MRI Predictors of Residual Dysplasia in Developmental Dysplasia of the Hip Following Open and Closed Reduction.

BACKGROUND: Following open or closed reduction for children with developmental dysplasia of the hip, there remains a significant risk of residual acetabular dysplasia which can compromise the long-term health of the hip joint. The purpose of this study was to use postoperative in-spica magnetic resonance imaging (MRI) data to determine factors predictive of residual acetabular dysplasia at short-term follow-up. METHODS: We retrospectively reviewed 63 hips in 48 patients which underwent closed or open reduction and spica casting for developmental dysplasia of the hip. MRI performed in-spica at ∼3-week follow-up were used to assess 11 validated metrics and 2 subjective factors. Acetabular index (AI) was measured on anteroposterior pelvic radiographs at 2-year postoperative follow-up. Binary logistic regression was then used to identify variables predictive of residual dysplasia, defined as an AI greater than the 90th percentile for age based on historic normative data. RESULTS: Average age at surgical reduction was 9.3±3.2 months. 58.7% (37/63) of reductions were open. A total of 43 (68.3%) hips demonstrated residual acetabular dysplasia at 2 years postoperatively based on normative values. In those with persistent dysplasia, patients were on average older at the time of reduction (10.0 mo±3.2 vs. 8.0 mo±2.8, P=0.010) and more likely female (88.4% vs. 60.0%, P=0.010). Patients with residual dysplasia were more likely to have mild subluxation on postoperative MRI (40.0% vs. 10.5%, P=0.022). Hips with a cartilaginous acetabular index (CAI) of >23 degrees were 7.6 times more likely to develop residual dysplasia. Type of reduction (ie, closed vs. open) did not appear to influence the rate of residual dysplasia (P=0.682). CONCLUSION: In this series, the rate of residual dysplasia after surgical reduction was higher than most previous reports, with no appreciable difference between closed and open reductions. Older age, female sex, and a higher CAI were associated with a greater risk of persistent radiographic dysplasia. In particular, hips with a CAI >23 degrees were 7.6 times more likely to be dysplastic at 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Study Groups and POSNA: A Review of Podium Presentations From 2006 to 2020.

BACKGROUND: Study groups are multicenter collaborations aimed at improving orthopaedic decision-making through higher-powered, more generalizable studies. New research is disseminated through peer-reviewed literature and academic meetings, including the Pediatric Orthopaedic Society of North America (POSNA) annual meeting, which brings together academic and medical professionals in pediatric orthopaedics. The goal of this study was to identify patterns in podium presentations (PP) at the POSNA annual meeting resulting from multicenter study groups during a 15-year period. METHODS: A total of 2065 PP from the 2006 to 2020 POSNA annual meetings were identified. The abstracts of each PP were reviewed to determine if they resulted from a multicenter study group and for characteristics including subspecialty focus. PP from 2006 to 2018 were further reviewed for publication in academic journals. Pearson correlation was used to assess change in the number of PP resulting from study groups overtime. Univariate analysis was used to compare characteristics of PP based on study group involvement (significance P<0.05). RESULTS: The proportion of PP resulting from study groups increased from 2.2% (n=2) in 2006 to 9.4% in 2020 (n=16) (R2=0.519, P=0.002). Of the PP resulting from study groups, 52.9% focused on spine, 26.5% on hip, 2.9% on sports, and 2.0% on trauma. This is compared with a distribution of 16.7% (P<0.001) spine, 15.9% (P=0.005) hip, 9.5% (P=0.026) sports, and 14.6% (P<0.001) trauma focus of PP not from study groups. There was no difference in publication rate of PP resulting from study groups compared with those that were not (69.1% vs. 66.2%, P=0.621). CONCLUSIONS: In the 15-year period from 2006 to 2020, there was a nearly 5-fold increase in the proportion of POSNA PP resulting from study groups. Spine surgery is disproportionately supported by study groups, suggesting that there is an opportunity to establish new study groups across the breadth of pediatric orthopaedics. LEVEL OF EVIDENCE: Level V.

Entire-spine Magnetic Resonance Imaging Findings and Costs in Children With Presumed Adolescent Idiopathic Scoliosis.

BACKGROUND: Patients with adolescent idiopathic scoliosis (AIS) are commonly monitored for curve progression with spinal radiographs; however, the utility of magnetic resonance imaging (MRI) screening is unclear. The purpose of this study was to assess the findings of screening MRI for patients with a nonsurgical curve size ordered during routine clinical care and compare them with MRI ordered for patients with large curves as part of preoperative screening. METHODS: All consecutive patients with presumed AIS who underwent entire-spine MRI with a presumed diagnosis of idiopathic scoliosis at a single institution between 2017 and 2019 were retrospectively reviewed. Patients were stratified based on MRI indication into the following groups: preoperative evaluation, pain, neurological symptoms, abnormal radiographic curve appearance, rapidly progressive curve, and other. Neural axis abnormalities recorded included concern for tethered spinal cord, syringomyelia, and Chiari malformation. The MRI findings of preoperative patients with large curves were compared with all other patients. The number needed to diagnose (NND) a neurological finding was calculated in patients whose MRIs were ordered during routine clinical care. The amount charged for each patient undergoing entire-spine MRI was determined by review of our institution's Financial Decision Support system. RESULTS: There were 344 patients included in this study with 214 (62%) MRIs performed for preoperative evaluation. Although MRI abnormalities were found in 49% of patients, only 7.0% (24/344) demonstrated neural axis abnormalities with no difference between preoperative and other indications (P=0.37). For patients with nonsurgical curves undergoing MRI due to a complaint of back pain (n=28), there were no neural axis abnormalities, and a lower rate of disk herniation/degenerative changes detected compared with preoperative MRI (3.6% vs. 18%, P=0.06). Among the 15 patients undergoing MRI for a neurological concern, 1 had a neural axis abnormality that required surgical detethering. The NND for MRI to detect a neural axis abnormality that potentially required neurosurgical intervention in nonpreoperative patients with a neurological concern was 34.4. The average cost for MRI was $17,816 (range: $2601 to $22,411) with a total cost of $2,368,439 for nonsurgical curves. CONCLUSIONS: Entire-spine MRI for nonpreoperative indications including pain, abnormal radiographic curve appearance, and rapid curve progression has minimal utility for patients with AIS. For patients with neurological complaints, the NND a potentially treatment-altering finding with MRI is 34.4. LEVEL OF EVIDENCE: Level II-diagnostic.

A Gender Gap in Publishing? Understanding the Glass Ceiling in Pediatric Orthopaedic Surgery.

BACKGROUND: Women are underrepresented across most surgical specialties and especially in the field of orthopaedic surgery. Despite pediatric orthopaedic surgery being one of the most gender diverse subspecialties in orthopaedics, women may still face barriers to academic advancement. Research presentations at national meetings and publication record are important drivers of advancement in the field of academic orthopaedic surgery. The aim of this study is to assess whether research abstracts authored by women are less likely to be published than abstracts authored by men. METHODS: Abstracts from research podium presentations given at the Pediatric Orthopaedic Society of North America annual meetings from 2006 to 2020 were reviewed to assess research quality and determine basic study characteristics. For each abstract, author gender was determined through a search of institutional websites and professional networking websites for gender-specific pronouns. Resulting publications corresponding to the 2006 to 2018 were identified using a systematic search of PubMed and Google Scholar databases. Kaplan-Meier inverse survival analysis with log rank test were used to determine differences in publication rates based on whether the last (senior) author was female versus male. Multivariate, binary logistic regression was performed to assess factors predictive of eventual publication. RESULTS: One thousand five hundred and eighty-one of 1626 (97.2%) of abstracts from 2006 to 2020 had an identifiable last author gender, with 17.8% (281/1581) female. No differences in study quality were identified across genders including sample size, level of evidence, or impact factor of journal if leading to publication. Women were more likely to author abstracts in foot, ankle, or lower extremity surgery [17.8% (50/281) vs. 12.9% (168/1300), P=0.032] and less likely to author abstracts focusing on the hip [11.0% (31/281) vs. 17.1% (222/1300), P=0.012]. Abstracts with women as the last author were significantly less likely to be published compared with abstracts with men as the last author [59.6% (143/240) vs. 67.9% (783/1154), P=0.013]. Multivariate analysis demonstrated that last author female gender was predictive of a lower likelihood of publication (odds ratio: 0.684, 95% confidence interval: 0.513-0.912, P=0.010). Women were less likely to be the last author of abstracts presented by study groups [2.1% (6/281) vs. 5.5% (71/1300), P=0.019]. CONCLUSION: In pediatric orthopaedic surgery, abstracts authored by women are less likely to reach publication, despite no identifiable differences in study quality. Reasons for this discrepancy must be explored including insufficient mentorship, exclusion from study group participation, or potential bias against female researchers in the field of orthopaedic surgery. LEVEL OF EVIDENCE: Level IV.

Risk of Scoliosis Progression in Nonoperatively Treated Adolescent Idiopathic Scoliosis Based on Skeletal Maturity.

BACKGROUND: Hand radiographs for skeletal maturity staging are now frequently used to evaluate remaining growth potential for patients with adolescent idiopathic scoliosis (AIS). Our objective was to create a model predicting a patient's risk of curve progression based on modern treatment standards. METHODS: We retrospectively reviewed all AIS patients presenting with a major curve <50 degrees, available hand radiographs, and complete follow up through skeletal maturity at our institution over a 3-year period. Patients with growth remaining underwent rigid bracing of curves >25 degrees, whereas patients between 10 and 25 degrees were observed. Treatment success was defined as reaching skeletal maturity with a major curve <50 degrees. Four risk categories were identified based on likelihood of curve progression. RESULTS: Of 609 AIS patients (75.4% female) presenting with curves over 10 degrees and reaching skeletal maturity at most recent follow up, 503 (82.6%) had major thoracic curves. 16.3% (82/503) of thoracic curves progressed into surgical treatment range. The highest risk group (Sanders 1 to 6 and curve 40 to 49 degrees, Sanders 1 to 2 and curve 30 to 39) demonstrate a 30% success rate with nonoperative treatment. This constitutes an 111.1 times (95% confidence interval: 47.6 to 250.0, P<0.001) higher risk of progression to surgical range than patients in the lowest risk categories (Sanders 1 to 8 and curve 10 to 19 degrees, Sanders 3 to 8 and curve 20 to 29 degrees, Sanders 5 to 8 and curve 30 to 39 degrees). CONCLUSIONS: Skeletal maturity and curve magnitude have strong predictive value for future curve progression. The results presented here represent a valuable resource for orthopaedic providers regarding a patient's risk of progression and ultimate surgical risk. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

What's New in Pain Management for Pediatric Orthopaedic Surgery.

BACKGROUND: Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS: An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS: A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS: There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE: Level IV-literature review.

Rib-based Distraction Device Implantation Before Age 3 Associated With Higher Unplanned Rate of Return to the Operating Room.

BACKGROUND: Surgical treatment of early-onset scoliosis (EOS) with rib-based implants such as the vertical expandable prosthetic titanium rib (VEPTR) is associated with a high rate of complications including surgical site infection, skin breakdown, and implant migration. Many of these complications warrant the need for unplanned reoperations, increasing the burden on an already vulnerable patient population, and introducing the further risk of infection. To provide insight into the risks of early intervention, we investigate the relationship between initial device implantation before the age of 3 and the rate of unplanned reoperation. METHODS: A retrospective review was performed of all patients at a single institution who had undergone VEPTR insertion for EOS with at least a 2-year follow-up from 2007 to 2016. Patients were stratified into the case-cohort (0 to 2 y of age) or the comparison cohort (3 to 10 y of age) based on age at the time of device implantation. Multivariate regression accounting for age and scoliosis etiology was performed to identify factors predictive of unplanned reoperation. RESULTS: A total of 137 of 185 patients treated with VEPTR were identified with 76 (56%) undergoing at least 1 unplanned reoperation during the study time period. There were 68 and 69 patients in the age 0- to 2-year and 3- to 10-year cohorts, respectively. Patients aged 0 to 2 years underwent a higher number of total procedures compared with those aged 3 to 10 (13.1±6.5 vs. 10.6±4.8, P=0.032). A significant difference was found in the rate of unplanned reoperation between the 2 cohorts with 44 (65%) patients aged 0 to 2 and 32 (46%) patients aged 3 to 10 undergoing at least 1 unplanned reoperation (P=0.031). Binary logistic multivariate regression accounting for age and scoliosis etiology demonstrated that patients aged 0 to 2 had a significantly greater odds of undergoing an unplanned reoperation (odds ratio=3.050; 95% confidence interval: 1.285-7.241; P=0.011) compared with patients aged 3 to 10 years. CONCLUSION: Overall, EOS patients aged 0 to 2 at initial VEPTR implantation are up to 3 times higher risk of undergoing an unplanned reoperation compared with those aged 3 to 10. LEVEL OF EVIDENCE: Level III.

Association between timing of kyphoplasty and opioid prescribing risk after vertebral fracture.

OBJECTIVE: Approximately 550,000 Americans experience vertebral fracture annually, and most receive opioids to treat the resulting pain. Kyphoplasty of the fractured vertebra is a procedural alternative that may mitigate risks of even short-term opioid use. While reports of kyphoplasty's impact on pain scores are mixed, no large-scale data exist regarding opioid prescribing before and after the procedure. This study was conducted to determine whether timing of kyphoplasty following vertebral fracture is associated with duration or intensity of opioid prescribing. METHODS: This retrospective cohort study used 2001-2014 insurance claims data from a single, large private insurer in the US across multiple care settings. Patients were adults with vertebral fractures who were prescribed opioids and underwent balloon-assisted kyphoplasty within 4 months of fracture. Opioid overdose risk was stratified by prescribed average daily morphine milligram equivalents using CDC guidelines. Filled prescriptions and risk categories were evaluated at baseline and 90 days following kyphoplasty. RESULTS: Inclusion criteria were met by 7119 patients (median age 77 years, 71.7% female). Among included patients, 3505 (49.2%) were opioid naïve before fracture. Of these patients, 31.1% had new persistent opioid prescribing beyond 90 days after kyphoplasty, and multivariable logistic regression identified kyphoplasty after 8 weeks as a predictor (OR 1.34, 95% CI 1.02-1.76). For patients previously receiving opioids, kyphoplasty > 4 weeks after fracture was associated with persistently elevated prescribing risk (OR 1.84, 95% CI 1.23-2.74). CONCLUSIONS: New persistent opioid prescribing occurred in nearly one-third of patients undergoing kyphoplasty after vertebral fracture, although early treatment was associated with a reduction in this risk. For patients not naïve to opioids before fracture diagnosis, early kyphoplasty was associated with less persistent elevation of opioid overdose risk. Subsequent trials must compare opioid use by vertebral fracture patients treated via operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.

Comparison of T1-S1 Spine Height of Postoperative Rib-based Implant Patients With Age-matched Peers.

BACKGROUND: Severe early-onset scoliosis leads to deficient spine height, thoracic growth inhibition, and ultimately pulmonary compromise. Rib-based growing instrumentation seeks to correct thoracic deformities, in part by correcting the spinal deformity, adding height, increasing thoracic volume, and allowing for continual spinal growth until maturity. However, the amount of growth in these patients relative to their peers is unknown. METHODS: Sixty patients who had undergone surgical intervention for the treatment of early-onset scoliosis were assessed via radiographic measurements of coronal T1-S1 height and major curve angle before implantation and again at most recent follow-up (minimum 2 years). T1-S1 measurements were then compared with age-matched peers to assess growth differences. Clinical information was examined for relevant parameters. RESULTS: The average age of our cohort at initial surgery and most recent follow-up was 4.4±3.8 and 10.0±4.4 years old, respectively. In this patient set, there was an average increase in T1-S1 height of 13.1±11.1 mm per year, with the majority of growth occurring in the first 2 years following implantation, and improvement in a major curve from 68±8 to 53±7 degrees. Overall, 77% of patients saw improvement in the major curve at most recent follow-up. Furthermore, a statistically significant greater percent of expected growth was seen in congenital compared with neuromuscular scoliosis (P<0.001). In addition, a weak negative correlation was observed between a number of surgical lengthenings and T1-S1 growth. CONCLUSIONS: Rib-based implant intervention has been shown to improve the major curve, but only improves growth potential to around 80% of expected growth. Scoliosis diagnosis type also influences growth rate potential, with congenital scoliosis patients being surgically treated earlier in life and having a growth rate approaching that of a healthy individual. LEVEL OF EVIDENCE: Level III-Case control.

Where Have All the Fractures Gone? The Epidemiology of Pediatric Fractures During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics. METHODS: This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019. RESULTS: In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P<0.001). The presenting age for all fractures decreased during the pandemic (7.5±4.3 vs. 9.4±4.4 y, P<0.001) because of decreased fracture burden among adolescents. There were also a decrease in the number of fractures requiring surgery (2.2±1.8/d vs. 0.8±0.8/d, P<0.001). During the pandemic, there was an increase in the proportion of injuries occurring at home (57.8% vs. 32.5%, P<0.001) or on bicycles (18.3% vs. 8.2%, P<0.001), but a decrease in those related to sports (7.2% vs. 26.0%, P<0.001) or playgrounds (5.2% vs. 9.0%, P<0.001). There was no increase in time-to-presentation. Patients with distal radius torus fractures were more likely to receive a velcro splint during the pandemic (44.2% vs. 25.9%, P=0.010). CONCLUSIONS: Pediatric fracture volume has decreased 2.5-fold during the COVID-19 pandemic, partially because of cessation of organized sports and decreased playground use. In endemic regions, lower trauma volume may allow redeployment of orthopaedic surgeons and staff to other clinical arenas. Given the rising proportion of bicycling injuries, an emphasis on basic safety precautions could improve public health. An observed increase in the prescription of velcro splints for distal radius fractures highlights an opportunity for simplified patient care during the pandemic. LEVEL OF EVIDENCE: Level III.

Safe Transportation in-Spica Following Surgical Treatment of Infantile DDH: Solutions and Threats.

BACKGROUND: Government regulations mandate appropriate vehicular restraints for children under 4 years of age. Patients treated for infantile developmental dysplasia of the hip (DDH) with spica casts often require special accommodations. Previous work suggests that car seat loaner programs may help achieve these goals while avoiding the need for costly ambulance transportation. The purpose of this study was to evaluate our center's experience with postdischarge transportation in a large population of DDH infants and identify future threats to our program. METHODS: We performed a retrospective review of patients 4 years or younger of age who underwent closed or open reduction for DDH at our center between 2011 and 2018. Only the initial surgery of staged procedures was included. Patient demographic factors were recorded, as were procedure type, final restraint used for postdischarge transportation, and any potential discharge delays secondary to transportation issues. Costs were compared amongst transportation options. RESULTS: Our cohort consisted of 130 patients (mean age, 1.4±0.9 y; 98 females) treated for DDH. In total 41 children (31.5%) underwent closed reduction procedures, whereas 89 patients (68.5%) underwent open reductions. After reduction, 62 (47.7%) received 2-legged spica casts and 68 (52.3%) received 1.5-legged casts. The most common restraint was a hospital-loaned Hippo car seat (73, 55.8%) followed by family-owned car seats (27, 20.8%). Eight patients (6.2%) experienced delays in discharge while waiting for adequate restraints, 6 patients (4.6%) were transported by ambulance, and 4 patients (3.1%) left against medical advice with inadequate restraints. CONCLUSIONS: Following surgical treatment of DDH, over 50% of patients with a spica cast were discharged using our center's car seat loaner program. However, availability and cost can present barriers for patients, with 4.6% of patients still being transported home by ambulance and 3.1% with inadequate restraints against medical advice. Costs of car seats are significant both for patients' families intending to purchase them, as well as for hospitals maintaining loaner programs and replacing used/lost seats. Moving forward, the recent cessation of production of the most common "spica car seat" threatens the longevity of existing loaner programs and calls renewed attention to the issue of safe transportation in-spica from providers and car-seat manufacturers alike. LEVEL OF EVIDENCE: Level III.

Quantifying cellular protrusion in alginate capsules with covalently crosslinked shells.

This work describes viability and distribution of INS-1E beta cells in shell-crosslinked alginate capsules, focussing on cells located near the capsule surface. Capsules were formed by air-shearing alginate suspensions of INS-1E cells into a gelling bath, and coating with poly-l-lysine (PLL) and 50% hydrolysed poly(methylvinylether-alt-maleic anhydride) to form crosslinked networks reinforcing the capsule surfaces. The percentage of cells at the capsule surface were determined using 2D and 3D confocal colocalization mapping. Encapsulated INS-1E cells showed high cell viability and progressive cell clustering out to six weeks. About 30% of cells were initially colocated with the 20 micrometer thick alginate-PLL-PMM50 shell, with 7% of cells protruded at the capsule surfaces, both reflecting random cell distributions. Protruding cells may cause cell-based immune responses, weaken capsules, and potentially result in cell escape from the capsules. The data shown indicate that reinforcing capsules with crosslinked shells may assist in preventing cell exposure and escape.

Effects of Lipid Tethering in Extremophile-Inspired Membranes on H(+)/OH(-) Flux at Room Temperature.

This work explores the proton/hydroxide permeability (PH+/OH-) of membranes that were made of synthetic extremophile-inspired phospholipids with systematically varied structural elements. A fluorescence-based permeability assay was optimized to determine the effects on the PH+/OH- through liposome membranes with variations in the following lipid attributes: transmembrane tethering, tether length, and the presence of isoprenoid methyl groups on one or both lipid tails. All permeability assays were performed in the presence of a low concentration of valinomycin (10 nM) to prevent buildup of a membrane potential without artificially increasing the measured PH+/OH-. Surprisingly, the presence of a transmembrane tether did not impact PH+/OH- at room temperature. Among tethered lipid monolayers, PH+/OH- increased with increasing tether length if the number of carbons in the untethered acyl tail was constant. Untethered lipids with two isoprenoid methyl tails led to lower PH+/OH- values than lipids with only one or no isoprenoid tails. Molecular dynamics simulations revealed a strong positive correlation between the probability of observing water molecules in the hydrophobic core of these lipid membranes and their proton permeability. We propose that water penetration as revealed by molecular dynamics may provide a general strategy for predicting proton permeability through various lipid membranes without the need for experimentation.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting.

BACKGROUND CONTEXT: Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated. PURPOSE: This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021. OUTCOME MEASURES: Thirty-day rates of serious and minor adverse events, readmission, reoperation, non-home discharge, and mortality. METHODS: A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) non-home discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences. RESULTS: Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs. 11.8%) and OP (92.7% vs. 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and non-home discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=0.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, non-home discharge, or death (p>.050 for all). CONCLUSIONS: Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Removing or Only Moving a Barrier? Screening Applications with US Medical Licensing Examination Step 2CK Instead of Step 1 May Benefit Women but Not Underrepresented Minorities in Orthopaedics.

Most orthopaedic surgery program directors report using a minimum score cutoff for the US Medical Licensing Examination Step 1 examination when evaluating residency applicants. The transition to a Pass/Fail grading system beginning in the 2022-2023 application cycle will alter applicant evaluation in the interview selection process. The impact of this change, particularly on women and underrepresented minority (URM) applicants, remains unclear. This study was designed to evaluate how a shift to screening applications using Step 2 Clinical Knowledge (CK) instead of Step 1 scores could impact selection for residency interviews. Methods: We reviewed all 855 Electronic Residency Application Service applications submitted to the University of Pennsylvania's orthopaedic surgery residency program in the 2020-2021 cycle. Applicant age, sex, medical school of graduation, self-identified race, and permanent zip code were evaluated for association with Step 1 and Step 2CK scores using a 2-sample t test. A multivariable linear regression analysis was conducted to understand the predictive value of demographic features and medical school features on Step 1 and 2CK scores. Results: Multivariable linear regression revealed both Step 1 and 2CK scores were lower for applicants of URM status (Step 1: p < 0.001; Step 2CK: p < 0.001) and from international medical schools (p = 0.043; p = 0.006). Step 1 scores but not Step 2CK scores were lower for applicants who were women (p < 0.001; p = 0.730), ≥30 years of age (p < 0.001; p = 0.079), and from medical schools outside the top 25 in National Institutes of Health (NIH) funding or US News and World Report (USNWR) ranking (p = 0.001; p = 0.193). Conclusions: Conversion of Step 1 grading to Pass/Fail may reduce barriers for groups with lower average Step 1 scores (URM, female, ≥30 years of age, and from institutions with lower NIH funding or USNWR rankings). However, if Step 2CK scores replace Step 1 as a screening tool, groups with lower Step 2CK scores, notably URM applicants, may not experience this benefit. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Publication Rates Vary Across Orthopaedic Subspecialties: A Longitudinal Analysis of AAOS Abstracts.

Background: Presentation of research at national orthopaedic meetings and subsequent publication are important for both information exchange among surgeons and individual academic advancement. However, the academic landscape and pressures that researchers face may differ greatly across different subspecialties. This study attempts to explore and quantify differences in research presented at national conferences and its implication on ultimate likelihood of publication in peer-reviewed journals. Methods: All abstracts from the Annual Meetings of the American Academy of Orthopaedic Surgeons (AAOS) from 2016 and 2017 were reviewed and categorized based on subspecialty focus. Resulting publications were identified using a systematic search of PubMed and Google Scholar databases. Multivariate binary logistic regression modelling was used to assess the predictive value of abstract characteristics on eventual publication. Results: A total of 1805 abstracts from the 2016 and 2017 AAOS conferences were reviewed. The overall publication rate of abstracts following the AAOS meetings was 71.6%, with an average time to publication from abstract submission deadline and impact factor of 19.8 months and 2.878, respectively. Statistical differences were observed across subspecialties with respect to publication rate (p<0.001), time to publication (p<0.001), and impact factor (p<0.001). The subspecialty with the highest publication rate, largest impact factor, and shortest average time to publication was Sports Medicine with 83.2%, 3.98, and 17.6 months, respectively; despite lower average sample size (p<0.001) and frequency of multicenter design (p<0.001) compared with other subspecialties. The subspecialty with the lowest publication rate and impact factor was Hand and Wrist with 53.3% and 1.41, respectively. Multivariate logistic regression analysis demonstrates a lower likelihood for internationally authored abstracts (OR: 0.75, p=0.021) and higher likelihood for basic science abstracts (OR: 1.52, p-value=0.023) to reach publication. Conclusion: Differences in publication rate across orthopaedic subspecialties were observed with articles in sports medicine more likely to be published, published quickly, and featured in a higher impact factor journals. Understanding these differences, and how they relate to the publication and promotion of novel research, is important for orthopaedic researchers. Level of Evidence: IV.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients.

BACKGROUND: The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them. PURPOSE: To validate the ACL-RSI scale for use with pediatric and adolescent patients. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort. RESULTS: A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions. CONCLUSION: The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

Changes in height, weight, and body mass index after posterior spinal fusion in juvenile and adolescent idiopathic scoliosis.

Purpose: Posterior spinal fusion for idiopathic scoliosis is known to increase spinal height, but the impacts on weight and resulting body mass index are unknown. This study assesses body mass index, weight, and height percentile changes over time after posterior spinal fusion for idiopathic scoliosis. Methods: Body mass index, weight, and height age- and sex-adjusted percentiles for patients with idiopathic scoliosis undergoing posterior spinal fusion between January 2016 and August 2022 were calculated based on growth charts from the Centers for Disease Control for Disease Control and compared to preoperative values at 2 weeks, 3 months, 6 months, 1 year, and 2 years. The data were analyzed for normality with a Shapiro-Wilk test, and percentiles were compared with the Wilcoxon signed-rank tests. Results: On average, 12.1 ± 2.3 levels were fused in 269 patients 14.4 ± 1.9 years, and percentiles for body mass index, weight, and height preoperatively were 55.5 ± 29.4%, 57.5 ± 28.9%, and 54.6 ± 30.4%, respectively. Body mass index and weight percentiles decreased at 2 weeks (-10.7%, p < 0.001; -4.6%, p < 0.001, respectively) and 3 months (-6.9%, p < 0.001; -3.2%, p < 0.001, respectively) postoperatively. Postoperative weight loss at 2 weeks averaged 2.25 ± 3.09% of body weight (0.98 ± 4.5 kg), normalizing by 3 months. Body mass index percentile normalized at 1 year, but height percentile was increased at 2 weeks (2.42 ± 1.72 cm, p < 0.001) and through 2 years. Conclusion: Despite initial height increase due to deformity correction, acute postoperative weight and body mass index percentile decreases postoperatively normalize by 1-year body mass index percentile. Physicians may benefit from utilizing this information when discussing the postoperative course of posterior spinal fusion with idiopathic scoliosis. Level of evidence: 4, Retrospective Case Series.

Changes in research quality and surgical trends at the international congress on early-onset scoliosis.

PURPOSE: The founding of the International Congress for Early Onset Scoliosis (ICEOS) and first annual meeting in 2007 represented a significant milestone in advancing the care of patients with EOS. Due to the complexity and rarity of EOS, this annual conference is the premiere venue for physicians, researchers, and advanced practice providers to identify and understand the best treatments for children with EOS. This study examines the trend of various treatment modalities presented at ICEOS and the changes in research quality since its inception. METHODS: Podium presentations from the 2007 through 2021 ICEOS annual meetings were reviewed to determine the number of study patients, use of a study group, and key features of study design. Treatment strategies being evaluated were recorded and included non-operative treatments (casting/bracing), traditional growing rods (TGR), vertical expandable prosthetic titanium rib (VEPTR), Shilla growth guidance, magnetically controlled growing rods (MCGR), and vertebral body tethering (VBT). Linear regressions were performed to analyze changes in research topic and study group utilization. RESULTS: A total of 532 abstracts were reviewed. An average of 97.5 ± 81.3 patients were included per study with a significant increase from 42.3 ± 89.7 in 2007 to 337.6 ± 587.4 in 2021 (r2 = 0.632, p < 0.001). A total of 130 (24.4%) abstracts resulted from multicenter study groups with the proportion increasing significantly from 13.0% in 2007 to 36.4% in 2021 (p = 0.039, r2 = 0.289). The majority (96.2%) of study group-based projects were from either the Growing Spine Study Group (GSSG), Chest Wall and Spine Deformity Study Group (CWSDG), Children's Spine Study Group (CSSG), or the Pediatric Spine Study Group (PSSG). Additionally, a significant increase in studies utilizing patient-reported outcome measures (PROMs) was observed (r2 = 0.336, p = 0.023). Significant increases in the proportion of presentations discussing MCGR (r2 = 0.738, p < 0.001) and VBT (r2 = 0.294, p = 0.037) as surgical treatments were observed. CONCLUSION: The trends in EOS device implantation observed in registry studies align with the trends in research presented at ICEOS including the increased proportion of studies focusing on MCGR and VBT over the past decade. An attempt to increase the quality of research presented at ICEOS through multicenter study groups, increased patient recruitment, and utilization of PROMs has been seen since its inception. LEVEL OF EVIDENCE: V.

A Glass Ceiling in Orthopedic Surgery: Publication Trends by Gender.

Women are underrepresented across the field of orthopedic surgery and may face barriers to academic advancement. Research presentation at national meetings and publication record are important drivers of advancement in academic orthopedic surgery. However, little is known regarding potential gender differences in publication after orthopedic conference research presentation. This investigation analyzed research presentations at the Annual Meeting of the American Academy of Orthopaedic Surgeons in 2016 and 2017. Author gender was determined through a search of institutional and professional networking websites for gender-specific pronouns. Resulting publications were identified using a systematic search of PubMed and Google Scholar databases. A total of 1696 of 1803 (94.1%) abstracts from 2016 to 2017 had identifiable gender for both the first and last authors, with 1213 (71.5%) abstracts ultimately being published. There were no differences in average sample size or level of evidence between genders. Abstracts authored by women were significantly less likely to lead to publication compared with those by men (67.1% vs 72.1%, P=.023), with articles authored by women having a longer median time to publication (median, 20 months [interquartile range, 19] vs 17 months [interquartile range, 15]; P=.003). This discrepancy was most apparent in adult reconstruction, with women having a 15.5% lower rate of publication (55.1% [27/49] vs 70.6% [307/435]; P=.026) and lower publication journal impact factor (2.7±1.4 vs 3.4±3.4, P=.040) than men. Potential reasons for these discrepancies, including disproportionate domestic obligations, inadequate mentorship, and bias against female researchers, should be addressed. [Orthopedics. 2023;46(2):e118-e124.].