Risk factors for intracellular fatty accumulation in rotator cuff muscle: a histologic analysis.

BACKGROUND: Fatty accumulation in rotator cuff muscles has been associated with shoulder dysfunction, risk of repair failure, and poor postoperative outcomes. This study sought to assess risk factors associated with true fatty accumulation based on histologic analysis and determine whether preoperative function directly correlated with this fatty rotator cuff accumulation. METHODS: Supraspinatus muscle biopsy specimens obtained prospectively from patients undergoing arthroscopic rotator cuff repair were stained with LipidTOX to quantify lipid accumulation. Two-step cluster analysis with Goutallier classification was used to define the fatty and non-fatty rotator cuff groups. We further performed a receiver operating characteristic curve analysis to confirm the group cutoff values. RESULTS: In total, 51 patients (aged 60.1 ± 10.5 years) were included. There were 19 high-grade partial tears, 10 small tears, 7 medium tears, 10 large tears, and 5 massive tears. Both cluster and receiver operating characteristic curve analyses yielded a cutoff value of 30% LipidTOX/4',6-diamidino-2-phenylindole (DAPI) separating the fatty vs. non-fatty groups. In the univariate analysis, patients with fatty rotator cuffs were aged 63.2 years on average compared with 59.7 years in the non-fatty group (P = .038). Female patients made up 57.1% of the fatty cohort, which was statistically higher than the non-fatty group (P = .042). Massive and large tears were more likely to occur in the fatty group (P = .005). In the multivariate analysis, full tendon tears had the largest predictive status of falling into the fatty group (odds ratio, 15.4; P = .008), followed by female sex (odds ratio, 4.9; P = .036). Patients in the fatty group had significantly higher American Shoulder and Elbow Surgeons scores (P = .048) and lower visual analog scale scores (P = .002). DISCUSSION AND CONCLUSION: This prospective histologic assessment revealed that full-thickness rotator cuff tears and female sex were the largest risk factors for intracellular lipid accumulation. Although tear size correlated with fatty accumulation, the sex disparity is a noteworthy finding that warrants further research.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients.

OBJECTIVE: To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature. MATERIALS AND METHODS: We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18 years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected. RESULTS AND CONCLUSIONS: Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

How dimensions can guide surgical planning and training: a systematic review of Kambin's triangle.

OBJECTIVE: The authors sought to analyze the current literature to determine dimensional trends across the lumbar levels of Kambin's triangle, clarify the role of imaging techniques for preoperative planning, and understand the effect of inclusion of the superior articular process (SAP). This compiled knowledge of the triangle is needed to perform successful procedures, reduce nerve root injuries, and help guide surgeons in training. METHODS: The authors performed a search of multiple databases using combinations of keywords: Kambin's triangle, size, measurement, safe triangle, and bony triangle. Articles were included if their main findings included measurement of Kambin's triangle. The PubMed, Scopus, Ovid, Cochrane, Embase, and Medline databases were systematically searched for English-language articles with no time frame restrictions through July 2022. RESULTS: Eight studies comprising 132 patients or cadavers were included in the study. The mean ± SD age was 66.69 ± 9.6 years, and 53% of patients were male. Overall, the size of Kambin's triangle increased in area moving down vertebral levels, with L5-S1 being the largest (133.59 ± 4.36 mm2). This trend followed a linear regression model when SAP was kept (p = 0.008) and removed (p = 0.003). There was also a considerable increase in the size of Kambin's triangle if the SAP was removed. CONCLUSIONS: Here, the authors have provided the first reported systematic review of the literature of Kambin's triangle, its measurements at each lumbar level, and key areas of debate related to the definition of the working safe zone. These findings indicate that CT is heavily utilized for imaging of the safe zone, the area of Kambin's triangle tends to increase caudally, and variation exists between patients. Future studies should focus on using advanced imaging techniques for preoperative planning and establishing guidelines for surgeons.

Short-Term Outcomes of Jones-Specific Implant Versus Intramedullary Screw and Plate Fixation for Proximal Fifth Metatarsal Fractures.

Although intramedullary screw fixation is commonly performed for proximal fifth metatarsal fractures, high rates of nonunion, refracture, and hardware prominence have been reported. The Jones Specific Implant (JSI) is a novel surgical implant which contours to the native curvature of the fifth metatarsal allowing for a more anatomic fixation. The purpose of this study was to compare short-term complication rates and outcomes of patients treated with the JSI to other fixation types such as plates and intramedullary screws. Electronic records were queried for adult patients with proximal fifth metatarsal fractures who underwent primary fixation from 2010 to 2021. All patients were treated by a foot and ankle fellowship-trained surgeon with intramedullary screws, plates, or JSI (Arthrex Inc., Naples, FL). Visual analog scale (VAS) and the American Orthopedic Foot and Ankle Score (AOFAS) were recorded and compared using univariate statistics. Eighty-five patients underwent fixation using intramedullary screw (n = 51, 60%), plate (n = 22, 25.9%), or JSI (n = 12, 14.1%) with a mean follow-up of 11.1 ± 14.6 months. The total cohort demonstrated a significant improvement in VAS pain (p < .0001) as well as AOFAS (p < .0001) scores. When comparing the cohort treated with JSI and the cohort treated with all other types of fixation, there were no significant differences in postoperative VAS or AOFAS scores. Only 3 complications, one with JSI (3.5%) required removal of the symptomatic hardware. The JSI is a novel treatment for proximal fifth metatarsal fractures, with similar early outcomes and complication rates when compared with intramedullary screw and plate fixation.

Analyzing the quality and educational value of Achilles tendinopathy-related videos on TikTok.

BACKGROUND: Social media platforms, like TikTok, have become popular options for the consumption and distribution of healthcare information. Due to the lack of scientific oversight, the consistency of healthcare-related videos has become a focus of the current literature. However, orthopaedic surgery has lagged behind other specialties in acknowledging the widespread utilization of TikTok videos for medical information. This study aims to assess the quality and educational benefits of Achilles tendinopathy-related TikTok videos. METHODS: TikTok was queried using the hashtags "#achillestendonexercises", "achillestendonitisexercises", "achillestendinosisexercises", and "achillestendinopathyexercises". 100 videos (25 for each term) were included after applying the exclusion criteria. The number of views, likes, shares, comments, and favorites was recorded. The content was graded using DISCERN (a well-validated informational analysis tool) and ATEES (a self-designed tool for exercise evaluation). RESULTS: The total number of views of the 100 videos was 1647,148, with a median of 7562.5 (IQR = 2,281- 19,575). The videos collectively received 73,765 likes, 1125 comments, 14,491 favorites and 6897 shares with a median of 283 (IQR= 73.8-957.8), 7 (IQR= 1.8-16.0), 61.5 (IQR= 8.8-184.3), and 18.5 (IQR= 2.0-49.8), respectively. General users uploaded slightly less (48%) when compared to healthcare professionals (52%). Healthcare professionals had more videos graded as "very poor" (43.4%) in comparison to the general users (36.2%). General users had more videos graded as "poor" (63.8%) in comparison to healthcare professionals (54.7%). However, there were no significant differences between the groups on either of the video grading scales. CONCLUSION: Although TikTok is a powerful tool for information distribution, the educational value of the videos related to Achilles tendinopathy exercises was poor. With only 1% of videos receiving a grade of 'fair,' and no videos reaching a score of 'good' or 'excellent', healthcare professionals should be aware of the high viewership of low-quality content easily accessible on TikTok.

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus.

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m2, and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Minimally-invasive trans-facet lumbar interbody fusion using a dual-dimension expandable cage: preliminary results of a multi-institutional retrospective study.

Background: Minimally-invasive trans-facet lumbar interbody fusion (LIF) is an emerging technique that offers the advantages of being safe, enabling decompression, and facilitating patient recovery. An innovative cage that expands in two dimensions has been introduced to restore segmental lordosis and disc height while minimizing the risk of cage subsidence. This study aimed to report our surgical technique of trans-facet LIF utilizing the innovative cag and to report the early clinical outcomes. Methods: We retrospectively reviewed the medical records and radiographs of patients who underwent trans-facet LIF with dual-dimension expandable cages from two institutions: Duke University Hospital and Vail-Summit Orthopaedics and Neurosurgery. The analysis covered patient demographics, Oswestry Disability Index (ODI), visual analogue scale (VAS) for back pain, surgical data, complications, and radiographic parameters. Clinical outcomes were compared between pre- and one year post-operation, while radiographic outcomes were compared between pre- and three months post-operation. Results: Twenty patients with a mean age of 61.2 years were included. Seventeen patients (85.0%) had spondylolisthesis, and L4/5 (68.2%) was the most common pathology level. Twelve patients (60.0%) underwent awake surgery, and the mean operative time was 164.5±36.1 minutes, with an estimated blood loss of 64.0±39.5 mL and a hospital stay of 1.75±1.2 days. Four patients (20.0%) experienced cage subsidence; however, none required additional surgery. The VAS score significantly improved from a preoperative average of 7.3±2.7 to 2.6±1.6 one year post-operation (P=0.02). The ODI score also showed a significant decrease, from 48.7±22.9 preoperatively to 16.4±11.1 one year postoperatively (P=0.03). Notably, 80% and 83.3% of patients achieved the minimum clinically important difference in VAS and ODI scores, respectively. The degree of spondylolisthesis was significantly reduced from a median of 5.9 mm preoperatively to 0 mm postoperatively (P<0.001). Additionally, both anterior and posterior disc heights significantly increased after surgery, from 9.8±4.7 to 15.1±2.6 mm (anterior) and from 4.9±3.3 to 10.5±2.2 mm (posterior) (P<0.001 for both). The mean segmental lordosis increased by 2.9 degrees and was associated with cage height (P=0.03), while spinopelvic parameters remained unchanged. Conclusions: Minimally-invasive trans-facet LIF with dual-dimension expandable cages demonstrates a substantial capacity for spondylolisthesis reduction and disc height restoration, and provides good short-term clinical outcomes. It may be the most appropriate method for deploying this large cage as it allows for a large, unobstructed pathway to the disc. However, future studies are needed to determine the long-term outcomes, including the arthrodesis rate.

Reduction and Fixation of Bilateral Sacroiliac Fracture-Dislocations with Pelvic Brim Screws and Robotic-Assisted Lumbopelvic Fixation: A Case Report.

CASE: A 53-year-old man with bilateral sacroiliac (SI) fracture-dislocations underwent open reduction internal fixation with subsequent loss of fixation. Revision involved the placement of pelvic brim screws and robotic-assisted lumbopelvic fixation, resulting in minimal blood loss and soft-tissue injury. At 3-month follow-up, the patient had healed and was advanced to full weight-bearing status. CONCLUSION: Percutaneous SI screws and robotic-assisted spinopelvic fixation effectively managed bilateral SI fracture-dislocations, despite narrow osseous corridors, providing adequate stabilization while minimizing complications. The combination of these 2 techniques helped overcome anatomical limitations and reduced technical challenges, leading to a successful short-term outcome.

Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report.

The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application.

The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology.

BACKGROUND: The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. METHODS: In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. RESULTS: A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001). CONCLUSIONS: Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.

Evolution of the Transforaminal Lumbar Interbody Fusion (TLIF): From Open to Percutaneous to Patient-Specific.

The transforaminal lumbar interbody fusion (TLIF) has seen significant evolution since its early inception, reflecting advancements in surgical techniques, patient safety, and outcomes. Originally described as an improvement over the posterior lumbar interbody fusion (PLIF), the TLIF began as an open surgical procedure, that notably reduced the need for the extensive neural retractation that hindered the PLIF. In line with the broader practice of surgery, trending toward minimally invasive access, the TLIF was followed by the development of the minimally invasive TLIF (MIS-TLIF), a technique that further decreased tissue trauma and postoperative complications. Subsequent advancements, including Trans-Kambin's Triangle TLIF (percLIF) and transfacet LIF, have continued to refine surgical access, minimize surgical footprint, and reduce the risk of injury to the patient. The latest evolution, as we will describe it, the patient-specific TLIF, is a culmination of the aforementioned adaptations and incorporates advanced imaging and segmentation technologies into perioperative planning, allowing surgeons to tailor approaches based on individual patient anatomy and pathology. These developments signify a shift towards more precise methods in spine surgery. The ongoing evolution of the TLIF technique illustrates the dynamic nature of surgery and emphasizes the need for continued adaptation and refinement.

Machine learning in the diagnosis, management, and care of patients with low back pain: a scoping review of the literature and future directions.

BACKGROUND CONTEXT: Low back pain (LBP) remains the leading cause of disability globally. In recent years, machine learning (ML) has emerged as a potentially useful tool to aid the diagnosis, management, and prognostication of LBP. PURPOSE: In this review, we assess the scope of ML applications in the LBP literature and outline gaps and opportunities. STUDY DESIGN/SETTING: A scoping review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. METHODS: Articles were extracted from the Web of Science, Scopus, PubMed, and IEEE Xplore databases. Title/abstract and full-text screening was performed by two reviewers. Data on model type, model inputs, predicted outcomes, and ML methods were collected. RESULTS: In total, 223 unique studies published between 1988 and 2023 were identified, with just over 50% focused on low-back-pain detection. Neural networks were used in 106 of these articles. Common inputs included patient history, demographics, and lab values (67% total). Articles published after 2010 were also likely to incorporate imaging data into their models (41.7% of articles). Of the 212 supervised learning articles identified, 168 (79.4%) mentioned use of a training or testing dataset, 116 (54.7%) utilized cross-validation, and 46 (21.7%) implemented hyperparameter optimization. Of all articles, only 8 included external validation and 9 had publicly available code. CONCLUSIONS: Despite the rapid application of ML in LBP research, a majority of articles do not follow standard ML best practices. Furthermore, over 95% of articles cannot be reproduced or authenticated due to lack of code availability. Increased collaboration and code sharing are needed to support future growth and implementation of ML in the care of patients with LBP.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management.

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

A Novel Technique for Lateral Ankle Ligament Reconstruction with Total Ankle Total Talus Replacement: A Case Report.

CASE: A 65-year-old man with severe left talar avascular necrosis, arthritis, and chronic lateral ankle instability underwent total ankle total talus replacement (TATTR) with lateral ligament reconstruction. Tibial component placement was performed using preoperative computed tomography navigation and patient-specific guides. A custom, total talus replacement to mate with the fixed-bearing tibial component was implanted. Last, a modified Brostrom procedure was performed to restore lateral ankle stability. The patient has performed well through 1 year with improved pain-free function. CONCLUSION: This case report details a novel technique for performing a modified Brostrom procedure in conjunction with TATTR to restore lateral ankle stability.

Analyzing the Quality, Reliability, and Educational Value of ACL Rehabilitation Exercises on TikTok: A Cross-Sectional Study.

Background: Videos relating to rehabilitation exercises for common injuries relevant to younger populations such as anterior cruciate ligament (ACL) tear receive high view counts on social media platforms such as TikTok. Purpose/Hypothesis: The purpose of this study was to analyze the quality, reliability, and educational value of TikTok videos among the patient population for ACL injury. It was hypothesized that TikTok videos related to ACL rehabilitation exercises would lack quality, reliability, and educational value. Study Design: Cross-sectional study. Methods: TikTok was queried for relevant videos using the hashtags "#ACLrehab" and "#ACLexercises." For each included video, the type of uploader (general user or health care professional) was identified. In addition, the number of views, likes, shares, comments, and favorites for each included video was recorded, and the content of each video was graded using the DISCERN (a well-validated informational analysis tool) and the ACL exercise education score (ACLEES - a custom-designed tool for the evaluation of ACL-related exercises). Results: A total of 111 videos with 5,520,660 cumulative views were included; the median number of views per video was 9801.0 (interquartile range [IQR], 3583.0-28,000.0). Of these videos, 84 and 27 were created by the general public and health care professionals, respectively. The videos collectively received 335,577 likes, 2969 comments, 22,856 favorites, and 6142 shares, with a median of 439 (IQR, 111-1374), 10 (IQR, 2.5-25.5), 54 (IQR, 18-172.5), and 12 (IQR, 2-36), respectively. The tabulated scores for the DISCERN and ACLEES between general users and health care professionals were all statistically nonsignificant. Health care professionals had a higher percentage of videos with a "very poor" DISCERN score in comparison with the general public (66.67% vs 53.57%, respectively). Conclusion: The overall educational value of the TikTok videos related to ACL rehabilitation exercises was very poor. Health care professionals should be aware of the broad distribution of ACL rehabilitation exercise videos that are accessible on TikTok and raise awareness of the deficiencies of the platform as a medium for educational medical-related information.

Evaluating Failure Mechanisms for Total Talus Replacement: Contemporary Review.

BACKGROUND: As total talus replacement (TTR) grows in popularity as a salvage option for talar collapse, a critical evaluation of the complications associated with this procedure is indicated. METHODS: In this review of the literature, we present a patient report and provide a review of several complications seen after TTR, including ligamentous instability, infection, and adjacent joint osteoarthritis, which we have encountered in our practice. RESULTS: Total talus replacement has the potential to reduce pain and preserve range of motion. However, the treating surgeon must be cognizant of the variety of adverse outcomes. We have presented cases of potential devastating complications from our own clinical experience and the literature. CONCLUSIONS: In conclusion, TTR may have utility in the properly selected patient with end-stage talar collapse, but implant composition, indications, and patient demographic variables complicate the interpretation of the literature.Levels of Evidence: Level III.

A New Trend in Social Media and Medicine: The Poor Quality of Videos Related to Ankle Sprain Exercises on TikTok.

Background: Social media platforms, like TikTok, have become popular options for the distribution of health care information. Because of the lack of scientific oversight, the quality of health care-related videos has become a focus of the current literature. However, orthopaedic surgery has lagged behind other fields in acknowledging the widespread utilization of TikTok videos for medical information consumption. This study aims to assess the quality and educational benefits of ankle sprain-related TikTok videos. Methods: TikTok was queried using the hashtag "#anklesprainexercises." One hundred videos were included after applying the exclusion criteria. The number of views, likes, shares, comments, and favorites was recorded. The content was graded using DISCERN (a well-validated informational analysis tool) and ASEES (a self-designed tool for exercise evaluation). We hypothesized that information on TikTok related to ankle sprain exercises would be poor in quality. Results: The total number of views of the 100 videos was 6 483 412, with a median of 5377.5 (IQR = 1074-20 275). The videos collectively received 385 847 likes, 3642 comments, 55 574 favorites, and 14 918 shares with a median of 267.5 (IQR = 41.5-1678.0), 4.0 (IQR = 0.0-23.0), 42.0 (IQR = 4.8-264.5), and 13.0 (IQR = 1.8-67.8), respectively. General users had a higher percentage of their videos graded as "very poor" (61.8%) in comparison to the number of videos uploaded by health care professionals deemed "very poor" (34.4%). Neither general user nor health care professionals had videos graded as "good" or "excellent." There were significant differences between the 2 groups for DISCERN 1, 3, and ASSES scores. Conclusion: Although TikTok is a powerful tool for information distribution, the educational value of the videos related to ankle sprain injury exercises was poor. With only 2% of videos receiving a grade of "fair," and no videos reaching a score of "good" or "excellent," health care professionals should be aware of the low-quality content easily accessible on TikTok. Level of Evidence: Level III, cross-sectional study.

Evaluating the Distribution, Quality, and Educational Value of Videos Related to Shoulder Instability Exercises on the Social Media Platform TikTok.

BACKGROUND: Because of the lack of scientific oversight, the quality, applicability, and consistency of healthcare-related TikTok videos have become a focus of research exploration. The orthopaedic surgery literature lags behind other medical fields in analyzing the widespread utilization of TikTok videos for medical information delivery. METHODS: TikTok was queried using the hashtag #shoulderstabilityexercises, and 109 videos were included. The videos were collected by two authors and independently evaluated using DISCERN (a well-validated informational analysis tool) and shoulder stability exercise education score (a self-designed tool for the evaluation of shoulder instability-related exercises). RESULTS: DISCERN scores of videos uploaded by general users had significantly lower scores in all four categories than those uploaded by healthcare professionals (P < 0.001, P = 0.005, P = 0.002, and P < 0.001). For the shoulder stability exercise education score, general users had a significantly lower score than the healthcare professionals at 3.36 and 4.91 on a 25-point scale, respectively (P = 0.034). General users had more videos graded as very poor (84.2%) in comparison to the number of videos uploaded by healthcare professionals deemed very poor (51.5%). However, the remainder of healthcare professionals had their videos graded as poor (48.5%). CONCLUSION: Despite slightly improved video quality from healthcare professionals, the overall educational of the videos related to shoulder instability exercises was poor.

Enterothecal fistula as a rare cause of adult pneumocephalus and meningitis: a case report.

Background: Enterothecal fistulas are pathological connections between the gastrointestinal system and subarachnoid space. These rare fistulas occur mostly in pediatric patients with sacral developmental anomalies. They have yet to be characterized in an adult born without congenital developmental anomaly yet must remain on the differential diagnosis when all other causes of meningitis and pneumocephalus have been ruled out. Good outcomes rely on aggressive multidisciplinary medical and surgical care, which are reviewed in this manuscript. Case Description: A 25-year-old female with history of a sacral giant cell tumor resected via anterior transperitoneal approach followed by posterior L4-pelvis fusion presented with headaches and altered mental status. Imaging revealed that a portion of small bowel had migrated into her resection cavity and created an enterothecal fistula resulting in fecalith within the subarachnoid space and florid meningitis. The patient underwent a small bowel resection for fistula obliteration, and subsequently developed hydrocephalus requiring shunt placement and two suboccipital craniectomies for foramen magnum crowding. Ultimately, her wounds became infected requiring washouts and instrumentation removal. Despite a prolonged hospital course, she made significant recovery and at 10-month following presentation, she is awake, oriented, and able to participate in activities of daily living. Conclusions: This is the first case of meningitis secondary to enterothecal fistula in a patient without a previous congenital sacral anomaly. Operative intervention for fistula obliteration is the primary treatment and should be performed at a tertiary hospital with multidisciplinary capabilities. If recognized quickly and appropriately treated, there is a possibility of good neurological outcome.

A Comparison of Percutaneous Pedicle Screw Accuracy Between Robotic Navigation and Novel Fluoroscopy-Based Instrument Tracking for Patients Undergoing Instrumented Thoracolumbar Surgery.

BACKGROUND: The accuracy of pedicle screws placed with instrument tracking and robotic navigation are individually comparable or superior to placement using standard fluoroscopy, however head-to-head comparisons between these adjuncts in a similar surgical population have yet to be performed. METHODS: Consecutive patients undergoing percutaneous thoracic and lumbosacral spinal instrumentation were retrospectively enrolled. Instrumentation was performed using either fluoroscopy-based instrument tracking system (TrackX, TrackX Technologies) or robotic-navigation (ExcelsiusGPS, Globus Medical). Postinstrumentation computed tomography scans were graded for breach according to the Gertzbein-Robbins scale, with "acceptable" screws deemed as Grade A or B and "unacceptable" screws deemed as Grades C through E. Accuracy data was compared between both instrumentation modalities. RESULTS: Fifty-three patients, comprising a total of 250 screws (167 robot, 83 instrument tracking) were included. The overall accuracy between both modalities was similar, with 96.4% and 97.6% of screws with acceptable accuracy between instrument tracking and robotic navigation, respectively (I-squared 0.30, df = 1, P = 0.58). Between instrument tracking and robotic navigation, 92.8% and 95.8% of screws received Grade A, 3.6% and 1.8% a Grade B, 1.2% and 1.2% a Grade C, 1.2% and 0.6% a Grade D, and 1.2% and 0.6% a Grade E, respectively. The robot was abandoned intraoperatively in 2 cases due to unrecoverable registration inaccuracy or software failure, leading to abandonment of 8 potential screws (4.8%). CONCLUSIONS: In a similar patient population, there is a similarly high degree of instrumentation accuracy between fluoroscopy-based instrument tracking and robotic navigation. There is a rare chance for screw breach with either surgical adjunct.