Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study.

PURPOSE: To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years. METHODS: The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05. RESULTS: A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R2 = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R2 = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001). CONCLUSIONS: The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population. LEVEL OF EVIDENCE: Level III, retrospective database epidemiological study.

In vitro evaluation of a lentiviral two-step transcriptional amplification system using GAL4FF transactivator for gene therapy applications in bone repair.

In this study, we developed a lentiviral two-step transcriptional amplification (TSTA) system expressing bone morphogenetic protein-2 (BMP-2) under the control of a GAL4FF transactivator to enhance gene expression and limit toxicity for bone repair applications. To this end human MSCs, isolated from bone marrow or adipose tissue, were transduced overnight with a LV-TSTA system (GAL4FF or GAL4vp16) expressing BMP-2 or GFP and evaluated in vitro for transduction efficiency, mean fluorescence intensity, cell viability, and BMP-2 production. FACS analysis of GFP-transduced MSCs confirmed successful transduction with the GAL4FF+GFP vector. Moreover, ELISA demonstrated abundant BMP-2 production by GAL4FF+BMP2-transduced human MSCs over a period of 8 weeks, with minimal cytotoxicity at all time points. Compared to GAL4vp16, GAL4FF was superior with respect to BMP production at 1, 2, 4, 6, and 8 weeks in BMSCs. In ASCs, GAL4FF was still associated with higher BMP-2 production at weeks 2-8, but this difference was not as prominent as in BMSCs. To our knowledge, this is the first report of GAL4FF-mediated BMP-2 production by human BMSCs and ASCs. Compared to the standard GAL4vp16TSTA vector, GAL4FF was associated with lower cytotoxicity and higher in vitro gene expression in both BMSCs and ASCs.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications.

BACKGROUND AND OBJECTIVES: Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. METHODS: A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. RESULTS: A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. CONCLUSIONS: FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Washer and Post Augmentation of 90/90 Wiring for Proximal Interphalangeal Joint Arthrodesis: A Biomechanical Study.

PURPOSE: To describe a novel construct for proximal interphalangeal (PIP) joint arthrodesis using headless cannulated screws as an intramedullary washer to augment 90/90 intraosseous wiring and compare the biomechanical properties of this construct with those of the 90/90 intraosseous wiring without headless screw augmentation. METHODS: Biomechanical evaluation of augmented 90/90 intraosseous wiring with headless cannulated screws (group 1) or 90/90 intraosseous wiring without augmentation (group 2) for PIP joint arthrodesis was performed in 3 matched-pair cadaveric specimens (12 digits per group). Each group was loaded to 10 N in the sagittal and coronal planes and the resultant stiffness from the load-displacement curve was calculated. In extension, each group then underwent load to permanent deformation and load to catastrophic failure. RESULTS: The augmented 90/90 intraosseous wiring with cannulated screws construct demonstrated significantly greater stiffness by 132%, 64%, 79%, and 75% in flexion, extension, ulnar, and radial displacement, respectively. During load to permanent deformation testing, a 42% greater force was required to create permanent deformation in group 1 compared than group 2. There was no significant difference between the 2 groups during load to catastrophic failure testing. CONCLUSIONS: Augmenting 90/90 intraosseous wiring for PIP joint arthrodesis with 2 headless cannulated screws in the sagittal plane that serve as intramedullary washers for the sagittal wire and posts for the coronal wire significantly increases stiffness in all directions as well as load to permanent deformation compared with 90/90 intraosseous wiring without cannulated screw augmentation. CLINICAL RELEVANCE: Augmentation of the 90/90 intraosseous wire construct with headless cannulated screws can be considered in patients at risk for wire cutout or implant failure.

Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma.

BACKGROUND: Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH. METHODS: Demographics, outcomes, and bacterial speciation in patients with tibial fractures at a level 1 trauma center from 2007 to 2014 were reviewed. The primary outcome was infection suppression, while secondary outcomes included limb salvage, amputation, and osseous union. RESULTS: Twenty-five patients underwent soft tissue reconstruction for salvage of iIFH. Average age was 41, 19 (76%) were male, average BMI 30.1 kg/m2 , 10 (40%) patients smoked. Tibial fractures were closed in 8 (32%), Gustilo-Anderson grade I in 1 (4%), II in 8 (32%), IIIb in 5 (20%), and IIIc in 1 (4%). Staphylococcus was most commonly cultured with 11 (44%) demonstrating methicillin-resistance. Soft tissue reconstruction was performed by local flap in 15 (60%) and free flap in 10 (40%). At an average of 16.1 months, 19 (76%) hardware salvage patients demonstrated clinical suppression of infection, 11 of 19 (57.9%) patients had bony union, and 24 (96%) maintained a salvaged limb. One patient was amputated for recurrent infection. CONCLUSIONS: Following complex, infected tibial fractures, salvage of the lower extremity may be attempted even when iIFH cannot be removed. Thorough debridement, antibiotics, and vascularized soft tissue may suppress infection long enough to facilitate osseous union and subsequent removal of iIFH.

A Biomechanical Comparison of Distal Fixation for Bridge Plating in a Distal Radius Fracture Model.

PURPOSE: To compare the biomechanical properties of second versus third metacarpal distal fixation when using a radiocarpal spanning distraction plate in an unstable distal radius fracture model. METHODS: Biomechanical evaluation of the radiocarpal spanning distraction plate comparing second versus third metacarpal distal fixation was performed using a standardized model of an unstable wrist fracture in 10 matched-pair cadaveric specimens. Each fixation construct underwent a controlled cyclic loading protocol in flexion and extension. The resultant displacement and stiffness were calculated at the fracture site. After cyclic loading, each specimen was loaded to failure. The stiffness, maximum displacement, and load to failure were compared between the 2 groups. RESULTS: Cyclic loading in flexion demonstrated that distal fixation to the third metacarpal resulted in greater stiffness compared with the second metacarpal. There was no significant difference between the 2 groups with regards to maximum displacement at the fracture site in flexion. Cyclic loading in extension demonstrated no significant difference in stiffness or maximum displacement between the 2 groups. The average load to failure was similar for both groups. CONCLUSIONS: Fixation to the third metacarpal resulted in greater stiffness in flexion. All other biomechanical parameters were similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a spanning internal distraction plate. CLINICAL RELEVANCE: The treating surgeon should choose distal metacarpal fixation primarily based on fracture pattern, alignment, and soft tissue integrity. If a stiffer construct is desired, placement of the radiocarpal spanning plate at the third metacarpal is preferred.

Distal Radius Fractures: Approaches, Indications, and Techniques.

Distal radius fractures remain among the most common fractures of the upper extremity. The indications for operative management continue to evolve based on outcomes from the most recent clinical studies. Advancements over the past decade have expanded the variety of fixation options available; however, the clinical superiority of a particular treatment modality remains without consensus. Each approach requires the use of unique surgical techniques, and the choice of a particular implant system should be based on the surgeon's familiarity with the implant design and its limitations. As our understanding of the management of distal radius fractures improves, so will our indications for each specific treatment modality.

Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty. METHODS: The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates. RESULTS: In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001). CONCLUSION: The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Demographic analysis of open and arthroscopic distal clavicle excision in a private insurance database.

PURPOSE: The purpose of this study was to evaluate and quantify the demographic characteristics of patients undergoing open and arthroscopic distal clavicle excision (DCE) in the United States while also describing changes in practice patterns over time. METHODS: Patients who underwent DCE from 2004 to 2009 were identified by Current Procedural Terminology (CPT) codes in a national database of orthopaedic insurance records. The year of procedure, age, sex, geographic region, and concomitant rotator cuff repair or subacromial decompression (SAD) were recorded for each patient. Results were reported as the incidence of procedures identified per 10,000 patients searched in the database. RESULTS: Between 2004 and 2009, 73,231 DCEs were performed; 74% were arthroscopic and 26% were open. The incidence of arthroscopic DCE increased from 37.8 in 2004 to 58.5 in 2009 (P < .001), whereas the incidence of open DCE decreased from 21.1 in 2004 to 14.1 in 2009 (P < .001). Sixty-one percent of DCEs were performed in men (P < .001). Women were more likely to undergo an arthroscopic procedure (P < .001). Arthroscopic DCE was most common in patients aged 50 to 59 years (P < .001). Open DCE was most common in patients aged 60 to 69 years (P < .001). Open rotator cuff repair and SAD were concomitantly performed in 38% and 23% of open DCEs, respectively. Arthroscopic rotator cuff repair and SAD were concomitantly performed in 33% and 95% arthroscopic DCEs, respectively. CONCLUSIONS: This analysis of DCE using a private insurance database shows that arthroscopic DCEs progressively increased, whereas open DCEs concomitantly decreased between 2004 and 2009. The majority of DCEs were performed in men between the ages of 50 and 59 years. Both arthroscopic and open DCEs are frequently performed in conjunction with rotator cuff repair or SAD. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

The Incidence of Vertebral Artery Injury in Cervical Spine Surgery.

BACKGROUND: Previously reported estimates of vertebral artery injuries (VAIs) during cervical spine surgery relied on self-reported survey studies and retrospective cohorts, which may not be reflective of national averages. The largest study to date reports an incidence of 0.07%; however, significant variation exists between different cervical spine procedures. This study aimed to identify the incidence of VAIs in patients undergoing cervical spine procedures for degenerative pathologies. METHODS: In this retrospective cohort study, a national insurance database was used to access data from the period 2010-2020 of patients who underwent anterior cervical discectomy and fusion, anterior corpectomy, posterior cervical fusion (C3-C7), or C1-C2 posterior fusion for degenerative pathologies. Patients who experienced a VAI were identified, and frequencies for the different procedures were compared. RESULTS: This study included 224,326 patients, and overall incidence of VAIs across all procedures was 0.03%. The highest incidence of VAIs was estimated in C1-C2 posterior fusion (0.12%-1.10%). The number of patients with VAIs after anterior corpectomy, anterior cervical discectomy and fusion, and posterior fusion was 14 (0.06%), 43 (0.02%), and 26 (0.01%), respectively. CONCLUSIONS: This is the largest study to date to our knowledge that provides frequencies of VAIs in patients undergoing cervical spine surgery in the United States. The overall incidence of 0.03% is lower than previously reported estimates, but significant variability exists between procedures, which is an important consideration when counseling patients about risks of surgery.

Top 25 Most-Cited Articles on Robotic-Assisted Lumbar Spine Surgery.

BACKGROUND: Robot-guided lumbar spine surgery has evolved rapidly with evidence to support its utility and feasibility compared with conventional freehand and fluoroscopy-based techniques. The objective of this study was to assess trends among the top 25 most-cited articles pertaining to robotic-guided lumbar spine surgery. METHODS: An "advanced document search" using Boolean search operator terms was performed on 16 November 2022 through the Web of Science and SCOPUS citation databases to determine the top 25 most-referenced articles on robotic lumbar spine surgery. The articles were compiled into a directory and hierarchically organized based on the total number of citations. RESULTS: Cumulatively, the "Top 25" list for robot-assisted navigation in lumbar spine surgery received 2240 citations, averaging 97.39 citations annually. The number of citations ranged from 221 to 40 for the 25 most-cited articles. The most-cited study, by Kantelhardt et al, received 221 citations, averaging 18 citations per year. CONCLUSIONS: As utilization of robot-guided modalities in lumbar spine surgery increases, this review highlights the most impactful studies to support its efficacy and implementation. Practical considerations such as cost-effectiveness, however, need to be better defined through further longitudinal studies that evaluate patient-reported outcomes and cost-utility. CLINICAL RELEVANCE: Through an overview of the top 25 most-cited articles, the present review highlights the rising prominence and technical efficacy of robotic-guided systems within lumbar spine surgery, with consideration to pragmatic limitations and need for additional data to facilitate cost-effective applications.

Cervical Disc Arthroplasty: Rationale, Designs, and Results of Randomized Controlled Trials.

BACKGROUND: This review outlines clinical data and characteristics of current Food and Drug Administration (FDA)-approved implants in cervical disc replacement/cervical disc arthroplasty (CDR/CDA) to provide a centralized resource for spine surgeons. METHODS: Randomized controlled trials (RCTs) on CDR/CDA were identified using a search of the PubMed, Web of Science, and Google Scholar databases. The initial search identified 69 studies. Duplicates were removed, and the following inclusion criteria were applied when determining eligibility of RCTs for the current review: (1) discussing CDR/CDA prosthesis and (2) published within between 2010 and 2020. Studies without clinical data or that were not RCTs were excluded. All articles were reviewed independently by 2 authors, with the involvement of an arbitrator to facilitate consensus on any discrepancies. RESULTS: A total of 34 studies were included in the final review. Findings were synthesized into a comprehensive table describing key features and clinical results for each FDA-approved CDR/CDA implant and are overall suggestive of expanding indications and increasing utilization. CONCLUSIONS: RCTs have provided substantial evidence to support CDR/CDA for treating single- and 2-level cervical degenerative disc disease in place of conventional anterior cervical discectomy and fusion. CLINICAL RELEVANCE: This review provides a resource that consolidates relevant clinical data for current FDA-approved implants to help spine surgeons make an informed decision during preoperative planning.

Top 25 Most Cited Articles on Intraoperative Computer Tomography-Guided Navigation in Spine Surgery.

BACKGROUND: In recent years, the use of intraoperative computer tomography-guided (CT-guided) navigation has gained significant popularity among health care providers who perform minimally invasive spine surgery. This review aims to identify and analyze trends in the literature related to the widespread adoption of CT-guided navigation in spine surgery, emphasizing the shift from conventional fluoroscopy-based techniques to CT-guided navigation. METHODS: Articles pertaining to this study were identified via a database review and were hierarchically organized based on the number of citations. An "advanced document search" was performed on September 28th, 2022, utilizing Boolean search operator terms. The 25 most referenced articles were combined into a primary list after sorting results in descending order based on the total number of citations. RESULTS: The "Top 25" list for intraoperative CT-guided navigation in spine surgery cumulatively received a total of 2742 citations, with an average of 12 new citations annually. The number of citations ranged from 246 for the most cited article to 60 for the 25th most cited article. The most cited article was a paper by Siewerdsen et al., with 246 total citations, averaging 15 new citations per year. CONCLUSIONS: Intraoperative CT-guided navigation is 1 of many technological advances that is used to increase surgical accuracy, and it has become an increasingly popular alternative to conventional fluoroscopy-based techniques. Given the increasing adoption of intraoperative CT-guided navigation in spine surgery, this review provides impactful evidence for its utility in spine surgery.

Patients with Hip Osteoarthritis Have a Higher Rate of Spinal Reoperation Following Lumbar Spinal Fusion.

BACKGROUND: Lumbar spinal pathology is known to affect outcomes following total hip arthroplasty (THA). However, the effect of hip osteoarthritis (OA) on outcomes following lumbar fusion has not been well studied. The purpose of this study was to determine the association between hip OA and spinal reoperation following lumbar spinal fusion. METHODS: The 5% Medicare Part B claims database was queried for all patients who underwent primary elective lumbar fusion from 2005 to 2019. Patients were divided into 2 groups: those who underwent elective THA within 1 year after primary lumbar fusion, indicating that they had severe hip OA at the time of lumbar fusion, and those who underwent lumbar fusion with no diagnosed hip OA and no THA during the study period. Exclusion criteria included THA as a result of trauma, revision THA or primary THA in the 5-year period before primary lumbar fusion, <65 years of age, and no enrollment in the database for 5 years before and 1 year after primary lumbar fusion. The primary outcome was spinal reoperation within 1, 3, and 5 years. Multivariable Cox regression was performed with age, sex, diabetes, heart disease, obesity, smoking status, osteoporosis, number of levels fused, use of posterior instrumentation, use of an interbody device, use of bone graft, and surgical approach as covariates. RESULTS: Overall, 1,123 patients (63.4% female; 91.3% White; mean age, 76.8 ± 4.1 years) were included in the hip OA group and 8,893 patients (56.2% female; 91.3% White; mean age, 74.8 ± 4.9 years) were included in the control group. After multivariable analysis, patients with severe hip OA had significantly greater rates of revision surgery at 3 years (odds ratio [OR], 1.61; p < 0.001) and 5 years (OR, 1.87; p < 0.001) after the index lumbar fusion. CONCLUSIONS: Patients with severe hip OA at the time of primary lumbar fusion had a significantly increased risk of spinal reoperation at 3 and 5 years postoperatively. These data provide further evidence to support performing THA prior to lumbar fusion in the unsettled debate regarding which surgery should be prioritized for patients with simultaneous degenerative diseases of the hip and lumbar spine. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation.

STUDY DESIGN: Systematic review. OBJECTIVES: Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions. METHODS: A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2. RESULTS: All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001). CONCLUSION: Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Fusion Rates and Complications Following Surgery for Degenerative Cervical Spine Pathology.

BACKGROUND: As the elderly population grows, the increasing prevalence of osteoporosis presents a unique challenge for surgeons. Decreased bone strength and quality are associated with hardware failure and impaired bone healing, which may increase the rate of revision surgery and the development of complications. The purpose of this review is to determine the impact of osteoporosis on postoperative outcomes for patients with cervical degenerative disease or deformity. METHODS: A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Medical Subject Headings terms involving spine surgery for cervical degenerative disease and osteoporosis were performed. This review focused on radiographic outcomes, as well as surgical and medical complications. RESULTS: There were 16 studies included in the degenerative group and 9 in the deformity group. Across degenerative studies, lower bone mineral density was associated with increased rates of cage subsidence in osteoporotic patients undergoing operative treatment for cervical degenerative disease. Most studies reported varied results on the relationship between osteoporosis and other outcomes such as revision and readmission rates, costs, and perioperative complications. Our meta-analysis suggests that osteoporotic patients carry a greater risk of reduced fusion rates at 6 months and 1 year postoperatively. With respect to cervical deformity correction, although individual complication rates were unchanged with osteoporosis, the collective risk of incurring any complication may be increased in patients with poor bone stock. CONCLUSIONS: Overall, the literature suggests that outcomes for osteoporotic patients after cervical spine surgery are multifactorial. Osteoporosis seems to be a significant risk factor for developing cage subsidence and pseudarthrosis postoperatively, whereas reports on medical and hospital-related metrics were inconclusive. Our findings highlight the challenges of caring for osteoporotic patients and underline the need for adequately powered studies to understand how osteoporosis changes the risk index of patients undergoing cervical spine surgery. CLINICAL RELEVANCE: In patients undergoing cervical spine surgery for degenerative disease, osteoporosis is a significant risk factor for long-term postoperative complications-notably cage subsidence and pseudarthrosis. Given the elective nature of these procedures, interdisciplinary collaboration between providers should be routinely implemented to enable medical optimization of patients prior to cervical spine surgery.

Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Reoperation Rates and Complications after Surgical Management of Lumbar Degenerative Disease.

BACKGROUND: There is considerable heterogeneity in findings and a lack of consensus regarding the interplay between osteoporosis and outcomes in patients with lumbar degenerative spine disease. Therefore, the purpose of this systematic review and meta-analysis was to gather and analyze existing data on the effect of osteoporosis on radiographic, surgical, and clinical outcomes following surgery for lumbar degenerative spinal disease. METHODS: A systematic review was performed to determine the effect of osteoporosis on the incidence of adverse outcomes after surgical intervention for lumbar degenerative spinal diseases. The approach focused on the radiographic outcomes, reoperation rates, and other medical and surgical complications. Subsequently, a meta-analysis was performed on the eligible studies. RESULTS: The results of the meta-analysis suggested that osteoporotic patients experienced increased rates of adjacent segment disease (ASD; p=0.015) and cage subsidence (p=0.001) while demonstrating lower reoperation rates than non-osteoporotic patients (7.4% vs. 13.1%; p=0.038). The systematic review also indicated that the length of stay, overall costs, rates of screw loosening, and rates of wound and other medical complications may increase in patients with a lower bone mineral density. Fusion rates, as well as patient-reported and clinical outcomes, did not differ significantly between osteoporotic and non-osteoporotic patients. CONCLUSIONS: Osteoporosis was associated with an increased risk of ASD, cage migration, and possibly postoperative screw loosening, as well as longer hospital stays, incurring higher costs and an increased likelihood of postoperative complications. However, a link was not established between osteoporosis and poor clinical outcomes.

The Effect of Osteoporosis on Complications and Reoperation Rates After Surgical Management of Adult Thoracolumbar Spinal Deformity: A Systematic Review and Meta Analysis.

STUDY DESIGN: Systematic Review. OBJECTIVES: While substantial research has explored the impact of osteoporosis on patients undergoing adult spinal deformity (ASD) correction, the literature remains inconclusive. As such, the purpose of this study is to synthesize and analyze existing studies pertaining to osteoporosis as a predictor of postoperative outcomes in ASD surgery. METHODS: We performed a systematic review and meta-analysis to determine the effect that a diagnosis of osteoporosis, based on ICD-10 coding, dual-energy X-ray absorptiometry (DEXA) or computed tomography, has on the incidence of adverse outcomes following surgical correction of ASD. Statistical analysis was performed using Comprehensive Meta-Analysis (Version 2) using a random effects model to account for heterogeneity between studies. RESULTS: After application of inclusion and exclusion criteria, 36 and 28 articles were included in the systematic review and meta-analysis, respectively. The meta-analysis identified greater rates of screw loosening amongst osteoporotic patients (70.5% vs 31.9%, P = .009), and decreased bone mineral density in patients who developed proximal junctional kyphosis (PJK) (.69 vs .79 g/cm2, P = .001). The systematic review demonstrated significantly increased risk of any complication, reoperation, and proximal junctional failure (PJF) associated with reduced bone density. No statistical difference was observed between groups regarding fusion rates, readmission rates, and patient-reported and/or functional outcome scores. CONCLUSION: This study demonstrates a higher incidence of screw loosening, PJK, and revision surgery amongst osteoporotic ASD patients. Future investigations should explore outcomes at various follow-up intervals in order to better characterize how risk changes with time and to tailor preoperative planning based on patient-specific characteristics.

Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients.

STUDY DESIGN: Retrospective review of private neuromonitoring databases. OBJECTIVES: To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels. METHODS: Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared. RESULTS: A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level (P = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 (P < .03). CONCLUSIONS: IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.

Preoperative Depression Screening in Primary Lumbar Fusion: An Evaluation of Its Modifiability on Outcomes in Patients with Diagnosed Depressive Disorder.

OBJECTIVE: Studies have reported the detrimental effects of depression following spine surgery; however, none have evaluated whether preoperative depression screening in patients with a history of depression is protective from adverse outcomes and lowers health care costs. We studied whether depression screenings/psychotherapy visits within 3 months before 1- to 2-level lumbar fusion were associated with lower medical complications, emergency department utilization, readmissions, and health care costs. METHODS: The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1- to 2-level lumbar fusion. Two cohorts were 1:5 ratio matched and included DD patients with (n = 2,622) and DD patients without (n = 13,058) a preoperative depression screen/psychotherapy visit within 3 months of lumbar fusion. A 90-day surveillance period was used to compare outcomes. Logistic regression models computed odds ratio (OR) of complications and readmissions. P value < 0.003 was significant. RESULTS: DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR 2.71, P < 0.0001). Rates of emergency department utilization were increased in patients without screening versus screening (15.78% vs. 4.23%; OR 4.25, P < 0.0001), despite no difference in readmissions (9.31% vs. 9.53%; OR 0.97, P = 0.721). Finally, 90-day reimbursements ($51,160 vs. $54,731) were significantly lower in the screened cohort (all P < 0.0001). CONCLUSIONS: Patients who underwent a preoperative depression screening within 3 months of lumbar fusion had decreased medical complications, emergency department utilization, and health care costs. Spine surgeons may use these data to counsel their patients with depression before surgical intervention.