Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data.

INTRODUCTION: In this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation. METHODS: This study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance. RESULTS: Robotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses-In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038). CONCLUSION: This is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Telling the truth to patients before hip fracture surgery.

BACKGROUND: Hip fracture repair surgery carries a certain mortality risk, yet evidence suggests that orthopedic surgeons often refrain from discussing this issue with patients prior to surgery. AIM: This study aims to examine whether orthopedic surgeons raise the issue of one-year post-surgery mortality before hip fracture repair surgery and to explore factors influencing this decision. METHOD: The study employs a cross-sectional design, administering validated digital questionnaires to 150 orthopedic surgeons. RESULTS: A minority of orthopedic surgeons reported always informing patients about the risk of mortality in the year following hip fracture surgery. The main reasons for not discussing this risk were a desire to avoid frightening patients, time constraints, and concerns about undermining patient hope. Orthopedic surgeons reported a medium-high level of perceived self-efficacy, with higher self-efficacy associated with a reduced likelihood of discussing one-year mortality risk. Conversely, older age and holding a specialist status in orthopedic surgery were associated with an increased likelihood of discussing this risk with patients. CONCLUSIONS: These findings suggest a need for interventions to address communication barriers and ensure consistent provision of essential information to patients undergoing hip fracture surgery. Additionally, they highlight the importance of considering individual factors such as self-efficacy, age, and expertise in designing strategies to improve patient-provider communication in orthopedic care settings. TRIAL REGISTRATION: The study doesn`t report the results of a health care intervention.

Robotic-assisted total knee arthroplasty reduces postoperative complications and length of stay without increased cost compared to navigation-guided techniques: A national analysis.

INTRODUCTION: This study compares postoperative outcomes of robotic-assisted total knee arthroplasty (RA-TKA) versus navigation-guided total knee arthroplasty (NG-TKA). Using Nationwide Inpatient Sample (NIS) data, it provides an analysis of postoperative complications, mortality, hospital costs and duration of stay. METHODS: The study analysed 217,715 patients (81,830 RA-TKA; 135,885 NG-TKA) using NIS data from 2016 to 2019. Elective TKA patients were identified through the International Classification of Diseases, 10th Revision codes. Statistical analyses, including logistic regression modelling, were performed using Statistical Package for the Social Sciences and MATLAB. RESULTS: RA-TKA patients were younger (66.1 vs. 67.1 years, p < 0.0001) and had similar mortality rates (0.024% vs. 0.018%, p = 0.342) but shorter length of stay (LOS) (1.89 vs. 2.1 days, p < 0.0001). Mean total charges were comparable between RA-TKA ($66,180) and NG-TKA ($66,251, p = 0.669). RA-TKA demonstrated lower incidences of blood-related complications (11.67% vs. 14.19%, p < 0.0001), pulmonary oedema (0.0306% vs. 0.066%, p < 0.0001), deep vein thrombosis (0.196% vs. 0.254%, p = 0.006) and acute kidney injury (AKI) (1.356% vs. 1.483%, p = 0.016). CONCLUSION: RA-TKA reduces postoperative complications and LOS without increasing costs, highlighting the relevance of this technology in patient care. LEVEL OF EVIDENCE: Level III.

Trends and epidemiology in robotic-assisted total knee arthroplasty: Reduced complications and shorter hospital stays.

INTRODUCTION: This study provides an in-depth analysis of the immediate postoperative outcomes and implications or robotic-assisted total knee arthroplasty (RA-TKA) compared with conventional TKA (C-TKA), particularly with regard to mortality, complications, hospital stay and costs, drawing from a comprehensive nationwide data set. METHODS: The Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient healthcare database in the United States, was used to identify all patients who underwent RA-TKA or C-TKA from 2016 to 2019. A total of 527,376 cases, representing 2,638,679 patients who underwent elective TKA were identified, of which 88,415 had RA-TKA. To mitigate potential variations and selection bias in baseline characteristics between the two groups, a propensity score-matched analysis was employed to further balance and refine our data set, resulting in 176,830 patients evenly distributed between the groups. Analysis was performed according to demographics, immediate post-operative complications, and economic data, including payor class, length of stay and total charges. RESULTS: There was a marked shift towards RA-TKA, from an initial 0.70% in 2016 to a notable 7.30% by 2019. Patients who underwent RA-TKA were slightly younger (66.2 ± SD years), compared to the C-TKA group (66.7 ± SD years). Hospital stay was 1.89 days and 2.29 days for RA-TKA and C-TKA, respectively. Charges metrics revealed slightly higher charges for RA-TKA. Less postoperative complications were found in the RA-TKA group, such as blood loss, anaemia, acute kidney injury, venous thromboembolism, pulmonary embolism, pneumonia and surgical wound complication. Even following the propensity score matching, these findings remained consistent and statistically significant. CONCLUSIONS: RA-TKA use in the United States has grown substantially in the last few years and has been associated with significantly reduced immediate post-operative complications and length of hospital stay compared to C-TKA, offering safer surgical management for TKA patients. Further studies on the short- and long-term outcomes of RA-TKA would improve the understanding of the full potential of this technology. LEVELS OF EVIDENCE: Level III.

Patient perspectives on the role of orthopedic nurse practitioners: a cross-sectional study.

BACKGROUND: The inclusion of nurse practitioners (NPs) specializing in orthopedics shows potential for improving the quality of care for orthopedic patients. A critical aspect of assessing the feasibility and acceptance of introducing NPs into orthopedic settings involves understanding patients' perspectives on this role. This study aims to explore the receptiveness of orthopedic patients to treatment by orthopedic Nurse Practitioners (NPs). Additionally, it investigates potential associations between patients' willingness to engage with NPs, their familiarity with the NPs role, perceptions of nursing, and satisfaction with orthopedic nursing care. METHODS: This cross-sectional study involved patients admitted to an orthopedic department in a central Israeli hospital between January and February 2023. Data was collected using a questionnaire consisting of five sections, validated by content experts. Statistical analyses, performed using SPSS, included descriptive statistics, independent samples t-tests, Pearson correlations, and linear regression. RESULTS: Orthopedic patient participants demonstrated a moderate willingness to undergo treatment by orthopedic NPs, with over two-thirds expressing strong openness. Patients displayed a high willingness for NPs to engage in various clinical tasks, albeit showing lesser enthusiasm for medication management and preoperative evaluation. Positive attitudes towards nurses and familiarity with the NP's role emerged as significant predictors of patient receptiveness to NPs' treatment. CONCLUSION: Patient acceptance of orthopedic NPs varies across different aspects of care. While there is overall willingness to receive care from NPs, these nuanced preferences should be considered when implementing NPs in orthopedic settings. Awareness and positive perceptions play crucial roles in shaping patients' willingness to receive care from these NPs. TRIAL REGISTRATION: The research doesn't report the results of a health care intervention.

Israeli Female Physicians' Motives for Choosing Orthopedics as Their Specialty Choice.

BACKGROUND: Orthopedics is not a popular field of specialization among female medical students. Therefore, the purpose of the study was to examine factors related to women's choice of orthopedics as their field of specialty, compared to those who chose other fields. METHODS: In this cross-sectional survey, 149 female medical residents from Israel-33 specializing in orthopedics and 116 in other fields-completed a questionnaire. A comparison was held between the two groups. RESULTS: Orthopedic residents were more likely to have received clinical training in this field during their medical studies and were more likely to have expressed a desire to specialize in orthopedics before and at the completion of their studies. In addition, orthopedic residents ascribed greater importance to job security when choosing a field of specialty and, in contrast, ascribed no importance at all to lifestyle. No difference was found between the two groups in their level of dissatisfaction as a result of their residency. However, orthopedic residents were more inclined to perceive gender discrimination in the field of orthopedics but, despite this, had a greater intention to recommend a residency in orthopedics. A negative association was found between the level of dissatisfaction as a result of the residency and intention to recommend a residency in orthopedics. CONCLUSIONS: Differences between the two groups point to potential factors that might have been related to women's choice of orthopedics as their field of specialty. The findings may help form strategies for attracting women to specialize in orthopedics.

Should I Ask Doctor Google? Reliability of Israeli Web-based Information Regarding General Orthopedic Injuries and Symptoms.

BACKGROUND: Websites serve as a source of medical information for a large part of the public, some claim to be a substitute for a physician's consultation. Many patients meet a physician after conducting internet research. Medical staff are concerned that internet sources of information are unreliable and may lead to erroneous decisions by patients. OBJECTIVES: To examine the reliability of web-based sources of information (through the Google™ search engine) regarding five common orthopedic complaints and injuries. METHODS: We performed a search of five common orthopedic complaints and injuries using the Google search engine. The reliability of web-based information was measured by the DISCERN tool, which is a valid and verified tool for examining the reliability of medical information sources to the public. The reliability of 47 websites was examined by two orthopedic surgeons and two senior residents. RESULTS: The overall average score given to the sites was 2.8, on a scale of 1 to 5. We found that the higher the site appeared in the search results, the higher the quality of its information. Commercial sites scored higher than general internet information sources. CONCLUSIONS: The internet network is a very broad source of information. For those who lack scientific education and training it is not easy to distinguish between reliable and unreliable or biased sources. The trend of searching for medical information and self-healing is increasing. We must strengthen the network with reliable sources by creating official scientific position papers by medical teams and promoting them online.

Injury and Sociodemographic Characteristics of Intimate Partner Violence in Women in Israel: A Single-Center Retrospective Cohort Study.

BACKGROUND: Intimate partner violence is a growing public health concern worldwide, and nurses are uniquely positioned to help identify and refer patients for services. Yet, intimate partner violence injury patterns and characteristics often go unrecognized. OBJECTIVE: The purpose of this study is to explore injury and sociodemographic characteristics associated with intimate partner violence in women presenting to a single emergency department in Israel. METHODS: This retrospective cohort study analyzed medical records of married women injured by their spouse who presented to a single emergency department in Israel from January 1, 2016, to August 31, 2020. RESULTS: In total, 145 cases were included, of which 110 (76%) were Arab and 35 (24%) were Jewish, with a mean age of 40. Patients' injury patterns consisted of contusions, hematomas, and lacerations to the head, face, or upper extremities, not requiring hospitalization, and having a history of emergency department visits in the past 5 years. CONCLUSION: Identifying intimate partner violence characteristics and patterns of injury will help nurses identify, initiate treatment, and report suspected abuse.

Association Between Type of Face Mask and Visual Analog Scale Scores During Pain Assessment.

AIMS: To examine the association between the type of mask worn by health care professionals and assessment of pain intensity in patients after orthopedic surgery using the visual analog scale (VAS). DESIGN: A nonrandomized controlled trial conducted among 176 patients hospitalized in an orthopedic department of a hospital located in northern-central Israel from January to March 2021. METHODS: In the intervention group (n = 83), pain assessment using the VAS was performed by a health care professional wearing a transparent face mask, while in the control group (n = 93), pain assessment was performed by a health care professional wearing a standard nontransparent face mask. The initial assessment was performed by a nurse, and 15 minutes later, an additional assessment was performed by a physician. RESULTS: Health care professionals wearing a standard non-transparent mask obtained higher VAS scores than health care professionals wearing a transparent mask. In addition, nurses obtained lower VAS scores than physicians. The discrepancy in VAS scores between nurses and physicians was found in 50% of cases. This discrepancy was more prevalent among female patients, patients after knee replacement or spinal surgery, and when health care professionals were wearing a standard nontransparent mask. CONCLUSIONS: This study supports the use of transparent face masks by health care professionals in an orthopedic department, particularly by nurses. In addition, this study supports the assumption of problems involving the reliability of VAS.

Factors Associated With Referral of Children With a Femur Fracture to a Social Worker by an Orthopedist for Suspected Child Abuse.

OBJECTIVES: This article explores factors associated with referral of children with a femur fracture to a social worker by an orthopedist for suspected child abuse. METHODS: This retrospective chart review study included 131 children younger than 5 years who sustained a femur fracture and were hospitalized in a major 495-bed hospital located in the northern-central Israel from 2009 to 2021. Data on children who were referred to a social worker by the treating orthopedist and those who were not were compared. RESULTS: More than half the children studied (58.8%, n = 77) were referred to a social worker by an orthopedist for suspected child abuse. However, only a fifth of these cases were eventually reported to the authorities. Male sex (odds ratio [OR], 2.44), younger age of the child (OR, 0.95), and spiral femur fracture type (OR, 5.30) increased the likelihood of referral. In addition, treatment of the child by an orthopedic specialist (as compared with an orthopedic resident; OR, 3.12) and lengthier professional experience of the treating orthopedist (OR, 1.08) increased the likelihood of referral. CONCLUSIONS: Younger male children presenting with a spiral femur fracture have a higher likelihood to be referred to a social worker because of suspected child abuse by treating orthopedic specialists with lengthier professional experience. The findings point to the need to improve the capacity of orthopedic residents to report child abuse.

[REGENERATIVE MEDICINE IN ORTHOPEDICS - UPDATES AND COMMON USES].

INTRODUCTION: Regenerative medicine is a medical field that aims to heal, rehabilitate, repair, and facilitate the regeneration of diseased and damaged cells, tissues and organs. Regenerative medicine is based on mobilizing the body's self-healing abilities. The use of regenerative medicine to treat various musculoskeletal conditions is an evolving field within orthopedics and sports medicine called 'ortho-biology' or 'ortho-regenerative medicine'. There are currently well-founded findings regarding the safety of ortho-biological treatments, their manner of action, effect, and potential effectiveness. However, there is need for more controlled studies with strong scientific proof in order to better understand the potential of these treatments and how to best use them.

Hip Fracture Following a Fall among Older Adults during the COVID-19 Pandemic.

BACKGROUND: Little is known regarding the impact of the coronavirus disease-2019 (COVID-19) pandemic on the incidence of hip fractures among older adults. OBJECTIVES: To compare the characteristics of patients with a hip fracture following a fall during the COVID-19 pandemic year and during the preceding year. METHODS: We conducted a retrospective cohort study of older patients who had undergone surgery for hip fracture repair in a major 495-bed hospital located in northern central Israel following a fall. Characteristics of patients who had been hospitalized in 2020 (pandemic year, n=136) and in 2019 (non-pandemic year, n=151) were compared. RESULTS: During the pandemic year, patients were less likely to have fallen in a nursing facility, to have had muscle or balance problems, and to have had a history of falls and fractures following a fall. Moreover, the average length of stay (LOS) in the hospital was shorter; however, the average time from the injury to hospitalization was longer. Patients were less likely to have acquired a postoperative infection or to have died. During the pandemic year, postoperative infection was only associated with prolonged LOS. CONCLUSIONS: The COVID-19 pandemic may have had a positive impact on the behavior of older adults as well as on the management of hip fracture patients. However, healthcare providers should be aware of the possible reluctance to seek care during a pandemic. Moreover, further research on the impact of the change in management during COVID-19 on hip fracture survival is warranted.

Retrospective study of older patient characteristics that increase the likelihood that a fracture was associated with abuse.

Searching for clinical manifestations of elder abuse may help healthcare professionals identify cases of elder abuse. The aim of the present study was to explore characteristics of older patients with fractures that increase the likelihood that the fracture was associated with abuse. This is a retrospective chart review study of 1,000 patients aged 65 and older who presented to an emergency department in northern-central Israel with a fracture during 2019. The chart review included participant characteristics - sociodemographic data, medical data, data regarding the fracture, and data on the presence of forensic markers of elder abuse in individual patients. Descriptive statistics and regression models were used for the analyses. Older age, presence of dementia, and hand and facial fractures were associated with the presence of forensic markers, and were also found to predict having at least one forensic factor. This study provides further support for the creation of clinical guidelines for identification of elder abuse.

[ANTERIOR APPROACH FOR TOTAL HIP ARTHROPLASTY - THE PREFERRED APPROACH OR A PASSING TREND?]

INTRODUCTION: Both the direct and anterior approach (DAA) for total hip replacement (THR) surgery have gained much popularity in recent years. The suggested benefits of the muscle-sparing and nerve-sparing approach which could lead to a faster and easier recovery process, have led to an increase in the prevalence of the anterior approach in THR. These potential benefits have drawn the attention of both orthopaedic surgeons as well as patients as a faster return to their active lifestyle. While the potential advantages and benefits of the DAA for THR are obvious, several disadvantages have been highlighted over the years including technical pitfalls, a relatively long and steep learning curve and characteristic associated complications. In addition, while there has been a surge in published research involving the DAA in recent years, significant differences in terms of clinical outcomes in the mid and long term have not been evident. The current editorial explores the increasing popularity and utilization of the DAA in THR procedures and the various factors influencing it.

[ROBOTIC TOTAL KNEE ARTHROPLASTY].

INTRODUCTION: Total Knee Arthroplasty (TKA) is one of the most common operations performed in the orthopaedic surgery field. TKA is usually performed as a result of primary osteoarthritis which causes pain and a major decrease in the patient's quality of life. TKA is considered a successful operation with a success rate of 80-85%. In recent years, orthopaedic surgeons have started to perform robotic assisted TKA. In Israel, these operations have been performed since 2019. In this article we reviewed this topic and the latest clinical data comparing a conventional TKA and robotic assisted TKA. In the world, there are several robotic systems in use. Four systems are in use in Israel. The robotic system assists in the pre-operative and intra-operative planning, in order to perform precise cuts of the femur and tibia. The precision helps to achieve better soft tissue balance reconstruction of the lower limb axis. While robotic surgery performed in Israel has been rising since the technology came into use in 2019, the clinical data are not showing a significant advantage to either one of the operations. Recent studies have shown evidence of better imaging results in the robotic-assisted operation, however, the clinical benefits are still in doubt, due to the lack of large and long-term studies.

[111 INDIUM LABELED LEUKOCYTE SCINTIGRAPHY IS A LOW SENSITIVITY TEST FOR DIAGNOSING PROSTHETIC JOINT INFECTION IN EQUIVOCAL CASES].

INTRODUCTION: Nuclear medicine techniques are suggested to be used in equivocal cases only. Nuclear medicine procedures, specifically labeled leucocytes however, are widely used in the diagnosis of joint infection across Europe. The aim of our study was to determine if Indium 111 labeled leukocyte scintigraphy has a role in the diagnosis of infected prosthetic joints. METHODS: In this retrospective cohort study, the records of a total of 146 prosthetic hip or knee revision surgeries, in 116 patients, performed in our Institute between the years 2013-2016 were reviewed. A total of 34 patients with labeled leukocyte scans were analyzed. Ten patients had more than one scan (two to four times). The scintigraphy result reports were correlated with the outcome with respect to intra-/post-operative diagnosis of prosthetic joint infection. RESULTS: The findings of 42 of 44 scintigraphy tests were negative. One study in a patient who had three prior negative labeled white blood cells (WBC) scintigraphies was equivocal. One study was positive, but a later test in the same patient was negative. Of these 34 patients, nine were demonstrated intra- or post operatively as positive for infected prosthetic joint, including the two positive cases above. The remaining 25 patients went through revision surgery with no evidence of infection; 30 of 38 bone scans were positive. Of these 30 patients, seven were demonstrated intra- or post-operatively as positive for infected prosthetic joint. CONCLUSIONS: In our study population indium labeled leukocyte scintigraphy was found to be a non-sensitive test for the diagnosis of a prosthetic joint infection and had a poor negative predictive value. It is expected that following the guidelines more strictly and choosing the appropriate modality for assessing prosthetic joint infection will improve the diagnostic accuracy of these techniques.

[THE RELATIONSHIP BETWEEN INJURIES, SHOES AND STYLE IN THE RUNNER'S POPULATION].

INTRODUCTION: We are now standing four decades after the 'running revolution' which occurred during the 70's of the previous century. Despite the developments that have occurred in medicine and the large budgets invested in the development of the sport's equipment, the runner's morbidity has not changed. In this article, we would like to review the changes in running that occurred throughout the years, as well as the common risk factors for running injuries. Furthermore, we would like to examine the scientific point of view regarding running shoes and running technique as risk factors for running injuries. A new trend, the "minimalist running", characterized by a unique technique and rigid shod might be the "game changer" in diminishing the injury rates in runners. Note, that minimalist running is not yet a common technique and thus, we might encounter a new set of injuries which we still have to evaluate.

Epidemiology of Kite Surfing Injuries among Recreational Athletes.

BACKGROUND: Kite surfing is one of the trendiest water sports worldwide. With its growing popularity evidence has begun to accumulate regarding its potential for injuries which range from minor insults to death. OBJECTIVES: To define the epidemiology and distribution of common kite surfing injuries among recreational athletes. METHODS: An open letter was published on the web calling for surfers to report injuries inflicted during recreational kite surfing. In addition, we received data from the National Center for Trauma and Emergency Medicine Research. RESULTS: Our survey yielded only a small series of 48 injuries. Most kite surfing injuries are isolated injuries, although some are life threatening as occurred in two surfers who died due to severe head injuries. Among the injuries, 72.9% are related to the musculoskeletal system, followed by head and chest injuries (18.7% and 14.6%, respectively). Of the orthopedic injuries 48.6% are fractures, the majority in the lower limbs (58.8%). CONCLUSIONS: Our findings combined with those of previous articles on kite surfing-associated injuries contribute to a better understanding of such injuries, raise awareness among emergency department personnel, and indicate precautions needed to avoid or lessen incapacitating and potentially life-threatening injuries.

[Lumbar nucleoplasty].

Low back pain (LBP) is one of the common reasons for people to seek treatment from a physician. A familiar cause of LBP and radicular pain is disc bulge or protrusion. The treatment for this indication is diverse and suited to the type pathology and its severity. The treatment can be conservative ranging from a diversity of minimal invasive surgical methods to an open discectomy. The classification of disc herniation is based on the severity of the bulge, whereby the lowest degree is protrusion/ prolapse, then extrusion and the most severe level is sequestered disc. This classification is important when considering the treatment options. One of the known possible treatments for disc protrusion is Nucleoplasty or disc Coblation. This percutaneous surgical method is used to treat discogenic back pain and radicular pain. This method is based on reducing disc volume by using radio frequency energy. During the last decade, many medical centers worldwide used this procedure. In recent years, this method is rising in popuLarity due to its percutaneous approach, low complication rate, good results at the post surgical stage reflecting improvement in symptoms and facilitating rapid return to normal life. The accepted indications for Nucleoplastia are discogenic radicular pain, contained disc herniation according to an MRI scan with intact annulus fibrosus, insufficient response to conservative treatment and absence of a medical emergency as in the case of Cauda Equina syndrome. Patient selection according to those parameters is very important. Today this surgical method is still controversial. In recent years many studies regarding Nucleoplasty have been published, although more research is necessary in order to evaluate long term results and tailor it to the appropriate patient and pathology.

Knowledge of the Mpox virus and conspiracy beliefs and their association with self-confidence in managing the virus among Israeli orthopedic surgeons.

In 2022, the Mpox viral outbreak signaled a global public health emergency. Infectious disease management and prevention are crucial tasks for healthcare workers. In their line of work, orthopedic surgeons could come across cases of the Mpox virus. The aim of the present study was to explore orthopedic surgeons' knowledge of the Mpox virus, their conspiracy beliefs regarding emerging viral infections, and their self-confidence in managing the Mpox virus. In this cross-sectional survey, 137 orthopedic surgeons completed an online questionnaire. The participants had low knowledge of the Mpox virus, providing on average 11.5 correct answers (SD = 2.68) of a possible 21. In addition, the participants tended to express moderate conspiracy beliefs and to have low self-confidence in managing the Mpox virus. Age 30 or older, a higher knowledge level, and lower conspiracy beliefs predicted greater self-confidence in managing the Mpox virus. In addition, a negative association was found between knowledge of the Mpox virus and conspiracy beliefs. Arab and younger orthopedic surgeons expressed stronger conspiracy beliefs. Interventions should include introduction of material regarding emerging tropical infections in medical curricula and in-service training programs. In addition, special attention should be paid to younger and Arab orthopedic surgeons, as these subgroups may endorse higher conspiracy beliefs.