Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors

BACKGROUND

It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States.

MATERIALS AND METHODS

County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon.

CONCLUSION

Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 202x;4x(x):xx-xx.].

Evaluating Funding for Authors Achieving High Citations vs. Online Popularity

INTRODUCTION

The Altmetric score is a validated tool that measures online attention of scientific studies. A relationship between government/industry funding for authors and their study's citations have been previously demonstrated. It is not known whether funding is related to greater online attention. We hypothesize authors publishing studies achieving greater online attention (higher Altmetric scores) receive greater monetary support from industry while authors publishing studies achieving critical acclaim (more citations) receive greater monetary support from the National Institute of Health (NIH).

METHODS

Top spine surgery studies between 2010 and 2021 were selected based on Altmetric scores and citation number. The Open Payments Database was accessed to evaluate industry financial relationships while the NIH Research Portfolio Online Reporting Tool was accessed to evaluate NIH funding. Payments were compared between groups and analyzed with the Student t-test, analysis of variance, and chi square analysis. Alpha <0.05.

RESULTS

There were 60 and 51 authors with payment data in the top 50 Altmetric and top 50 citation studies, respectively, with eight authors having studies in both groups. Total industry payments between groups were not markedly different. The eight authors with studies in both groups received markedly more industry payments for consulting, travel/lodging, and faculty/speaking fees. Authors with articles in both groups (50%) were significantly more likely to receive NIH support, compared with authors of the top Altmetric articles (5%; P < 0.001) and top citation articles (12%; P < 0.001). Authors receiving NIH support received significantly less industry payments compared with authors not receiving NIH support ($148,544 versus $2,159,526; P < 0.001).

DISCUSSION

These findings reject our hypothesis: no notable differences for industry payments and NIH funding between authors for top Altmetric and citation studies. Authors receiving funding from industry versus the NIH are generally two distinct groups, but there is a small group supported by both. These studies achieve both critical acclaim (citations) and online popularity (Altmetric scores).

DATA AVAILABILITY

Data can be available on reasonable request.

Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disk Disease in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVE

Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention.

SUMMARY OF BACKGROUND DATA

AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported.

MATERIALS AND METHODS

A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio.

RESULTS

Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01).

CONCLUSIONS

Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD.

Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors

PURPOSE

Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors.

METHODS

Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons.

CONCLUSION

Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.

Subject matter predicts where top pediatric spine articles are shared: citations vs. social media

STUDY DESIGN

Systematic review. The purpose of this study was to compare the top 25 articles on pediatric spine surgery by number of citations and Altmetric score. All published articles pertaining to pediatric spine surgery from 2010 to 2021 were assessed for: Altmetric scores, Altmetric score breakdown (e.g. Twitter, News), citation counts, and article topics. The top 25 Altmetric articles and top 25 cited articles were identified. Out of the 50 total articles, only 3 (6.0%) overlapped between the two groups. The top Altmetric articles had averages (mean ± SD) of 167 ± 130 Altmetric score and 66 ± 135 citations, while the top citation articles had averages of 22 ± 45 Altmetric score and 196 ± 114 citations. When evaluating article topics, articles on 'back pain' (36% vs. 4%; P = 0.003) and 'backpacks' (16% vs. 0%; P = 0.030) were published significantly more in the top Altmetric group, while articles on 'scoliosis' (93% vs. 36%; P < 0.001) and 'growth friendly surgery' (24% vs. 4%; P = 0.041) were published significantly more in the top citation group. The total number of citations and online mentions for both groups are presented in Table 2. The biggest differences were the top Altmetric score articles receiving greater percentages of Twitter mentions relative to overall mentions (87% vs. 57%). The most socially popular articles focused on back pain and backpacks, and the most cited articles focused on scoliosis and growth-friendly surgery. Twitter had the most mentions of all social media for both the top cited articles and the top Altmetric articles.

Vertebral Artery Dissection in the Setting of Unstable Os Odontoideum: A Case Report

CASE

A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae.

CONCLUSION

This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum.

Breast Cancer Incidence, Mortality, and Cost in Adolescent Idiopathic Scoliosis Patients and the Role of Low Dose Biplanar Radiography

INTRODUCTION

Patients with adolescent idiopathic scoliosis (AIS) are susceptible to high doses of radiation from radiographs. The purpose of this study was to examine the future cost of radiation-induced breast cancer in patients with AIS and its potential financial and mortality impact.

METHODS

A literature review identified articles relating radiation exposure in patients with AIS to increased risk for cancer. Based on population statistics and breast cancer treatment costs in the year 2020, the financial impact of radiation-induced breast cancer and the estimated number of additional deaths per year due to breast cancer for patients with AIS were calculated.

RESULTS

The US female population in 1970 was 205.1 million. Based on a prevalence of 3.0%, an estimated 3.1 million patients had AIS in 1970. With an incidence of breast cancer in the general population of 128.3/100,000 and a standardized incidence ratio of 1.82-2.4 for breast cancer in patients with scoliosis, there will be a 3,282 to 5,603 patient increase in radiation-induced breast cancer in patients with scoliosis over the general population. With a projected base cost of $34,979 per patient for the first year of breast cancer diagnosis in 2020, the cost of radiation-induced breast cancer will be 114.8 to 196.0 million dollars per year. Using a standardized mortality ratio of 1.68 for scoliosis radiation-induced breast cancer, there will be an expected increase in deaths of 420 patients due to breast cancer presumably secondary to radiation exposure in the evaluation and treatment of AIS.

CONCLUSION

The estimated radiation-induced breast cancer financial impact in 2020 will be between 114.8 and 196.0 million dollars per year, with an increase in deaths of 420 patients per year. Low-dose imaging systems reduce radiation exposure by up to 45 times while maintaining sufficient image quality. New low-dose radiography should be used whenever possible with patients with AIS.

LEVEL OF EVIDENCE

Level 5.

Deformity angular ratio is associated with neuromonitoring changes without a vertebral column resection: spinal deformity is more influential than type of surgery

PURPOSE

The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR).

METHODS

Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without.

RESULTS

Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p = 0.003) and was not associated with Cobb angle (p = 0.16). S-DAR (p = 0.03) and T-DAR (p = 0.005) were associated with IONM signal loss but C-DAR was not (p = 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p = 0.02) or T-DAR > 27 (p = 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1-4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3-10.9).

CONCLUSION

Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies.

LEVEL OF EVIDENCE II

Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement

PURPOSE

Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions.

METHODS

Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed.

RESULTS

64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999).

CONCLUSIONS

The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis.

STUDY DESIGN

Retrospective, Comparative.

LEVEL OF EVIDENCE

III.

Outcomes of Operatively Managed Lumbar and Sacral Facet Fractures in Pediatric Athletes: A Case Series

BACKGROUND

Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis.

METHODS

Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed.

RESULTS

Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo).

CONCLUSIONS

Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief.

Power versus manual pedicle tract preparation: a multi-center study of early adopters

STUDY DESIGN

Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety.

OBJECTIVE

Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology.

METHODS

Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique.

RESULTS

In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation.

CONCLUSION

This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique.

LEVEL OF EVIDENCE

III.

How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis

STUDY DESIGN

Retrospective, multicenter comparative.

OBJECTIVES

Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates.

METHODS

EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6).

EXCLUSION CRITERIA

< 2 years follow-up from fusion or inadequate radiographs.

RESULTS

A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04).

CONCLUSIONS

Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate.

LEVEL OF EVIDENCE

III.

C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report

CASE

There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery.

CONCLUSION

In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.

Using a dedicated spine radiology technologist is associated with reduced fluoroscopy time, radiation dose, and surgical time in pediatric spinal deformity surgery

STUDY DESIGN

Retrospective comparative study OBJECTIVES: The goal of this study was to investigate fluoroscopy time and radiation exposure during pediatric spine surgery using a dedicated radiology technologist with extensive experience in spine operating rooms. Repetitive use of intraoperative fluoroscopy during posterior spinal fusion (PSF) exposes the patient, surgeon, and staff to radiation.

METHODS

Retrospective review was conducted on patients with posterior spinal fusion (PSF) of ≥ 7 levels for adolescent idiopathic scoliosis (AIS) at a pediatric hospital from 2015 to 2019. Cases covered by the dedicated radiology technologist (dedicated group) were compared to all other cases (non-dedicated group). Surgical and radiologic variables were compared between groups.

RESULTS

230 patients were included. 112/230 (49%) were in the dedicated group and 118/230 (51%) were in the non-dedicated group. Total fluoroscopy time was significantly reduced in cases with the dedicated technologist (46 s) compared to those without (69 s) (p = 0.001). Radiation dose area product (DAP) and air kerma (AK) were reduced by 43% (p < 0.001) and 42% (p < 0.001) in the dedicated group, respectively. The dedicated group also had reduced total surgical time (4.1 vs. 3.5 h; p < 0.001) and estimated blood loss (447 vs. 378 cc (; p = 0.02). Multivariate regression revealed that using a dedicated radiology technologist was independently associated with decreased fluoroscopy time (p = 0.001), DAP (p < 0.001), AK (p < 0.001), surgical time (p < 0.001), and EBL (p = 0.02).

CONCLUSIONS

In AIS patients undergoing PSF, using a dedicated radiology technologist was independently associated with significant reductions in fluoroscopy time, radiation exposure, surgical time, and EBL. This adds to the growing body of research demonstrating that the experience level of the team-not just that of the surgeon-is necessary for optimal outcomes.

LEVEL OF EVIDENCE

III.

Standing in Schroth trained position significantly changes Cobb angle and leg length discrepancy: a pilot study

STUDY DESIGN

Retrospective.

OBJECTIVE

The aim of this study is to evaluate if standing in a Schroth trained position influences the radiographic assessment of Cobb angle and other radiographic parameters compared to a normal standing position. Schroth method has been associated with improved Cobb angle. This study aims to evaluate if standing in the Schroth trained position influences radiographic assessment of Cobb angle compared to a normal standing position.

METHODS

This is a retrospective review of patients with adolescent idiopathic scoliosis (AIS) who were participating in Schroth therapy at the time of radiographs. Ten pairs of radiographs were included in this study. Each pair consisted of two micro-dose biplanar PA thoracolumbar spine radiographs obtained on the same day, one with the patient standing in the Schroth trained position and one in their normal standing position. Each pair of radiographs was independently evaluated by three attending pediatric spine surgeons for Cobb angle, coronal balance, shoulder balance, and leg length discrepancy, for a total of 30 paired readings (3 readings for each of the 10 pairs of radiographs).

RESULTS

Major Cobb angle was a mean of 6° less (p = 0.02) and the compensatory curve was 5° less (p = 0.03) in the Schroth trained position compared to their normal standing position. Neither coronal balance (p = 0.40) nor shoulder balance (p = 0.16) was significantly different. Mean leg length discrepancy was 6.8 mm greater in the Schroth trained versus normal position (p < 0.001).

CONCLUSION

Standing in a Schroth trained position for a PA spine radiograph was associated with a mean change in major Cobb angle of 6° compared to a normal standing position. If bracing was recommended for curves > 25° and surgery for curves > 45°, different treatment recommendations would have been made in 33% (10/30) of attendings' readings for the Schroth versus normally paired radiographs taken on the same day on the same patient. Studies evaluating the effect of Schroth therapy on Cobb angle must report if patients are standing in a normal or Schroth trained position during radiographs for conclusions to be valid, or differences may be due to a temporary, voluntary change in posture.

LEVEL OF EVIDENCE

III.

Growth guidance constructs with apical fusion and sliding pedicle screws (SHILLA) results in approximately 1/3rd of normal T1-S1 growth

STUDY DESIGN

Retrospective, multicenter.

OBJECTIVE

To investigate clinical outcomes in particular T1-S1 growth in patients with SHILLA instrumentation independent of inventor's reports. Guided growth with apical fusion and sliding pedicle screws (GGC/SHILLA) is an alternative to distraction-based growing rods for the treatment of EOS. A recent report of patients treated with GGC primarily at the center where the procedure was invented reported surprisingly good spinal growth similar to normal growth.

METHODS

Retrospective review of EOS patients treated with GGC between 2007 and 2013 was performed from a multicenter database prior to final fusion. Inclusion criteria were < 10 years at index surgery and minimum 2-year follow-up. Patients with GGC performed at the inventor's institution or prior spinal instrumentation were excluded. Predicted normal T1-S1 change during the growth period was calculated for each patient based on Dimeglio's growth rates.

RESULTS

20 patients (mean age at surgery: 5.7 years) with the following diagnoses met inclusion criteria: syndromic (N = 9), neuromuscular (N = 5), idiopathic (N = 3) and congenital (N = 3). Preoperative mean Cobb was 77° (range 33°-111°). Mean increase in T1-S1 length from preoperative to postoperative was 51.5 mm, and change from postoperative to final follow-up was 21.8 mm (4.2 mm/year) which was 36% of predicted growth. 15/20 (75%) patients underwent 21 revision surgeries most commonly for implant complications (N = 26) and 8/20 (40%) underwent definitive fusion at a mean of 5.1 ± 1.2 years after guided growth surgery.

CONCLUSION

This study constitutes the largest case series of patients with EOS treated with GGC outside of the inventor's institution. The change in T1-S1 observed through the follow-up period in EOS patients treated with GGC was approximately 1/3rd of predicted normal growth, and less than 1/3rd of growth reported in previous reports. Similar curve correction and complication rates but less T1-S1 growth during the growth period were found compared to prior GGC (SHILLA) series.

Femoral shaft fractures in children with non-ambulatory neuromuscular disorders can be effectively treated using flexible intramedullary nails

PURPOSE

There is little information in the literature regarding flexible intramedullary nails (FIN) for treating femur fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in non-ambulatory children with neuromuscular disorders.

METHODS

A retrospective review was conducted on patients with femur fractures at a paediatric hospital between 2004 and 2018. Inclusion criteria were femoral shaft fracture treated with FIN. Outcomes were compared between patients with neuromuscular disorders (NM group) and a control group of those without neuromuscular disorders.

RESULTS

A total of 37 patients with 37 femoral shaft fractures were studied (12 patients in the NM group and 25 in the control group). All NM group patients were non-ambulatory at baseline. Fractures were length stable in all 25 patients in the control group and in 2/12 (17%) patients in the NM group. All fractures healed in both groups. Three complications (all nail migrations) requiring reoperation before fracture union occurred in the NM group, yielding a major complication rate of 25% (3/12) in the NM group versus 0% (0/25) in controls (p = 0.03). Angular deformity occurred in 5/12 (42%) NM group patients and 1/25 (4%) control group patient (p = 0.009); none required reoperation.

CONCLUSION

Femur fractures in non-ambulatory children with neuromuscular disorders can be successfully treated with FIN. Angular deformities are common in this population, but had no functional impact in the non-ambulatory NM group patients. Surgeons must also be vigilant for implant prominence and skin breakdown in these patients.

LEVEL OF EVIDENCE

III.

Isolated femoral shaft fractures in children rarely require a blood transfusion

BACKGROUND

No recent study has examined how a trend toward surgical fixation for pediatric femoral shaft fractures has impacted blood loss and transfusion requirements. The purpose of this study was to determine the factors influencing transfusions in the treatment of pediatric femoral shaft fractures.

METHODS

A retrospective review of patients with femoral shaft fractures treated surgically from 2004 - 2017 at a tertiary pediatric hospital was conducted. Electronic medical records were reviewed for fixation method, additional injuries, blood loss (estimated blood loss (EBL), hemoglobin, hematocrit) and transfusion. The relationship between fixation method with blood loss and transfusion was examined. Two groups were compared, those with and without additional injuries. Additional injuries were defined as additional fractures and/or abdominal, chest, or head injuries.

RESULTS

172 patients met inclusion criteria. There were 129 patients with isolated femoral shaft fractures and 43 patients with femoral shaft fractures and concomitant additional injuries. The transfusion rate in patients with isolated femoral shaft fractures was 0.8% (1/129) which was significantly lower than in patients with additional injuries; 39.5% (17/43) (p < 0.05). In patients with additional injuries, there was a significant relationship between number of additional surgeries and odds of transfusion (OR=2.1, CI: 1.2-3.6, p < 0.05). In patients with isolated femoral shaft fractures, EBL was higher in patients treated with rigid intramedullary nails (148.5 ± 119.0 mL) than flexible intramedullary nails (34.1 ± 56.3 mL) (p < 0.05). However, there was no significant difference in transfusion or changes in hemoglobin/hematocrit between fixation methods in patients with isolated femoral shaft fractures.

CONCLUSION

Pediatric patients with surgically treated isolated femoral shaft fractures rarely require transfusion (<1%), while patients with femoral shaft fractures and additional injuries had a high transfusion rate (39.5%). Surgical fixation method had a significant impact on EBL, with rigid intramedullary nail fixation having a significantly higher EBL than flexible intramedullary nails, however it did not lead to higher rates of transfusions. Blood transfusions are rarely needed in isolated femoral shaft fractures, despite the trend towards increase in surgical fixation and newer fixation techniques.

Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database

Demand and cost of total knee arthroplasty (TKA) has increased significantly over the past decade resulting in decreased hospital length of stay (LOS) to counterbalance increasing cost of health care. The purpose of this study was to determine the factors that influence LOS following primary TKA. Discharge data from the 2009-2011 Nationwide Inpatient Sample were used. Patients included underwent primary TKA and were grouped based on LOS; 3 days or less, and 4 days or more. Majority of patients had a hospital LOS of 3 or less (74.8%). The most significant predictors of increased hospital LOS (≥ 4 days) were age ≥ 80 years, Hispanic race, Medicaid payer status, lower median household income, weekend admission, rural non-teaching hospital, discharge to another facility and any complication.

Inpatient mortality after primary total hip arthroplasty: analysis from the National Inpatient Sample database

Although inpatient mortality rates following total hip arthroplasty are low, understanding factors that influence inpatient mortality rates is important. Discharge data from the 2007-2008 HCUP Nationwide Inpatient Sample database were used in this study. Patients were identified based on whether they were admitted for a primary total hip arthroplasty and grouped based on their mortality status. All hip and acetabular fracture patients were excluded. Discharge data revealed 508,150 primary total hip arthroplasties with an inpatient mortality rate of 0.13%. The most significant pre-operative predictors of inpatient mortality were increasing age, weekend admission, increased Charlson co-mobidity score, Medicare payer status, race and a Southern hospital region. The two most significant complications post-operatively leading to increased mortality were pulmonary and cardiovascular complications.

Relationship between bone bruise volume and the presence of meniscal tears in acute anterior cruciate ligament rupture

PURPOSE

To determine whether there is a relationship between the size of the bone bruise volume after an acute anterior cruciate ligament (ACL) rupture and the presence of meniscal tears in the medial and lateral compartment.

METHODS

Following Institutional Review Board approval, 50 patients with an acute ACL rupture and MRI imaging within 30 days of injury were identified. Two musculoskeletal radiologists evaluated the lateral and medial menisci and graded them as one of the following: no meniscal tear, tear of one meniscus (medial or lateral) or tear of both menisci (medial and lateral). Sagittal T2 fat-suppressed images were used to calculate bone bruise volume. The relationship between bone bruise volume and the presence of a meniscus tear was calculated.

RESULTS

Forty-three (86%) patients had a bone bruise, 16 (32%) patients had no tear, 7 (14%) patients had lateral meniscus tear, 13 (26%) patients had medial tear and 14 (28%) patients had medial and lateral tears. There was a statistically significant difference in femoral bone bruise volume when comparing no meniscal tear to medial and lateral tears as well as when comparing medial or lateral tears to medial and lateral tears.

CONCLUSION

There is a statistically significant relationship between femoral bone bruise volume and the presence of meniscal tears in ACL injury, especially in the setting of medial and lateral pathology.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

The impact of tort reform and quality improvements on medical liability claims: a tale of 2 States

The purpose of this study was to determine the effect of tort reform and quality improvement measures on medical liability claims in 2 groups of hospitals within the same multihospital organization: one in Texas, which implemented medical liability tort reform caps on noneconomic damages in 2003, and one in Louisiana, which did not undergo significant tort reform during the same time period. Significant reduction in medical liability claims per quarter in Texas was found after tort reform implementation (7.27 to 1.4; P<.05). A significant correlation was found between the increase in mean Centers for Medicare & Medicaid Services performance score and the decrease in the frequency of claims observed in Louisiana (P<.05). Although tort reform caps on noneconomic damages in Texas caused the largest initial decrease, increasing quality improvement measures without increasing financial burden also decreased liability claims in Louisiana. Uniquely, this study showed that increasing patient quality resulted in decreased medical liability claims.

Advances in acetabular osteolysis: biomarkers, imaging, and pharmacologic management

Acetabular osteolysis can be difficult to diagnose because patients often have no clinical symptoms even when there is substantial bone loss. Ideally, early detection would lead to early interventions. Imaging continues to be the frontline modality for the early detection of acetabular osteolysis. Although plain radiography is the current imaging modality most commonly used in routine follow-up examinations, its low sensitivity limits its usefulness. CT and MRI have proven to be better imaging modalities for the early detection of osteolysis; however, their use is limited by cost, radiation exposure, and time. Biomarkers hold promise for the early detection of osteolysis; however, their efficacy requires more rigorous research for validation. Early diagnosis and treatment of osteolysis may lead to better outcomes for patients.

Correlation between femoral tunnel length and tunnel position in ACL reconstruction

BACKGROUND

The position of the femoral tunnel affects the osseous geometry available for drilling during anterior cruciate ligament (ACL) reconstruction. The length of the tunnel changes with changes in the tunnel position and may have implications for femoral fixation.

METHODS

Forty-seven patients with a single-bundle ACL reconstruction underwent computed tomography (CT) evaluation to generate three-dimensional (3D) CT bone models. With use of a previously described anatomic coordinate system, the center of the femoral tunnel was quantified in the posterior-anterior and proximal-distal dimensions on 3D CT. Tunnel length was defined as the distance between the centers of the intra-articular and extra-articular tunnel apertures. The reconstructed knees were dichotomized by anatomy and technique into anatomic (n = 20) and nonanatomic (n = 27) groups as well as according to whether they had undergone medial portal drilling (n = 20) or transtibial drilling (n = 27) for analysis. In addition, a review of the literature on the relationship between tunnel length and tendon-to-bone healing was performed.

RESULTS

Femoral tunnels drilled with nonanatomic footprints were longer (mean [and standard deviation], 43.6 ± 8.5 mm; range, 28.2 to 60.7 mm) than tunnels drilled with anatomic footprints (31.0 ± 6.3 mm; 21.2 to 42.5 mm) (p &lt; 0.001). Tunnels drilled transtibially (44.4 ± 7.6 mm; 32.5 to 60.7 mm) were significantly longer than tunnels drilled through the medial portal (29.8 ± 5.0 mm; 21.2 to 40.3 mm) (p &lt; 0.001). There was a strong correlation between tunnel length and posterior-anterior femoral tunnel position (r = 0.78, p &lt; 0.05), with more anterior tunnel positioning associated with greater tunnel length. There was no correlation between posterior-distal femoral tunnel position and tunnel length (r = -0.05; p = 0.74). There was no consensus in the literature regarding adequate tunnel length for biologic fixation.

CONCLUSIONS

Femoral tunnels drilled with anatomic footprints had sufficient length for adequate femoral fixation. Femoral tunnels positioned anterior to the native insertion of the ACL were longer than those in anatomic position.

CLINICAL RELEVANCE

The results of this study can help the surgeon to consider the relationship between tunnel position and subsequent tunnel length in ACL reconstruction.

Patient demographics and risk factors in pediatric distal humeral supracondylar fractures

The literature on distal humeral supracondylar fractures does not systematically define relationships between patient characteristics and the severity or complications of these injuries. This study evaluated age, sex, height, and body mass index (BMI) in relation to fracture severity and posttreatment complications in a pediatric population. The medical records of 382 pediatric patients treated for distal humeral supracondylar fractures over a 5-year period at 1 institution were included. Variables included age, sex, height, weight, injury mechanism, fracture severity (Gartland Classification), treatment, follow-up duration, and treatment complications. Body mass index and BMI-for-age percentile were calculated. Descriptive statistics with univariate analyses and logistic regression analysis with odds ratios and 95% confidence intervals were used. Children sustaining Gartland type 3 fractures were significantly older and taller than those sustaining Gartland type 1 and 2 fractures. No significant difference existed in fracture occurrence between boys and girls. Fracture severity did not differ significantly due to sex, BMI, or BMI-for-age percentile. Severe fractures were associated with increased posttreatment complications. Complication rates did not vary significantly by age, sex, height, BMI, or BMI-for-age. Taller children aged 5 to 6 years were at the greatest risk for Gartland type 3 distal humeral supracondylar fractures. Severe fractures are associated with an increased complication risk. Sex, BMI, and BMI-for-age percentile had no effect on fracture severity or complication rates.

WITHDRAWN: Inpatient Mortality After Primary Total Hip Arthroplasty: Analysis From The National Inpatient Sample Database

This article has been withdrawn at the request of the author(s). The Publisher apologizes for any inconvenience this may cause. The full Elsevier policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Review of periprosthetic osteolysis in total joint arthroplasty: an emphasis on host factors and future directions

Periprosthetic osteolysis is one of the leading causes of total joint revision procedures. If allowed to progress in the absence of radiographic diagnosis and/or proper medical treatment, osteolysis may result in aseptic loosening yielding failure of the implant and the need for complex revision arthroplasty. The purpose of this review was to assess the current understanding of periprosthetic osteolysis with an emphasis on host factors and future directions. A PubMed search was conducted using the following key words; osteolysis, periprosthetic osteolysis, osteolysis imaging. Pertinent articles, as it pertained to the outline of the review, were selected. Periprosthetic osteolysis stems from numerous risk factors. Osteolysis host characteristic risk factors include gender, body weight, and genetics. Current implant designs have reduced the incidence of this disease; however no current design has been able to replicate the in vivo characteristics and therefore development of wear particles continues to be seen. Advanced methods of imaging diagnosis are on the rise, however early imaging diagnosis is currently ineffective. Pharmacologic intervention appears to be a logical avenue for medical intervention, but no approved drug therapy to prevent or inhibit periprosthetic osteolysis is currently available. Although the rate of periprosthetic osteolysis seems to be decreasing with advances in implant design and increased knowledge of the biological process of wear particle induced osteolysis, the rapid increase in the total number of total joint arthroplasties over the next two decades means that better ways of detecting and treating periprosthetic osteolysis are greatly needed.

Effect of social media in health care and orthopedic surgery

With the growth of social media platforms, their potential to affect health care, and orthopedics specifically, continues to expand. We reviewed the literature to obtain all pertinent information on social media in health care and examined its strengths and weaknesses from patient and physician perspectives. Health care professionals have slowly begun to use social media to stay connected with patients. The recent use of networking sites aims to improve education, provide a forum to discuss relevant medical topics, and allow for improved patient care. The use of social media, with the understanding of its limitations, may help promote patient happiness and safety and serve as an educational platform.

Medial portal drilling: effects on the femoral tunnel aperture morphology during anterior cruciate ligament reconstruction

BACKGROUND

A goal of anatomic anterior cruciate ligament (ACL) reconstruction should be to create a femoral tunnel aperture that resembles the native attachment site in terms of size and orientation. Aperture morphology varies as a function of the drill-bit diameter, the angle in the horizontal plane at which the drilled tunnel intersects the lateral notch wall (transverse drill angle), and the angle of knee flexion in the vertical plane during drilling.

METHODS

A literature search was conducted to determine population-based dimensions of the femoral ACL footprint. The tunnel aperture length, width, and area associated with the use of different drill-bit diameters and transverse drill angles were calculated. The effect of the knee flexion angle on the orientation (anteroposterior and proximodistal dimension) and size of the femoral tunnel aperture relative to the native femoral insertion of the ACL were calculated with use of geometric mathematical models.

RESULTS

The literature search revealed an average femoral insertion site size of 8.9 mm for width, 16.3 mm for length, and 136.0 mm2 for area. The use of a 9-mm drill bit at a transverse drill angle of 40° resulted in a tunnel aperture area of 99.0 mm2 and a tunnel aperture length of 14.0 mm. Decreasing the transverse drill angle from 60° to 20° led to an increase of 152.9% in length and of 153.1% in tunnel aperture area. When a 9-mm drill bit and a transverse drill angle of 40° were used, the aperture seemed to best match the native ACL footprint when drilling was performed at a knee flexion angle of 102°; deviations from this angle in either direction resulted in increasing tunnel area mismatch compared with the baseline aperture. Increasing the knee flexion angle to 130° decreased the proximodistal dimension of the aperture by 2.78 mm and increased the anteroposterior distance by 0.65 mm, creating a mismatched area of 13.5%.

CONCLUSIONS

The drill-bit diameter, transverse drill angle, and knee flexion angle can all affect femoral tunnel aperture morphology in medial portal drilling during ACL reconstruction. The relationship between drilling orientation and aperture morphology is critical knowledge for surgeons performing ACL reconstruction.