vs 598.0 ± 391.1 mm2, p = 0.018). Angular momentum excursion was not significantly different between baseline and the 3- and 6-month follow-ups. CONCLUSIONS: CSM patients displayed significant improvement in gait velocity and postural stability parameters after decompressive surgery. Dynamic stability parameters did not change significantly during the study period.

The "kickstand rod" technique for correction of coronal malalignment: two-year clinical and radiographic outcomes.

PURPOSE: Restoring coronal alignment in spine deformity patients has been shown to play an important role in improving patient reported outcomes (PRO). Recently, the "kickstand rod" (KSR) technique was developed as a novel coronal correction method in complex spine deformity cases. The goal of the present study was to assess outcomes of this technique at two years of follow-up. METHODS: Consecutive, unique adult patients who underwent KSR constructs for coronal spinal malalignment between 2015 and 2019 with a minimum 2 year clinical and radiographic follow-up were identified. A KSR construct includes a more laterally placed iliac screw and additional rod that effectively depresses the ipsilateral ilium/pelvis for coronal correction, while serving as a buttress to prevent future loss of correction. Outcomes included revision for instrumentation-related complications, radiographic alignment, and PROs. RESULTS: Twenty patients were included with a mean age of 54 years [range: 20-73 years]. Mean follow-up time was 2.5 years [range: 2.0-5.0]. Mean number of levels fused was 17.3 [range: 10-24]. There were significant improvements in coronal alignment (CVA: 5.8 cm ± 2.6 cm vs. 1.7 cm ± 1.5 cm), sagittal alignment (SVA: 5.6 cm ± 5.9 cm vs. 1.6 cm ± 2.5 cm) and major Cobb angle (55º ± 32 vs. 26º ± 21) maintained at 2 years (p < 0.05). One patient experienced an asymptomatic fracture at the shank of the KSR iliac screw. There were significant improvements in Oswestry Disability Index and SRS-22 domains (p < 0.05). CONCLUSION: The KSR technique is a safe and effective method for correcting coronal malalignment in complex spinal deformity patients with no revisions specific for the KSR or iliac screw and significantly improved PROs at a minimum two-year follow-up.

The BTK Safety Score: A Novel Scoring System for Risk Stratifying Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty.

Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p < 0.001) and CCI (0.599; p < 0.001). The BTK Safety Score developed and validated in our study can be used by surgeons and perioperative teams to risk stratify patients undergoing si-BTKA. Future work is needed to assess this scoring system's ability to predict long-term functional outcomes.

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.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). METHODS: A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. RESULTS: Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). CONCLUSION: Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Social Media Presence Is Associated With Diversity and Application Volume for Orthopedic Surgery Residency Programs.

The purpose of this study was to assess the association between social media presence (Twitter and Instagram), diversity in orthopedic surgery residency programs, and the number of applications received by a program. Data from Twitter and Instagram for 179 orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education were collected, including the presence of a social media account, date of first post, number of posts, and number of followers. Residency program data were collected from the Association of American Medical Colleges Residency Explorer Tool and included percentage of Whiteresidents, percentage of male residents, residency ranking, and number of applications submitted during the 2019 application cycle. Bivariate and multivariable analyses were performed with adjustment for program ranking. Of 179 residency programs, 34.6% (n=62) had Twitter, and 16.7% (n=30) had Instagram. Overall, 39.7% (n=71) had a social media presence, defined as having at least one of the two forms of social media. Programs with social media presences had higher average rankings (48.1 vs 99.6 rank, P<.001). After adjusting for program ranking, social media presence was associated with increased applications during the 2019 application cycle (odds ratio [OR]=2.76, P=.010). Social media presence was associated with increased odds of gender diversity (OR=3.07, P=.047) and racial diversity (OR=2.21, P=.041). Individually, Twitter presence was associated with increased odds of gender (OR=4.81, P=.018) and racial diversity (OR=4.00, P=.021), but Instagram was not (P>.05). Social media presence is associated with more residency program applications and increased resident diversity. Social media can be used to highlight inclusivity measures and related opportunities. [Orthopedics. 2023;46(1):47-53.].

How common is acute pelvic fixation failure after adult spine surgery? A single-center study of 358 patients.

OBJECTIVE: There is a paucity of literature on pelvic fixation failure after adult spine surgery in the early postoperative period. The purpose of this study was to determine the incidence of acute pelvic fixation failure in a large single-center study and to describe the lessons learned. METHODS: The authors performed a retrospective review of adult (≥ 18 years old) patients who underwent spinal fusion with pelvic fixation (iliac, S2-alar-iliac [S2AI] screws) at a single academic medical center between 2015 and 2020. All patients had a minimum of 3 instrumented levels. The minimum follow-up was 6 months after the index spine surgery. Patients with prior pelvic fixation were excluded. Acute pelvic fixation failure was defined as revision of the pelvic screws within 6 months of the primary surgery. Patient demographics and operative, radiographic, and rod/screw parameters were collected. All rods were cobalt-chrome. All iliac and S2AI screws were closed-headed screws. RESULTS: In 358 patients, the mean age was 59.5 ± 13.6 years, and 64.0% (n = 229) were female. The mean number of instrumented levels was 11.5 ± 5.5, and 79.1% (n = 283) had ≥ 6 levels fused. Three-column osteotomies were performed in 14.2% (n = 51) of patients, and 74.6% (n = 267) had an L5-S1 interbody fusion. The mean diameter/length of pelvic screws was 8.5/86.6 mm. The mean number of pelvic screws was 2.2 ± 0.5, the mean rod diameter was 6.0 ± 0 mm, and 78.5% (n = 281) had > 2 rods crossing the lumbopelvic junction. Accessory rods extended to S1 (32.7%, n = 117) or S2/ilium (45.8%, n = 164). Acute pelvic fixation failure occurred in 1 patient (0.3%); this individual had a broken S2AI screw near the head-neck junction. This 76-year-old woman with degenerative lumbar scoliosis and chronic lumbosacral zone 1 fracture nonunion had undergone posterior instrumented fusion from T10 to pelvis with bilateral S2AI screws (8.5 × 90 mm); i.e., transforaminal lumbar interbody fusion L4-S1. The patient had persistent left buttock pain postoperatively, with radiographically confirmed breakage of the left S2AI screw 68 days after surgery. Revision included instrumentation removal at L2-pelvis and a total of 4 pelvic screws. CONCLUSIONS: The acute pelvic fixation failure rate was exceedingly low in adult spine surgery. This rate may be the result of multiple factors including the preference for multirod (> 2), closed-headed pelvic screw constructs in which large-diameter long screws are used. Increasing the number of rods and screws at the lumbopelvic junction may be important factors to consider, especially for patients with high risk for nonunion.

Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures.

BACKGROUND: Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients' quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS: Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P < 0.001). Disseminated cancer, dependent functional status, >10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Incidence, mechanism, and protective strategies for 2-year pelvic fixation failure after adult spinal deformity surgery with a minimum six-level fusion.

OBJECTIVE: The purpose of this study was to determine the incidence, mechanism, and potential protective strategies for pelvic fixation failure (PFF) within 2 years after adult spinal deformity (ASD) surgery. METHODS: Data for ASD patients (age ≥ 18 years, minimum of six instrumented levels) with pelvic fixation (S2-alar-iliac [S2AI] and/or iliac screws) with a minimum 2-year follow-up were consecutively collected (2015-2019). Patients with prior pelvic fixation were excluded. PFF was defined as any revision to pelvic screws, which may include broken rods across the lumbosacral junction requiring revision to pelvic screws, pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws, a broken or loose pelvic screw, or sacral/iliac fracture. Patient information including demographic data and health history (age, sex, BMI, smoking status, American Society of Anesthesiologists score, osteoporosis), operative (total instrumented levels [TIL], three-column osteotomy [3CO], interbody fusion), screw (iliac, S2AI, length, diameter), rod (diameter, kickstand), rod pattern (number crossing lumbopelvic junction, lowest instrumented vertebra [LIV] of accessory rod[s], lateral connectors, dual-headed screws), and pre- and postradiographic (lumbar lordosis, pelvic incidence, pelvic tilt, major Cobb angle, lumbosacral fractional curve, C7 coronal vertical axis [CVA], T1 pelvic angle, C7 sagittal vertical axis) parameters was collected. All rods across the lumbosacral junction were cobalt-chrome. All iliac and S2AI screws were closed-headed tulips. Both univariate and multivariate analyses were performed to determine risk factors for PFF. RESULTS: Of 253 patients (mean age 58.9 years, mean TIL 13.6, 3CO 15.8%, L5-S1 interbody 74.7%, mean pelvic screw diameter/length 8.6/87 mm), the 2-year failure rate was 4.3% (n = 11). The mechanisms of failure included broken rods across the lumbosacral junction (n = 4), pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws (n = 3), broken pelvic screw (n = 1), loose pelvic screw (n = 1), sacral/iliac fracture (n = 1), and painful/prominent pelvic screw (n = 1). A higher number of rods crossing the lumbopelvic junction (mean 3.8 no failure vs 2.9 failure, p = 0.009) and accessory rod LIV to S2/ilium (no failure 54.2% vs failure 18.2%, p = 0.003) were protective for failure. Multivariate analysis demonstrated that accessory rod LIV to S2/ilium versus S1 (OR 0.2, p = 0.004) and number of rods crossing the lumbar to pelvis (OR 0.15, p = 0.002) were protective, while worse postoperative CVA (OR 1.5, p = 0.028) was an independent risk factor for failure. CONCLUSIONS: The 2-year PFF rate was low relative to what is reported in the literature, despite patients undergoing long fusion constructs for ASD. The number of rods crossing the lumbopelvic junction and accessory rod LIV to S2/ilium relative to S1 alone likely increase construct stiffness. Residual postoperative coronal malalignment should be avoided to reduce PFF.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Background: The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA). Methods: Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery. Results: A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group. Conclusion: Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.