Biomechanical evaluation of supplemental percutaneous lumbo-sacro-iliac screws for spinopelvic fixation following total sacrectomy.

STUDY DESIGN: This is a cadaveric biomechanical study evaluating the biomechanical properties of a novel spinopelvic fixation technique with percutaneous lumbo-sacro-iliac (LSI) screws in an unstable total sacrectomy model. OBJECTIVE: To compare standard posterior dual rod spinopelvic fixation alone with dual rod fixation supplemented with LSI screw fixation. SUMMARY OF BACKGROUND DATA: Primary or metastatic tumors of the sacrum requiring a total sacrectomy can result in spinopelvic instability if inadequate fixation is achieved. Many fixation techniques have been proposed to address this instability. However, to date, an optimal fixation technique has not been established. MATERIALS AND METHODS: Ten fresh-frozen cadaveric spinopelvic specimens were randomized according to bone mineral density (BMD) to either posterior rod fixation (control group) or posterior rod fixation with supplemental LSI screws (LSI group). After fixation, a total sacrectomy of each specimen was performed. Specimens where then potted and axially loaded in a caudal direction. Stiffness, yield load, energy absorbed at yield load, ultimate load, and energy absorbed at ultimate load were computed. A Student t test was used for statistical analysis with significance set at P<0.05. RESULTS: The average age and BMD were not significantly different between the control and LSI groups (age: P=0.255; BMD: P=0.810). After normalizing for BMD, there were no significant differences detected for any of the biomechanical parameters measured between the 2 fixation techniques: stiffness (P=0.857), yield load (P=0.219), energy at yield load (P=0.293), ultimate load (P=0.407), and energy at ultimate load (P=0.773). However, both fixation techniques were able to withstand physiological loads. CONCLUSIONS: Our study did not demonstrate any biomechanical advantage for supplemental LSI screw fixation in our axial loading model. However, given the theoretical advantage of this percutaneous technique, further studies are warranted that take into account forward bending and sagittal stability.

Biomechanical evaluation of augmentation of suture-bridge supraspinatus repair with additional anterior fixation.

BACKGROUND: Studies have recently focused on evaluating the ability of the supraspinatus repair to withstand rotational loads. Other studies have focused on the importance of minimizing gap formation to avoid decreased healing and failure of repair. The objective of this study was to use a loading model that incorporates external rotation to biomechanically evaluate augmenting a suture-bridge technique for supraspinatus repair with an additional anterior fixation. METHODS: Eight matched cadaveric shoulder pairs were randomized to 2 different types of repairs after a simulated supraspinatus tear. One group received a standard suture-bridge technique, and the other underwent a suture-bridge repair with an additional anterior fixation consisting of a 4.5-mm suture anchor. A custom apparatus was used to test all specimens, allowing for dynamic external rotation from 0° to 30° during loading. Cyclic loading was performed for 30 cycles from 0 to 90 N, followed by load to failure using a materials-testing machine. RESULTS: No differences were found in linear stiffness, yield load, ultimate load, and energy absorbed for load to failure between the 2 groups (P > .05). There was a reduction in anterior gapping at ultimate load between the anterior augmentation repair group (6.4 ± 3.1 mm) and the standard suture bridge (9.4 ± 2.8 mm; P = .037). CONCLUSION: There does not appear to be a biomechanical advantage with the addition of an anterior suture augmentation of a suture bridge for a supraspinatus repair. However, using an anterior augmentation for a suture bridge prevents gap formation at ultimate load in a biomechanical, dynamic external rotation model.

Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft.

BACKGROUND: Reconstruction of only the coracoclavicular (CC) ligaments may restore superior-inferior (S-I) but not anterior-posterior (A-P) stability of the acromioclavicular (AC) joint. Concomitant reconstruction of both the AC and CC ligaments may more reliably restore intact biomechanical characteristics of the AC joint. METHODS: Ten matched pairs of shoulders were utilized. Five specimens underwent CC ligament reconstruction while an equal number underwent combined AC and CC ligament reconstruction utilizing an intramedullary tendon graft. Each of the reconstructions was compared with the intact contralateral control. Translational and load to failure characteristics were compared between groups. RESULTS: No difference was found in S-I translation between intact specimens and CC-only reconstructions (P = .20) nor between intact specimens and AC/CC reconstructions (P = .33) at 10 Newton (N) loads. Significant differences were noted in A-P translation between intact specimens and CC-only reconstructions (P < .001) but no difference in A-P translation between intact specimens and AC/CC reconstructions (P = .34). CONCLUSION: The A-P and S-I translational biomechanical characteristics of the AC joint were restored using the new technique described. Reconstruction of the CC ligaments only (versus AC/CC combined) led to significantly increased translational motion in the A-P plane as compared to intact control specimens.

COVID-19 and Spine Surgery: A Review and Evolving Recommendations.

Coronavirus-19 (COVID-19) has disrupted the normal delivery of healthcare for spine surgeons across the world. In this review, we will provide an overview of COVID-19's clinical features, and discuss the optimization and treatment of spine pathology during the ongoing global pandemic.

Cervical Disc Replacement: Trends, Costs, and Complications.

STUDY DESIGN: Retrospective review of insurance database. PURPOSE: To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population. OVERVIEW OF LITERATURE: As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest. METHODS: Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative. RESULTS: Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was US $33,696.28 and US $34,675.12, respectively (p=0.29). CONCLUSIONS: This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.

Return to Recreational Sport Following Lumbar Fusion.

STUDY DESIGN: This was a retrospective questionnaire study at a single academic medical center. OBJECTIVE: The objective of this study was to obtain information on rates of return to sport following lumbar fusion as well as sport-specific effects to improve evidence-based preoperative patient counseling. SUMMARY OF BACKGROUND DATA: Lumbar spinal fusion is one of the fastest-growing surgical procedures, with the majority being in patients aged 60 years and older. Remaining active is an important consideration for elderly patients undergoing lumbar spinal fusion. Golf, swimming, and biking are common forms of recreational exercise for an older population in whom lumbar fusion is often performed. There is a lack of data in the current literature regarding rates of return to recreational sporting activities following elective lumbar fusion. METHODS: Following Institutional Review Board approval, all patients undergoing lumbar fusion at a single institution from 2012 to 2016 were screened and included in this study. A minimum of 1-year postoperative follow-up was required. A total of 117 patients were identified undergoing single-level or multilevel lumbar fusion during this time period. The average age was 63 years. Questionnaires were obtained to screen and identify patients who participated in 1 of 3 recreational sports before surgery (golf, swimming, and biking). Preoperative and postoperative collected outcome measures were then compared using the Student t test. RESULTS: Of the 117 identified lumbar fusion patients, 32 patients (27%) participated in 1 of the 3 most common recreational sporting activities of golf, swimming, or biking. Within the golf cohort (n=13), 100% of patients returned to recreational golfing postoperatively. There was a statistically significant reduction in Visual Analog Scale (VAS) pain scores postoperatively (6.3±3.7-1.8±2.4, P=0.01). Driving distance was reduced postoperatively (223.3±42.7-212.1±44.4 yards, P=0.042) and handicaps increased (12.8±8.4-17.0±11.4, P=0.02). Within the swimming cohort (n=9), 100% of patients returned to recreational swimming following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (9.1±1.7-2.2±2.3, P=0.01). There was a trend towards increased amounts of swimming (times per week) postoperatively, however, this was not statistically significant (2.1±1.7-3.7±1.5, P=0.10). Within the biking cohort (n=10), 100% of patients returned to recreational biking following lumbar fusion. There was a statistically significant reduction in VAS pain scores postoperatively (6.7±4.0-1.3±1.7, P=0.03). There was a trend towards increased amounts of biking (times per week) postoperatively, however, this was not statistically significant (2.5±1.8-3.7±1.6 postoperatively, P=0.20). CONCLUSIONS: In the cohort of patients from this study who partook in golfing, swimming or bicycling, 100% were able to return to their respective sport by 3-9 months postoperatively and all had a significant reduction in pain. With regards to golfers, lumbar fusion likely has an adverse effect on their golfing ability with an increase in handicap and an expected reduction in driving distance.

Frailty Syndrome and the Use of Frailty Indices as a Preoperative Risk Stratification Tool in Spine Surgery: A Review.

This comprehensive narrative literature review aims to extract studies related to frailty indices and their use in elective spine procedures, as limited studies regarding frailty exist in the spine literature. Most studies are retrospective analyses of prospectively collected databases. Evidence suggests a positive correlation between frailty level and mortality rate, postoperative complication rate, length of stay, and the possibility of discharge to a skilled nursing facility; these correlations have been illustrated across various spine procedures. The leading index is the modified frailty index, which measures 11 deficits. The development of more comprehensive frailty indices, such as the Adult Spinal Deformity Frailty Index, are promising and have high predictive value regarding postoperative complication rate in patients with spinal deformity. However, a frailty index that combines clinical, radiographic, and laboratory measures awaits development. Perhaps, the use of a frailty index in preoperative risk stratification for elective spine procedures could serve multiple purposes, including screening for high-risk patients, enhancement of operative decision making, approximation of complication rate for informed decision making, and refinement of perioperative care. Further prospective studies are warranted to determine clinically meaningful interventions in frail individuals.

Video Review as a Tool to Improve Orthopedic Residents׳ Performance of Closed Manipulative Reductions.

OBJECTIVE: Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and long-term skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance. DESIGN: Closed reductions performed by orthopaedic residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program. SETTING: University-based Level I Trauma Center. PARTICIPANTS: Orthopedic surgery residents and faculty. RESULTS: All junior orthopedic residents (postgraduate year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents (PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p = 0.02). CONCLUSIONS: Video review provides a useful, innovative, and inexpensive method to improve resident competency in closed fracture reduction-a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation.

Surgical Management of Complex Lower-Extremity Trauma With a Long Hindfoot Fusion Nail: A Case Report.

UNLABELLED: High-energy injuries can result in complete or partial loss of the talus. Ipsilateral fractures to the lower limb increase the complexity of surgical management, and treatment is guided by previous case reports of similar injuries. A case of complex lower-extremity trauma with extruded and missing talar body and ipsilateral type IIIB open tibia fracture is presented. Surgical limb reconstruction and salvage was performed successfully with a single orthopaedic implant in a manner not described previously in the literature. The purpose of this case report is to present the novel use of a single orthopaedic implant for treatment of a complex, open traumatic injury. Previous case reports in the literature have described the management of complete or partial talar loss. We describe the novel use of a long hindfoot fusion nail and staged bone grafting to achieve tibiocalcaneal arthrodesis for the treatment of complex lower-extremity trauma. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Construct Validity for a Cost-effective Arthroscopic Surgery Simulator for Resident Education.

INTRODUCTION: Arthroscopy is one of the most challenging surgical skills to assess and teach. Although basic psychomotor arthroscopic skills, such as triangulation and object manipulation, are incorporated into many simulation exercises, they are not always individually taught or objectively evaluated. In addition, arthroscopic instruments, arthroscopy cameras, and the cadaver or joint models necessary for practice are costly. METHODS: A low-cost arthroscopic simulator was created to practice triangulation, probing, horizon changes, suture management, and object manipulation. The simulator materials were purchased exclusively from national hardware stores with a total cost averaging $79. The universal serial bus (USB) camera is included in the total cost. Three residency programs accredited by the Accreditation Council for Graduate Medical Education were tested on the simulator. Replica boards were created at each institution. Participants included medical students (20), residents (46), and attending physicians (9). RESULTS: Construct validity-the ability to differentiate between novice, intermediate, and senior level participants-was obtained. On all tasks, junior residents scored at a statistically significant lower rate than senior residents and attending physicians. CONCLUSIONS: This cost-effective arthroscopic surgical simulator objectively demonstrated that attending physicians and senior residents performed at a higher level than junior residents and novice medical students. The results of this study demonstrate that this simulator could be an important training tool for resident education.