Can Artificial Intelligence Improve the Readability of Patient Education Materials?

BACKGROUND: The recommended readability of online health education materials is at or below the sixth- to eighth-grade level. Nevertheless, more than a decade of research has demonstrated that most online education materials pertaining to orthopaedic surgery do not meet these recommendations. The repeated evidence of this limited progress underscores that unaddressed barriers exist to improving readability, such as the added time and cost associated with writing easily readable materials that cover complex topics. Freely available artificial intelligence (AI) platforms might facilitate the conversion of patient-education materials at scale, but to our knowledge, this has not been evaluated in orthopaedic surgery. QUESTIONS/PURPOSES: (1) Can a freely available AI dialogue platform rewrite orthopaedic patient education materials to reduce the required reading skill level from the high-school level to the sixth-grade level (which is approximately the median reading level in the United States)? (2) Were the converted materials accurate, and did they retain sufficient content detail to be informative as education materials for patients? METHODS: Descriptions of lumbar disc herniation, scoliosis, and spinal stenosis, as well as TKA and THA, were identified from educational materials published online by orthopaedic surgery specialty organizations and leading orthopaedic institutions. The descriptions were entered into an AI dialogue platform with the prompt "translate to fifth-grade reading level" to convert each group of text at or below the sixth-grade reading level. The fifth-grade reading level was selected to account for potential variation in how readability is defined by the AI platform, given that there are several widely used preexisting methods for defining readability levels. The Flesch Reading Ease score and Flesch-Kincaid grade level were determined for each description before and after AI conversion. The time to convert was also recorded. Each education material and its respective conversion was reviewed for factual inaccuracies, and each conversion was reviewed for its retention of sufficient detail for intended use as a patient education document. RESULTS: As presented to the public, the current descriptions of herniated lumbar disc, scoliosis, and stenosis had median (range) Flesch-Kincaid grade levels of 9.5 (9.1 to 10.5), 12.6 (10.8 to 15), and 10.9 (8 to 13.6), respectively. After conversion by the AI dialogue platform, the median Flesch-Kincaid grade level scores for herniated lumbar disc, scoliosis, and stenosis were 5.0 (3.3 to 8.2), 5.6 (4.1 to 7.3), and 6.9 (5 to 7.8), respectively. Similarly, descriptions of TKA and THA improved from 12.0 (11.2 to 13.5) to 6.3 (5.8 to 7.6) and from 11.6 (9.5 to 12.6) to 6.1 (5.4 to 7.1), respectively. The Flesch Reading Ease scores followed a similar trend. Seconds per sentence conversion was median 4.5 (3.3 to 4.9) and 4.5 (3.5 to 4.8) for spine conditions and arthroplasty, respectively. Evaluation of the materials that were converted for ease of reading still provided a sufficient level of nuance for patient education, and no factual errors or inaccuracies were identified. CONCLUSION: We found that a freely available AI dialogue platform can improve the reading accessibility of orthopaedic surgery online patient education materials to recommended levels quickly and effectively. Professional organizations and practices should determine whether their patient education materials exceed current recommended reading levels by using widely available measurement tools, and then apply an AI dialogue platform to facilitate converting their materials to more accessible levels if needed. Additional research is needed to determine whether this technology can be applied to additional materials meant to inform patients, such as surgical consent documents or postoperative instructions, and whether the methods presented here are applicable to non-English language materials.

Thoracic outlet syndrome.

Thoracic outlet syndrome is a well-described disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. Neurogenic thoracic outlet syndrome is the most common manifestation, presenting with pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity. Vascular complications of thoracic outlet syndrome are uncommon and include thromboembolic phenomena and swelling. The clinical presentation is highly variable, and no reproducible study exists to confirm the diagnosis; instead, the diagnosis is based on a physician's judgment after a meticulous history and physical examination. Both nonsurgical and surgical treatment methods are available for thoracic outlet syndrome. Whereas nonsurgical management appears to be effective in some persons, surgical treatment has been shown to provide predictable long-term cure rates for carefully selected patients. In addition, physicians who do not regularly treat patients with thoracic outlet syndrome may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment.

Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study.

BACKGROUND: Surgical site infections (SSI) continue to be a significant source of morbidity despite the introduction of perioperative intravenous antibiotics. Our objective was to assess the efficacy of local vancomycin powder on lowering deep SSI rates in high-energy tibial plateau and pilon fractures. MATERIALS AND METHODS: A retrospective review of all tibial plateau and pilon fractures treated in 2012 at our level I trauma center identified 222 patients. Of these, 107 patients sustained high-energy injuries that required staged fixation, and 93 had minimum 6 month follow-up. Ten patients received 1 gram vancomycin powder directly into the surgical wound at the time of definitive fixation, and the remaining 83 patients served as controls. SSI was defined according to criteria from the Centers for Disease Control. Demographic data, patient comorbidities, injury and treatment details, and infection details were recorded. Descriptive and comparative statistics were performed. RESULTS: Amongst the vancomycin powder group, 1 patient (10 %) developed a deep SSI; in the control group, 14 (16.7 %) developed deep SSI. The rate of deep SSI between the groups was not statistically significantly different (P = 1.0). The groups were statistically similar with regard to injuries, treatment, comorbidities, and infectious outcomes (P values range = 0.06-1.0). CONCLUSIONS: The application of local vancomycin powder into surgical wounds of high-energy tibial plateau and pilon fractures did not reduce the rate of deep SSI in this retrospective review. There is a need to find effective, cheap, and widely available methods for prevention of SSI. Basic science and larger prospective clinical studies are needed to further delineate the role of local vancomycin powder as a modality to reduce deep SSI in extremity trauma.

Modified Clavien-Dindo-Sink Classification System for operative complications in adult spine surgery.

OBJECTIVE: Currently there is no standardized mechanism to describe or compare complications in adult spine surgery. Thus, the purpose of the present study was to modify and validate the Clavien-Dindo-Sink complication classification system for applications in spine surgery. METHODS: The Clavien-Dindo-Sink complication classification system was evaluated and modified for spine surgery by four fellowship-trained spine surgeons using a consensus process. A distinct group of three fellowship-trained spine surgeons completed a randomized electronic survey grading 71 real-life clinical case scenarios. The survey was repeated 2 weeks after its initial completion. Fleiss' and Cohen's kappa (κ) statistics were used to evaluate interrater and intrarater reliabilities, respectively. RESULTS: Overall, interobserver reliability during the first and second rounds of grading was excellent with a κ of 0.847 (95% CI 0.785-0.908) and 0.852 (95% CI 0.791-0.913), respectively. In the first round, interrater reliability ranged from good to excellent with a κ of 0.778 for grade I (95% CI 0.644-0.912), 0.698 for grade II (95% CI 0.564-0.832), 0.861 for grade III (95% CI 0.727-0.996), 0.845 for grade IV-A (95% CI 0.711-0.979), 0.962 for grade IV-B (95% CI 0.828-1.097), and 0.960 for grade V (95% CI 0.826-1.094). Intraobserver reliability testing for all three independent observers was excellent with a κ of 0.971 (95% CI 0.944-0.999) for rater 1, 0.963 (95% CI 0.926-1.001) for rater 2, and 0.926 (95% CI 0.869-0.982) for rater 3. CONCLUSIONS: The Modified Clavien-Dindo-Sink Classification System demonstrates excellent interrater and intrarater reliability in adult spine surgery cases. This system provides a useful framework to better communicate the severity of spine-related complications.

Reported Events Associated With Spine Robots: An Analysis of the Food and Drug Administration's Manufacturer and User Facility Device Experience Database.

STUDY DESIGN: Cross-Sectional Analysis. OBJECTIVES: To summarize medical device reports (MDRs) between August 1, 2017 and November 30, 2021 relating to robot-assisted spine systems within the Manufacturer and User Facility Device Experience (MAUDE) database maintained by The Food and Drug Administration (FDA). METHODS: The MAUDE database was abstract for all MDRs relating to each FDA-approved robot-assisted spine system. Event descriptions were reviewed and characterized into specific event types. Outcome measures include specific robot-assisted spine systems and reported events as detailed by the MDRs. All data is de-identified and in compliance with the Health Insurance Portability and Accountability Act (HIPAA). RESULTS: There were 263 MDRs consisting of 265 reported events. Misplaced screws represented 61.5% (n = 163) of reported events. Of the 163 reported events, 57.1% (n = 93) described greater than 1 misplaced screw, 15.3% (n = 25) required return to the operating room, 8.6% (n = 14) resulted in neurologic injury, 4.3% (n = 7) resulted in dural tear, and 1.2% (n = 2) resulted in hemorrhage or bleeding. Reported events other than misplaced screws included system imprecision detected prior to screw placement (58/265, 21.9%), mechanical failure (23/265, 8.7%), and software failure (18/265, 6.8%). CONCLUSIONS: As more robot-assisted spine systems gain FDA approval and the adoption of these systems continues to grow, documenting and understanding the range of reported events associated with each "tool" is imperative to balancing patient safety with surgical innovation. This study of the MAUDE database provides a unique summary of reported events associated with robot-assisted spine systems that is not directly linked to a research setting.

Few Randomized Controlled Trials in Spine Surgery in the United States Include Sociodemographic Patient Data: A Systematic Review.

INTRODUCTION: The importance of sociodemographic factors such as race, education, and income on spine surgery outcomes has been well established, yet the representation of sociodemographic data within randomized controlled trials (RCTs) in spine literature remains undefined in the United States (U.S). METHODS: Medical literature was reviewed within PubMed for RCTs with "spine" in the title or abstract published within the last 8 years (2014 to 2021) in seven major spine journals. This yielded 128 results, and after application of inclusion criteria (RCTs concerning adult spine pathologies conducted in the U.S), 54 RCTs remained for analysis. Each article's journal of publication, year of publication, and spinal pathology was recorded. Pathologies included cervical degeneration, thoracolumbar degeneration, adult deformity, cervical trauma, and thoracolumbar trauma. Sociodemographic variables collected were race, ethnicity, insurance status, income, work status, and education. The Fisher's exact test was used to compare inclusion of sociodemographic data by journal, year, and spinal pathology. RESULTS: Sociodemographic data were included in the results and in any section of 57.4% (31/54) of RCTs. RCTs reported work status in 25.9% (14/54) of results and 38.9% (21/54) of RCTs included work status in any section. Income was included in the results and mentioned in any section in 13.0% (7/54) of RCTs. Insurance status was in the results or any section of 9.3% (5/54) and 18.5% (10/54) of RCTs, respectively. There was no association with inclusion of sociodemographic data within the results of RCTs as a factor of journal ( P = 0.337), year of publication ( P = 0.286), or spinal pathology ( P = 0.199). DISCUSSION: Despite evidence of the importance of sociodemographic factors on the natural history and treatment outcomes of myriad spine pathologies, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery. Failure to include sociodemographic factors in RCTs potentially bias the generalizability of outcome data.

To Use or Not Use Intraoperative Neuromonitoring: Utilization of Neuromonitoring During Spine Surgeries and Associated Conflicts of Interest, a Cross-Sectional Survey Study.

INTRODUCTION: There are no universal guidelines that dictate the indications for the use of intraoperative neuromonitoring (IONM) in spine surgery resulting in its variable use. The choice to use IONM has been both cited in malpractice lawsuits and insurance claims, but no data exist regarding surgeons' rationale for making this choice. The goal of this study was to assess (1) the use of certain IONM modalities during common spine surgeries, (2) surgeons' rationale for use of IONM, and (3) IONM practices and potential conflicts of interest associated with its use. METHODS: Respondents were asked to select each IONM modality they used during 20 different surgical scenarios within the spine followed by rating the importance of several reasons when selecting to use IONM. Finally, the occurrence of conflicts of interest, out-of-network billing, and cost were assessed. RESULTS: Approximately one-half (47%) of respondents who perform anterior cervical diskectomy and fusion/total disk arthroplasty for radiculopathy use IONM, opposed to 76% for myelopathy. The presence of cord compression and/or neurologic symptoms increased IONM use by approximately 30% during trauma cases. Medicolegal was the reason of highest importance when choosing to use IONM (7.4 ± 2.9; mean ± SD), followed by surgeon reassurance (6.2 ± 2.7; P < 0.0001 versus medicolegal) and belief it affects patient outcomes (5.2 ± 3.0; P = 0.004 versus reassurance). CONCLUSIONS: Although there is increasing use of IONM, this has not translated to an absolute requirement for every spine surgery. Surgeons are faced with opposing influences of the medicolegal system and insurance payers. Future guidelines on using IONM should not be absolute, but rather should consider the risks of each procedure, along with how patients and surgeons value these risks, in addition to the costs. The findings of this study should help to serve as a guide to surgeons, payers, and courts as contemporary, common practices for the use of IONM during spinal surgical scenarios.

Does Publication History Predict Future Publication Output in Orthopaedics?

Background The number of publications is widely used as a measure of academic productivity in the field of orthopaedics. How "productive" a physician is has a great influence on consideration for employment, compensation, and promotions. Predictors of potential high-output researchers would be of value to the orthopaedic department and university leadership for new faculty evaluation. Methods The study population included orthopaedic faculty from the top 10 orthopaedic institutions in the United States. Their names and the number of publications at each point in their training (medical school, residency, and fellowship) and early career (first five and 10 years following fellowship) along with a total number of publications to date were collected by using PubMed. Results Strong correlations were seen between publications during total training and publications output in the first five years following fellowship (rs =0.717, P<0.0001). However, no significant correlations were found comparing publications during each stage of training and the first 10 years following fellowship. A moderate positive correlation was found when comparing publications during medical school and residency output (rs =0.401, P<0.0001). Conclusions The data presented here may be utilized by department chairs during the evaluation of faculty and candidates to not interpret the number of publications during training and early career as a gauge of research interest and potential for future publications. Program directors may also use the only moderate correlation between publications in medical school and residency when evaluating applications as support of a more holistic review of applicants to determine research interest.

Normal functional range of motion of the cervical spine during 15 activities of daily living.

STUDY DESIGN: Prospective clinical study. OBJECTIVE: The purpose of this investigation was to quantify normal cervical range of motion (ROM) and compare these results to those used to perform 15 simulated activities of daily living (ADLs) in asymptomatic subjects. SUMMARY OF BACKGROUND DATA: Previous studies looking at cervical ROM during ADLs have been limited and used measuring devices that do not record continuous motion. The purpose of this investigation was to quantify normal cervical ROM and compare these results with those used to perform 15 simulated ADLs in asymptomatic subjects. METHODS: A noninvasive electrogoniometer and torsiometer were used to measure the ROM of the cervical spine. The accuracy and reliability of the devices were confirmed by comparing the ROM values acquired from dynamic flexion/extension and lateral bending radiographs to those provided by the device, which was activated while the radiographs were obtained. Intraobserver reliability was established by calculating the intraclass correlation coefficient for repeated measurements on the same subjects by 1 investigator on consecutive days. These tools were employed in a clinical laboratory setting to evaluate the full active ROM of the cervical spines (ie, flexion/extension, lateral bending, and axial rotation) of 60 asymptomatic subjects (30 females and 30 males; age, 20 to 75 y) as well as to assess the functional ROM required to complete 15 simulated ADLs. RESULTS: When compared with radiographic measurements, the electrogoniometer was found to be accurate within 2.3+/-2.2 degrees (mean+/-SD) and the intraobserver reliabilities for measuring the full active and functional ROM were both excellent (intraclass correlation coefficient of 0.96 and 0.92, respectively). The absolute ROM and percentage of full active cervical spinal ROM used during the 15 ADLs was 13 to 32 degrees and 15% to 32% (median, 20 degrees/19%) for flexion/extension, 9 to 21 degrees and 11% to 27% (14 degrees/18%) for lateral bending, and 13 to 57 degrees and 12% to 92% (18 degrees/19%) for rotation. Backing up a car required the most ROM of all the ADLs, involving 32% of sagittal, 26% of lateral, and 92% of rotational motion. In general, personal hygiene ADLs such as washing hands and hair, shaving, and applying make-up entailed a significantly greater ROM relative to locomotive ADLs including walking and traveling up and down a set of stairs (P<0.0001); in addition, compared with climbing up these steps, significantly more sagittal and rotational motion was used when descending stairs (P=0.003 and P=0.016, respectively). When picking up an object from the ground, a squatting technique required a lower percentage of lateral and rotational ROM than bending at the waist (P=0.002 and P<0.0001). CONCLUSIONS: By quantifying the amounts of cervical motion required to execute a series of simulated ADLs, this study indicates that most individuals use a relatively small percentage of their full active ROM when performing such activities. These findings provide baseline data which may allow clinicians to accurately assess preoperative impairment and postsurgical outcomes.

Normal functional range of motion of the lumbar spine during 15 activities of daily living.

STUDY DESIGN: Prospective clinical study. OBJECTIVE: The purpose of this investigation was to quantify normal lumbar range of motion (ROM) and compare these results with those used to perform 15 simulated activities of daily living (ADLs) in asymptomatic subjects. SUMMARY OF BACKGROUND DATA: Previous studies reporting the ROM of the lumbar spine during ADLs have been limited, only focusing on 4 ADLs. The purpose of this investigation was to quantify the extent of normal lumbar ROM and determine how much motion is necessary to perform 15 simulated ADLs. METHODS: A noninvasive electrogoniometer and torsiometer were used to measure the ROM of the lumbar spine. The accuracy and reliability of the devices were confirmed by comparing the ROM values acquired from dynamic flexion/extension and lateral bending radiographs with those provided by the device that was activated while the radiographs were obtained. Intraobserver reliability was established by calculating the intraclass correlation coefficient for repeated measurements on the same subjects by 1 investigator on consecutive days. These tools were employed in a clinical laboratory setting to evaluate the full active ROM of the lumbar spines (ie, flexion/extension, lateral bending, and axial rotation) of 60 asymptomatic subjects (30 women and 30 men; age 20 to 75 y) and to assess the functional ROM required to complete 15 simulated ADLs. RESULTS: When compared with radiographic measurements, the electrogoniometer was found to be accurate within 2.3+/-2.6 degrees (mean+/-SD). The intraobserver reliabilities for assessing full and functional ROM were both excellent (intraclass correlation coefficient of 0.96 and 0.88, respectively). The absolute ROM and percentage of full active lumbar spinal ROM used during the 15 ADLs was 3 to 49 degrees and 4% to 59% (median: 9 degrees/11%) for flexion/extension, 2 to 11 degrees and 6% to 31% (6 degrees/17%) for lateral bending, and 2 to 7 degrees and 6% to 20% (5 degrees/13%) for rotation. Picking up an object from the ground, either using a bending or squatting technique, required the most ROM of all the ADLs. Squatting required a significantly less amount of sagittal motion compared with bending at the waist (42 vs. 48 degrees, P=0.003). No difference was seen in both lateral and rotation motion between these 2 techniques (11 vs. 11 degrees and 6 vs. 6 degrees, respectively). Both ascending and descending stairs required equivalent amounts of total motion in all 3 motion planes. As a whole, personal hygiene ADLs (hand washing, washing hair, shaving, and make-up application) required a similar amount of motion compared with the 3 locomotive ADLs (walking, up and down stairs). CONCLUSIONS: By quantifying the amounts of lumbar motion required to execute a series of simulated ADLs, this study indicates that most individuals use a relatively small percentage of their full active ROM when performing such activities. These findings provide baseline data that may allow clinicians to accurately assess preoperative impairment and postsurgical outcomes.

Quantifying Dysfunction of the Lumbar Multifidus Muscle After Radiofrequency Neurotomy and Fusion Surgery: A Preliminary Study.

The multifidus is an important muscle for the active stabilization of the spine. Unfortunately, clinical procedures such as posterior lumbar fusion (PLF) and radio frequency neurotomy (RFN) cause injury to these muscles affecting their function. However, evaluating multifidus function using traditional biomechanical methods is challenging due to its unique anatomical features. The change in muscle shear modulus during contraction has been corrected to force generation for several skeletal muscles. Therefore, the change in shear modulus can be used to quantify muscle contraction. The objective of this study was to evaluate multifidus dysfunction by comparing changes in shear modulus during muscle contraction in healthy individuals and patients who received RFN and PLF in the lumbar spine. We used our recently developed protocol which consists of measuring changes of multifidus shear modulus at lying prone, sitting up, and sitting up with the arms lifted. In healthy individuals, the median multifidus shear modulus increased progressively from prone, sitting, and sitting with arms raised: 18.55 kPa, 27.14 kPa, and 38.45 kPa, respectively. A moderate increase in shear modulus for these body positions was observed in PLF patients: 9.81 kPa, 17.26 kPa, and 21.85 kPa. In RFN patients, the shear modulus remained relatively constant: 14.44 kPa, 16.57 kPa, and 17.26 kPa. Overall, RFN and PLF caused a reduction in the contraction of multifidus muscles. However, the contraction of multifidus muscle slightly increased during multifidus activation in PLF patients, while it did not change in RFN patients. These preliminary measurements suggest that the proposed protocol using SWE can provide important information about the function of individual spine muscles to guide the design and evaluation of postsurgical rehabilitation protocols.

Factors in Orthopaedic Residency Decision-making for Female Applicants: A Cross-sectional Study.

BACKGROUND: Orthopaedics continues to remain the medical specialty with the lowest sex diversity in the United States. Orthopaedic residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for orthopaedic residency selection. METHODS: A two-part survey was sent to female orthopaedic residents by e-mails available in the American Academy of Orthopaedic Surgery directory, residency program coordinators, Doximity, and institutional websites. The survey included 17 characteristics of residency programs that participants were asked to score for importance and then asked to rank their top five most influential factors when selecting an orthopaedic surgery residency. RESULTS: The most important factors included camaraderie among residents, happiness of current residents, variety/number of cases, fellowship placement, and early surgical/clinical experience, respectively. The least important factors included sex diversity of faculty and residents, number of female residents, concurrent fellows, number of female faculty geographic location near spouse, and finally, attitudes toward maternity leave. DISCUSSION: These data support the notion that efforts by orthopaedic residency programs to improve desirability for female applicants should focus on highlighting some of the more universal, nonsex-related factors such as the happiness and camaraderie among residents and the anticipated clinical experiences. This is opposed to showcasing features, such as maternity leave and number of current female faculty or residents, which would seemingly appeal to female applicants.

Factors in Residency Decision Making for Female Neurosurgery Applicants.

BACKGROUND: Neurosurgery remains a specialty with one of the largest gender gaps in the United States. Neurosurgery residency programs are highly motivated to attract the best female candidates in an effort to improve their program diversity, but no studies currently exist that examine the factors of highest importance to female applicants for neurosurgery residency selection. The purpose of this study was to determine factors that female neurosurgery residents used when selecting their residency. METHODS: A 2-part survey was sent to female neurosurgical residents by e-mails collected from the American Association of Neurological Surgeons directory and residency program websites. The survey asked participants to score 17 characteristics of residency programs in terms of importance and then asked them to rank their top 5 most influential factors when selecting a neurosurgery residency. RESULTS: The most important factors included variety/number of cases, camaraderie and happiness of current residents, early surgical/clinical experience, and academic reputation. The least important factors included gender diversity of faculty and residents, number of female residents, number of female faculty, and attitudes toward maternity leave. CONCLUSIONS: Efforts to increase female applicants in neurosurgery residency programs should focus on highlighting some more universal, non-gender-related factors, such as happiness and camaraderie among residents and anticipated clinical experiences, as opposed to showcasing features that would seemingly appeal to female applicants, such as maternity leave and number of current female faculty or residents.

External Orthopaedic Implants in the Magnetic Resonance Environment: Current Concepts and Controversies.

MRI provides diagnostic three-dimensional imaging and remains extremely important in the diagnosis and management of spinal trauma as well as other acute traumatic injuries, including those of the extremities. The American Society for Testing and Materials has created standards against which all implantable medical devices are tested to ensure safety in an MR environment. Most implantable passive orthopaedic devices can undergo MRI without consequence to the patient. However, the American Society for Testing and Materials has recently updated its terminology resulting in confusion among providers and institutions. Primary safety concerns are radiofrequency-induced heating and magnetically induced torque or displacement. These safety concerns have emerged as a recent source of debate, particularly regarding the imaging of patients with external fixation and cervical immobilization devices in place. Surveys have shown a lack of consensus among radiologists regarding this issue. Having an institutional protocol in place for the imaging of these patients streamlines the diagnosis and early stabilization of certain polytraumatized patients. The purpose of this review is to summarize the pertinent literature as well as the current industry recommendations regarding the safety of commonly used external fixation, cervical immobilization, and traction devices in the MR environment.

Which regions of the operating gown should be considered most sterile?

Various guidelines have been proposed regarding which portions of a surgical gown may be considered sterile. Unfortunately, the validity of these recommendations has not been definitively established. We therefore evaluated gown sterility after major spinal surgery to assess the legitimacy of these guidelines. We used sterile culture swabs to obtain samples of gown fronts at 6-inch increments and at the elbow creases of 50 gowns at the end of 29 spinal operations. Another 50 gowns were swabbed immediately after they were applied to serve as negative controls. Bacterial growth was assessed using semiquantitative plating techniques on a nonselective, broad-spectrum media. Contamination was observed at all locations of the gown with rates ranging from 6% to 48%. Compared with the negative controls, the contamination rates were greater at levels 24 inches or less and 48 inches or more relative to the ground and at the elbow creases. The section between the chest and operative field had the lowest contamination rates. Based on these results, we consider the region between the chest and operative field to be the most sterile and any contact with the gown outside this area, including the elbow creases, should be avoided to reduce the risk of infection.

Actual knee motion during continuous passive motion protocols is less than expected.

Investigations of the usefulness of continuous passive motion (CPM) after TKA have yielded mixed results, with evidence suggesting its efficacy is contingent on the presence of larger motion arcs. Surprisingly, the range of motion (ROM) the knee actually experiences while in a CPM machine has not been elucidated. In this study, the ability of a CPM apparatus to bring about a desired knee ROM was assessed with an electrogoniometer. The knee experienced only 68% to 76% of the programmed CPM arc, with the higher percentages generated by elevating the head of the patient's bed. This disparity between true knee motion and CPM should be accounted for when designing CPM protocols for patients or investigations evaluating efficacy of CPM.

Blood-loss Management in Spine Surgery.

Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon's attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.

Are Low Patient Satisfaction Scores Always Due to the Provider?: Determinants of Patient Satisfaction Scores During Spine Clinic Visits.

STUDY DESIGN: A prospective study. OBJECTIVE: The aim of this study was to investigate the impact of various components on patient satisfaction scores SUMMARY OF BACKGROUND DATA.: Patient satisfaction has become an important component of quality assessments. However, with many of these sources collecting satisfaction data reluctant to disclose detailed information, little remains known about the potential determinants of patient satisfaction. METHODS: Two hundred patients were contacted via phone within 3 weeks of new patient encounter with 11 spine providers. Standardized patient satisfaction phone survey consisting of 25 questions (1-10 rating scale) was administered. Questions inquired about scheduling, parking, office staff, teamwork, wait-time, radiology, provider interactions/behavior, treatment, and follow-up communication. Potential associations between these factors and three main outcome measures were investigated: (1) provider satisfaction, (2) overall clinic visit satisfaction, and (3) quality of care. RESULTS: Significant associations (P < 0.0001) with provider satisfaction, overall clinic visit satisfaction, and perceived overall quality of care were found with appointment scheduling, parking, office staff, teamwork, wait time, radiology, provider interactions/behavior, treatment, and follow-up communication. Nurse-practitioner/resident involvement was positively associated with scores (P ≤ 0.03). A "candy-man" effect was not noted, as pain medication prescribing did not play a significant role in satisfaction (P > 0.05).In multivariate regression analysis, explanation of medical condition/treatment (P = 0.002) and provider empathy (P = 0.04) were significantly associated with provider satisfaction scores, while the amount of time spent with the provider was not. Conversely, teamwork of staff/provider and follow-up communication were significantly associated with both overall clinic visit satisfaction and quality of care (P ≤ 0.03), while provider behaviors or satisfaction were not. CONCLUSION: Satisfaction with the provider was associated with better explanations of the spine condition/treatment plan and provider empathy, but was not a significant factor in either overall clinic visit satisfaction or perceived quality of care. Patients' perception of teamwork between staff and providers along with reliable follow-up communication were found to be significant determinants of overall patient satisfaction and perceived quality of care. LEVEL OF EVIDENCE: 3.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

OBJECTIVES: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. DESIGN: Retrospective cohort. SETTING: American College of Surgeons Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. MAIN OUTCOME MEASUREMENTS: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. RESULTS: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Role of exertion or emotion as inciting events for acute aortic dissection.

It is well known that hypertension, aortic dilatation, and collagen disorders predispose to acute aortic dissection (AAD). The inciting events that precede the instant of AAD are incompletely understood. One hundred seventy-five consecutive patients having AAD, treated at our institution during a 10-year period, were reviewed; 65 were women and 110 were men (mean age 61 years). The ascending aorta was affected in 110 patients, and the descending in 65. Information was collected using patients' charts supplemented with direct telephone interviews. Ninety patients were contacted; 65 (24 women, 41 men, mean age 61 years, average aortic size 5.56 cm) could recall specific inciting events for their dissection. In 34 patients, the ascending aorta was involved and in 31 the descending. Eighteen patients (28%) had a positive family history of aortic disease, defined as having > or =1 first-degree relative with aortic disease (aneurysm or dissection). In 24 of the 90 patients contacted (27%), strenuous activity was identified as a clear precipitating factor before the acute onset of thoracic pain; in 36 of 90 (40%) severe emotional stress preceded the onset of dissection pain. Three dissections were iatrogenic. Two additional patients reported a severe exacerbation of chronic obstructive pulmonary disease before their acute onset of chest pain. In conclusion, severe physical and emotional stress may precipitate AAD, presumably on the basis of a transient, severe hypertensive reaction.