Single Position Lateral versus Prone Transpsoas Lateral Interbody Fusion Inclusive of L4-L5: A single surgeon experience examining early post-operative outcomes.

PURPOSE: The transpsoas lateral lumbar interbody fusion (LLIF) procedure is a minimally invasive lumbar spine approach that provides indirect neural decompression, improved sagittal alignment, and a high fusion rate. Typically accompanied by posterior pedicle screw insertion, there has been interest in performing LLIF in a single position to decrease cost and time under anesthesia. However, there is a paucity of direct comparisons between single-position LLIF via prone versus lateral decubitus positioning. Therefore, this stud aims to compare the outcomes of a single surgeon performing prone versus lateral single-position LLIF, inclusive of the L4-L5 level. METHODS: A retrospective review was performed of a consecutive case series of patients who underwent either prone or lateral, single-position LLIF by a single surgeon All cases involved the L4-L5 level. Demographic data, perioperative details, clinical outcomes, and pre- and postoperative lumbar lordosis were recorded. RESULTS: 63 patients underwent lateral, and 16 patients underwent prone single-position LLIF. Demographics and average interbody size were similar between groups. Operative time, change in lumbar lordosis, and length of hospital stay did not differ between the two positions. Both groups performed similarly in terms of pre- and postoperative VAS pain score, and complications. Patients who underwent lateral position LLIF ambulated farther on postoperative day 1 (250 vs. 200 feet, p=0.015). Average time to follow up was 53 weeks. CONCLUSIONS: This study demonstrates promising preliminary results indicating that single-position LLIF performs well, even at the L4-L5 level, in both the prone and lateral positions.

Magnetic Resonance Imaging in Pediatric Acetabulum Fractures with Open Triradiate Cartilage-A Report of 3 Cases.

We present three cases of posterior wall acetabulum fractures occurring in pediatric patients with open triradiate cartilage for whom preoperative magnetic resonance imaging was obtained and open reduction and internal fixation was done. All patients had excellent outcomes at an average of 68-week follow-up. Failure to adequately recognize the severity of pediatric acetabulum fractures can lead to detrimental long-term sequelae in acetabular development when treated nonsurgically. Management of this rare injury is not well reported in the literature. We highlight the utility of MRI in evaluating potential nonosseous injury and examining the articular surface to guide surgical management.

Characterizing Negative Online Reviews of Spine Surgeons.

DESIGN: Retrospective review. OBJECTIVE: Characterize negative reviews of spine surgeons in the United States. SUMMARY: Physician rating websites significantly influence the selection of doctors by other patients. Negative experiences are impacted by various factors, both clinical and nonclinical, geography, and practice structure. The purpose of this study was to evaluate and categorize negative reviews of spine surgeons in the United States, with a focus on surgical versus nonsurgical reviewers. METHODS: Spine surgeons were selected from available online professional society membership directories. A search for reviews was performed on Healthgrades.com, Vitals.com, and RateMDs.com for the past 10 years. Free response reviews were coded by complaint and qualitative analysis was performed. Chi-square and Fisher exact tests were used to compare categorical variables, and multiple comparisons were adjusted with Benjamini-Hochberg correction. A binary logistic regression model was performed for the top three most mentioned nonclinical and clinical complaint labels. A P-value<0.05 was considered statistically significant. RESULTS: A total of 16,695 online reviews were evaluated, including 1690 one-star reviews (10.1%). Amongst one-star reviews, 64.7% were written by nonsurgical patients and 35.3% by surgical patients. Nonclinical and clinical comments constituted 54.9% and 45.1% of reviews, respectively Surgeons in the South had more "bedside manner" comments (43.3%, P<0.0001), while Northeast surgeons had more "poor surgical outcome" remarks compared to all other geographic regions (14.4%, P<0.001). Practicing in the South and Northeast were independent predictors of having complaints about "bedside manner" and "poor surgical outcome", respectively. CONCLUSION: Most one-star reviews of spine surgeons were attributed to nonsurgical patients, who tended to be unsatisfied with nonclinical factors, especially "bedside manner". However, there was substantial geographic variation. These results suggest that spine surgeons could benefit from focusing on nonclinical factors (bedside manner), especially amongst nonoperative patients, and that regional nuances should be considered in delivering spine care. LEVEL OF EVIDENCE: Level 5.

Current Concepts on the Clinical and Economic Impact of Periprosthetic Joint Infections.

Total joint arthroplasty (TJA) is a common procedure performed throughout the entire world in hopes of alleviating debilitating hip or knee pain. The projected number of TJAs performed in the United States alone is projected to exceed 1.9 million by 2030 and 5 million by 2040. With the significant increase in TJA performed, more periprosthetic joint infections (PJIs) are likely to be encountered. PJIs are a devastating complication of TJA. The economic and clinical burden must be understood and respected to minimize occurrence and allow optimal patient outcomes.

Formal Radiologist Interpretations of Intraoperative Spine Radiographs Have Low Clinical Value.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To evaluate the clinical relevance, usefulness, and financial implications of intraoperative radiograph interpretation by radiologists in spine surgery. SUMMARY OF BACKGROUND DATA: Due to rising healthcare costs, spine surgery is under scrutiny to maximize value-based care. Formal radiographic analysis remains a potential source of unnecessary healthcare costs, especially for intra-operative radiographs. METHODS: A retrospective cohort analysis was performed on all adult elective spine surgeries at a single institution between July 2020 and July 2021. Demographic and radiographic data was collected, including intraoperative localization and post-instrumentation radiographs. Financial data was obtained through the institution's price estimator. Radiographic characteristics included time from radiographic imaging to completion of radiologist interpretation report, completion of radiologist interpretation report prior to the conclusion of surgical procedure, clinical relevance, and clinical usefulness. Reports were considered clinically relevant if spinal level of the procedure was described and clinically useful if completed prior to conclusion of the procedure and deemed clinically relevant. RESULTS: 481 intraoperative localization and post-instrumentation radiographs from 360 patients revealed a median delay of 128 minutes between imaging and completion of interpretive report. Only 38.9% of reports were completed before conclusion of surgery. There were 79.4% deemed clinically relevant and only 33.5% were clinically useful. Localization reports were completed more frequently before conclusion of surgery (67.2% vs. 34.4%), but with lower clinical relevance (90.1% vs. 98.5%) and clinical usefulness (60.3% vs. 33.6%) than post-instrumentation reports. Each patient was charged $32-$34 for interpretation fee, cumulating a minimum total cost of $15,392. CONCLUSION: Formal radiographic interpretation of intraoperative spine radiographs was of low clinical utility for spine surgeons. Institutions should consider optimizing radiology workflows to improve timeliness and clinical relevance or evaluate the necessity of reflexive consultation to radiology for intraoperative imaging interpretation to ensure that value-based care is maximized during spine surgeries. LEVEL OF EVIDENCE: 3.

Unique presentation of an intramuscular abscess caused by Bacteroides pyogenes in the setting of a cat bite: A case report.

Cat bites are a relatively common emergency department presentation. The most common species isolated from cat bite wounds is Pasteurella multocida. In this case report, we discuss a unique case of an intramuscular abscess caused by Bacteroides pyogenes. Antibiotic resistance in Bacteroides species is a growing concern and thus should be treated with caution. We present an 81-year-old female who presented to the emergency department with left calf pain that began 3 weeks prior to the emergency department presentation. She was initially seen by her primary care provider and was prescribed oral Trimethoprim/Sulfamethoxazole and Amoxicillin/Clavulanate. Despite oral antibiotics, she began to have worsening swelling, erythema, and fevers. In the emergency department, the patient's left calf was noticeably erythematous and tender to palpation. Lab work showed a C-reactive protein of 12.4 mg/dl, erythrocyte sedimentation rate of 38 mm/h, and white blood cell count of 15.1. Computed tomography imaging showed an irregularly shaped fluid collection at the junction of the calf musculature and upper aspect of the Achilles tendon. The decision was made to perform an operative incision and debridement on the evening of her presentation. On postoperative day 2, the wound cultures grew positive for both Pasturella multocida and Bacteroides pyogenes. She was subsequently discharged with oral Amoxicillin/Clavulanate 875 mg twice daily for 4 weeks. Further studies can be performed to identify the most efficient ways to isolate and treat this species. This case report emphasizes the importance of ordering both aerobic and anaerobic cultures and aiming antimicrobial therapy against both Pasteurella and anaerobic bacteria.

The Practicality of the Robotic Total Hip Arthroplasty for the Treatment of Complex Bilateral Adult Hip Dysplasia. Technology Makes It Easy.

Adult hip dysplasia provides many challenges for joint surgeons. Due to the abnormal bone morphology and altered biomechanics of the hip, surgeons must ensure accurate implant positioning to avoid postoperative complications. We present a 56-year-old female with a history of bilateral Legg-Calve-Perthes disease and subsequent dysplasia who underwent bilateral total hip arthroplasty using robotic navigation. We highlight the utility of robotic navigation in adult hip dysplasia to improve implant positioning and ensure optimal patient outcomes.

Examining the safety profile of a standard dose tranexamic acid regimen in spine surgery.

OBJECTIVE: Perioperative blood loss during spinal surgery is associated with complications and in-hospital mortality. Weight-based administration of tranexamic acid (TXA) has the potential to reduce blood loss and related complications in spinal surgery; however, evidence for standardized dosing is lacking. The purpose of this study was to evaluate the impact of a standardized preoperative 2 g bolus TXA dosing regimen on perioperative transfusion, blood loss, thromboembolic events, and postoperative outcomes in spine surgery patients. METHODS: An institutional review board approved this retrospective review of prospectively enrolled adult spine patients (> 18 years of age). Patients were included who underwent elective and emergency spine surgery between September 2018 and July 2021. Patients who received a standardized 2 g dose of TXA were compared to patients who did not receive TXA. The primary outcome measure was perioperative transfusion. Secondary outcomes included estimated blood loss and thromboembolic or other perioperative complications. Descriptive statistics were calculated, and continuous variables were analyzed with the two-tailed independent t-test, while categorical variables were analyzed with the Fisher's exact test or chi-square test. Stepwise multivariate regression analysis was performed to examine independent risk factors for perioperative outcomes. RESULTS: TXA was administered to 353 of 453 (78%) patients, and there were no demographic differences between groups. Although the TXA group had more operative levels and a longer operative time, the transfusion rate was not different between the TXA and no-TXA groups (7.4% vs 8%, p = 0.83). Stepwise multivariate regression found that the number of operative levels was an independent predictor of perioperative transfusion and that both operative levels and operative time were correlated with estimated blood loss. TXA was not identified as an independent predictor of any postoperative complication. CONCLUSIONS: A standardized preoperative 2 g bolus TXA dosing regimen was associated with an excellent safety profile, and despite increased case complexity in terms of number of operative levels and operative time, patients treated with TXA did not require more blood transfusions than patients not treated with TXA.

Arthrofibrosis in Robotic Total Knee Arthroplasty: An Investigation Into How Robotic Assistance May Contribute to a Tight Knee.

INTRODUCTION: Arthrofibrosis after total knee arthroplasty (TKA) can lead to pain and restricted range of motion. Matching native knee kinematics is crucial in avoiding arthrofibrosis postoperatively. However, manual jig-based instruments have demonstrated variability and inaccuracy during primary TKA. Robotic-arm-assisted surgery was developed to increase the precision and accuracy of bone cuts and component alignment. In the literature, limited information on arthrofibrosis after robotic-assisted TKA (RATKA) exists. The purpose of this study was to compare the incidence of arthrofibrosis after manual TKA (mTKA) with RATKA by examining the need for manipulation under anesthesia (MUA) postoperatively and evaluating preoperative and postoperative radiographic parameters. METHODS: A retrospective analysis of patients who underwent primary TKA from 2019 to 2021 was conducted. Rates of MUA were evaluated and perioperative radiographs were analyzed to determine posterior condylar offset ratio, Insall-Salvati Index, and posterior tibial slope (PTS) in patients who underwent mTKA versus RATKA. Range of motion was recorded for patients who required MUA. RESULTS: A total of 1234 patients were included, of which 644 underwent mTKA, and 590 underwent RATKA. Thirty-seven RATKA patients compared with 12 mTKA patients required MUA postoperatively (P < 0.0001). A significant decrease in PTS postoperatively was seen in the RATKA (7.10° ± 2.4° preoperatively versus 2.46° ± 1.2° postoperatively), with a mean decrease of the tibial slope of -4.6° ± 2.5° (P < 0.0001). In patients requiring MUA, a larger decrease was seen in the RATKA group when compared with the mTKA group (mean -5.5 ± 2.0 versus -5.3 ± 0.78, P = 0.6585). No significant difference was seen in the posterior condylar offset ratio and Insall-Salvati Index in both groups. DISCUSSION: When conducting RATKA, it is important to match PTS close to the native tibial slope to decrease the incidence of arthrofibrosis postoperatively, as a decrease in PTS can lead to decreased postoperative knee flexion and poor functional outcomes.

Preoperative identification of the initial burr hole site in retrosigmoid craniotomies: A teaching and technical note.

BACKGROUND: When fashioning a retrosigmoid craniotomy, precise placement of the initial burr hole is crucial to avoid iatrogenic sinusal injury and to facilitate a corridor that allows for minimal cerebellar retraction. METHODS: 3D CT reconstructions of 16 cadaveric sides were used to identify and measure three discrete anatomical points. These three points and distances between them were plotted onto the surface of the skull using a digital caliper to identify the optimal burr hole location. This technique was subsequently applied in 20 clinical cases. RESULTS: Optimal burr hole placement was achieved in 87.5% of specimens and, with minor refinement, 100% of clinical cases with no significant increase in operative time. Preoperative planning took an average of 10 minutes. CONCLUSION: This technique for localizing the location of the initial retrosigmoid burr hole is a simple, safe, reliable, rapid, and inexpensive solution for surgeons who do not have regular access to neuronavigation.