Preference Signaling Survey of Program Directors-After the Match

INTRODUCTION

The 2022 to 2023 orthopaedic residency cycle implemented a preference signaling program (PSP), allowing applicants to send "signals" to up to 30 programs to demonstrate their genuine interest. With the conclusion of the 2022 to 2023 cycle, the primary purpose of this study was to analyze program director (PD) perceptions of the PSP after the match cycle and provide a retrospective evaluation of the effects of the PSP on the orthopaedic resident selection process.

METHODS

A 21-question survey was distributed to 98 PDs (32.7% response rate). Contact information was obtained from a national database.

RESULTS

Most respondents (96.9%) participated in the American Orthopaedic Association's PSP. The majority (93.7%) view preference signaling as a positive change. Most PDs (56.2%) reported a decreased number in applications received compared with previous years. Receiving a preference signal was ranked among the most important factors in resident selection, and most PDs agreed that preference signaling should be used to screen applicants (84.4%) and differentiate similar applicants (96.8%). Moreover, 65.6% of PDs indicated that they would not rank or invite applicants to interview without a signal or completion of a formal away rotation. PDs report that in the 2022 to 2023 cycle, 98.5% of applicants who matched at their program had sent a preference signal.

DISCUSSION

Preference signaling was one of the most important factors assessed during its inaugural application cycle and is anticipated to remain a key tool for screening and differentiating candidates. Applicants should strategically select signal recipients to enhance their success in the match.

Autonomous Spinal Robotic System for Transforaminal Lumbar Epidural Injections: A Proof of Concept of Study

STUDY DESIGN

Phantom study.

OBJECTIVE

The aim of our study is to demonstrate in a proof-of-concept model whether the use of a marker less autonomous robotic controlled injection delivery system will increase accuracy in the lumbar spine.

METHODS

Ideal transforaminal epidural injection trajectories (bilateral L2/3, L3/4, L4/5, L5/S1 and S1) were planned out on a virtual pre-operative planning software by 1 experienced provider. Twenty transforaminal epidural injections were administered in a lumbar spine phantom model, 10 using a freehand procedure, and 10 using a marker less autonomous spinal robotic system. Procedural accuracy, defined as the difference between pre-operative planning and actual post-operative needle tip distance (mm) and angular orientation (degrees), were assessed between the freehand and robotic procedures.

RESULTS

Procedural accuracy for robotically placed transforaminal epidural injections was significantly higher with the difference in pre- and post-operative needle tip distance being 20.1 (±5.0) mm in the freehand procedure and 11.4 (±3.9) mm in the robotically placed procedure (P < .001). Needle tip precision for the freehand technique was 15.6 mm (26.3 - 10.7) compared to 10.1 mm (16.3 - 6.1) for the robotic technique. Differences in needle angular orientation deviation were 5.6 (±3.3) degrees in the robotically placed procedure and 12.0 (±4.8) degrees in the freehand procedure (P = .003).

CONCLUSION

The robotic system allowed for comparable placement of transforaminal epidural injections as a freehand technique by an experienced provider, with additional benefits of improved accuracy and precision.

Consensus-Based Best Practice Guidelines for the Management of Spinal Deformity and Associated Tumors in Pediatric Neurofibromatosis Type 1: Screening and Surveillance, Surgical Intervention, and Medical Therapy

BACKGROUND

Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1.

METHODS

Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs.

RESULTS

Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs.

CONCLUSION

We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Social Media Presence Is Associated With Diversity and Application Volume for Orthopedic Surgery Residency Programs

The purpose of this study was to assess the association between social media presence (Twitter and Instagram), diversity in orthopedic surgery residency programs, and the number of applications received by a program. Data from Twitter and Instagram for 179 orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education were collected, including the presence of a social media account, date of first post, number of posts, and number of followers. Residency program data were collected from the Association of American Medical Colleges Residency Explorer Tool and included percentage of Whiteresidents, percentage of male residents, residency ranking, and number of applications submitted during the 2019 application cycle. Bivariate and multivariable analyses were performed with adjustment for program ranking. Of 179 residency programs, 34.6% (n=62) had Twitter, and 16.7% (n=30) had Instagram. Overall, 39.7% (n=71) had a social media presence, defined as having at least one of the two forms of social media. Programs with social media presences had higher average rankings (48.1 vs 99.6 rank, P<.001). After adjusting for program ranking, social media presence was associated with increased applications during the 2019 application cycle (odds ratio [OR]=2.76, P=.010). Social media presence was associated with increased odds of gender diversity (OR=3.07, P=.047) and racial diversity (OR=2.21, P=.041). Individually, Twitter presence was associated with increased odds of gender (OR=4.81, P=.018) and racial diversity (OR=4.00, P=.021), but Instagram was not (P>.05). Social media presence is associated with more residency program applications and increased resident diversity. Social media can be used to highlight inclusivity measures and related opportunities. [Orthopedics. 2023;46(1):47-53.].

Rate of Tibiotalocalcaneal (TTC) Fusion Using the Surgical Implant Generation Network (SIGN) Intramedullary Nail in Developing Countries

Outcomes of the Surgical Implant Generation Network (SIGN) nail have been reported for femur and tibial fractures, but its use in tibiotalocalcaneal arthrodesis (TTCA) is not well studied. Radiographic and clinical outcomes of TTCA using the SIGN database in patients with > 6 months of radiographic follow up were analyzed. Rates of tibiotalar (TT) fusion and subtalar (ST) fusion at final follow up were assessed by two independent reviewers. Of the 62 patients identified, use of the SIGN nail for TCCA resulted in 53% rate of fusion in the TT joint and 20% in the ST joint. Thirty-seven patients (60%) demonstrated painless weight bearing at final follow up. There were no differences in incidence of painless weight bearing between consensus fused and not fused cohorts for TT and ST joints (p > 0.05). There were five implant failures, no cases of infection, and seven cases of reoperation. (Journal of Surgical Orthopaedic Advances 32(3):187-192, 2023).

Sacral-Alar-Iliac (SAI) Fixation in Patients With Previous Pelvic Osteotomy

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The purpose of this study was to investigate the technical challenges and outcomes of sacral-alar-iliac (SAI) fixation for scoliosis in patients who had previously undergone a pelvic osteotomy for hip dysplasia.

SUMMARY OF BACKGROUND DATA

Patients with neuromuscular disease are at high risk for developing hip dislocation and scoliosis. Surgical correction of one may affect the other.

METHODS

We reviewed the records of patients aged 18 years and below who underwent spinal fusion using SAI screws after having undergone a pelvic osteotomy, with ≥2-year follow-up. We recorded the SAI screw dimensions, time from osteotomy to SAI fixation, type of osteotomy, and any complications performing SAI fixation due to the pelvic osteotomy. Bivariate statistics were used to analyze the data with statistical significance defined as P -value <0.05.

RESULTS

Thirty-two patients were included. The average age was 10.3±3.2 years at pelvic osteotomy and 13.5±3.4 years at SAI fixation. Most patients had cerebral palsy (87.5%) and a unilateral Dega osteotomy (78.1%). Average screw dimensions were significantly shorter on the side of the osteotomy (66 vs. 72 mm, P <0.05). SAI screw placement was technically challenging in 8 patients (25%), due to pelvic distortion from the pelvic osteotomy. The use of a curved awl helped to find the intracortical channel. No patients had complications due to the SAI screw, and there were no significant differences in pelvic obliquity and major coronal curve correction. Two patients (6.3%) had screw lucency >2 mm around the SAI screw on the side of the pelvic osteotomy but no clinical symptoms.

CONCLUSIONS

SAI fixation in patients with previous pelvic osteotomy is technically challenging due to pelvic morphology and prior implants. Often, a shorter SAI screw is required on the side of the osteotomy. However, outcomes in this patient population are satisfactory, with no significant complications at a 2-year follow-up.

LEVEL OF EVIDENCE

Level IV.

Pelvic Osteotomy in Patients With Previous Sacral-Alar-Iliac (SAI) Fixation

INTRODUCTION

Patients with neuromuscular disease are at high risk for developing hip dysplasia and scoliosis. The purpose of this study was to investigate the technical challenges and outcomes of pelvic osteotomy in patients with prior sacral-alar-iliac (SAI) fixation.

METHODS

We reviewed clinical and radiographic records of patients aged 18 years and below who underwent pelvic osteotomy after SAI fixation. We recorded technical challenges during the osteotomy, time from SAI fixation to osteotomy, type of osteotomy, migration index, and distance from the SAI screw to the acetabulum. A 2-sample Wilcoxon rank-sum test was used to assess the data.

RESULTS

Nineteen patients were included. Technical challenges were defined as having greater intraoperative fluoroscopy times and noted difficult osteotomy in the operative report. The mean time from SAI fixation to pelvic osteotomy was 2.2±1.5 years. For all 12 Chiari osteotomies, the ilium could not be laterally displaced; however, medial displacement of the distal segment of the osteotomy allowed adequate coverage. All 7 Dega osteotomies were performed by cutting the cortex at the tip of the SAI screw. The screw improved proximal leverage and provided a strong buttress for bone graft. The mean migration index before pelvic osteotomy was 59±19%, and at most recent follow-up was 13±4%. Twelve patients, who had a noted complicated osteotomy, had SAI screws that were ≤1.87 cm ( P <0.01) from the acetabulum and significantly increased intraoperative fluoroscopy time (1.76 vs. 1.18 min, P <0.01).

CONCLUSIONS

The presence of SAI screws may cause iliac osteotomies to be technically challenging if the tip of the SAI screw is ≤1.87 cm to the acetabulum. When initially implanting SAI screws in neuromuscular patients, surgeons should attempt to place screw tips ∼2 cm from the acetabulum in the event these patients require subsequent pelvic osteotomy.

LEVEL OF EVIDENCE

Level IV.

Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up

INTRODUCTION

Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up.

METHODS

We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections.

RESULTS

Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications.

CONCLUSIONS

SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time.

LEVEL OF EVIDENCE

Level IV.

Can magnetically controlled growing rods be successfully salvaged after deep surgical site infection?

PURPOSE

The purpose is to compare the rate of recurrent deep wound infection in patients who retained MCGRs versus those who underwent implant removal and exchange following index deep wound infection.

METHODS

Using a multicenter registry, we identified patients with EOS who underwent surgical correction with MCGR. We defined deep SSI as any infection that required subsequent I&D and antibiotic therapy. Recurrent infection was defined as any additional deep SSI following treatment of index deep infection. We considered MCGR to be salvaged if implant exchange or removal was not performed for at least 1 year following date of infection. Bivariate statistical analyses were performed.

RESULTS

992 EOS patients were identified, of whom 33 (3.3%) developed deep SSI. The mean time between initial surgery and first deep SSI was 13.1 months (Interquartile range [IQR]: 1 to 25 months. Infection rates by EOS diagnosis were as follows: 13/354 patients (3.6%) had neuromuscular scoliosis (NMS), 9/225 (4.0%) syndromic, 6/248 (2.4%) idiopathic, 3/135 congenital (2.2%), and 2/30 (6.6%) unknown etiology. MCGR was salvaged in 69% of NMS patients, 77% of syndromic patients, 100% of congenital patients, and 83% of idiopathic patients (83%). There were only four recurrent infections (2/13 NMS, 2/9 syndromic) and no differences in rates of recurrent infection between salvaged or replaced/exchanged MCGR. (p = 0.97).

CONCLUSION

Deep wound infection occurred in 3% of MCGR patients at a mean of 13.1 months. There were no significant differences in rates of recurrent infection between salvaged implants and those removed or exchanged.

Hexokinase 1 cellular localization regulates the metabolic fate of glucose

The product of hexokinase (HK) enzymes, glucose-6-phosphate, can be metabolized through glycolysis or directed to alternative metabolic routes, such as the pentose phosphate pathway (PPP) to generate anabolic intermediates. HK1 contains an N-terminal mitochondrial binding domain (MBD), but its physiologic significance remains unclear. To elucidate the effect of HK1 mitochondrial dissociation on cellular metabolism, we generated mice lacking the HK1 MBD (ΔE1HK1). These mice produced a hyper-inflammatory response when challenged with lipopolysaccharide. Additionally, there was decreased glucose flux below the level of GAPDH and increased upstream flux through the PPP. The glycolytic block below GAPDH is mediated by the binding of cytosolic HK1 with S100A8/A9, resulting in GAPDH nitrosylation through iNOS. Additionally, human and mouse macrophages from conditions of low-grade inflammation, such as aging and diabetes, displayed increased cytosolic HK1 and reduced GAPDH activity. Our data indicate that HK1 mitochondrial binding alters glucose metabolism through regulation of GAPDH.

Connective Tissue Disease Patients Maintain Greater Distraction During Growth Friendly Surgery

STUDY DESIGN

Multicenter retrospective study.

BACKGROUND

Recent studies have demonstrated diminishing returns in patients with early onset scoliosis (EOS) undergoing repeated lengthening of growing rods. Little is known about whether this same phenomenon occurs in patients with lax connective tissue disease (CTD). The primary purpose of this study is to investigate whether EOS patients with connective tissue laxity disorders have diminishing returns during growth friendly surgery.

METHODS

CTD EOS patients below 10 years old, underwent growth friendly spine surgery with distal anchors and at least 1 proximal spine anchor, and had minimum follow-up of 5 years were included in this study. Coronal T1-S1 height at preindex surgery, postindex, and every available lengthening was assessed. Mean coronal height change during early set distractions and late set distractions were calculated for the cohort. To account for varying distraction intervals, we normalized the distractions by the time interval. The outcome parameter was T1-S1 height gain, mm/year.

RESULTS

Twenty-one CTD patients were included in this study. Total coronal height (T1-S1) was 26.7MHCcm before index, 32.2 cm at D1-D3, 34.7 cm at D4-D6, and 36.7 cm at D7-L10. There were no significant differences in coronal height gains between early and late distractions (P=0.70). Moreover, when normalized for time, there was no significant difference in net gain per year at different lengthening time points for the CTD group, P=0.59.

CONCLUSION

There is no evidence of diminishing returns in coronal T1-S1 height gain in patients with EOS in the setting of CTD.

LEVEL OF EVIDENCE

Level III.

Scoliosis in Pediatric Patients With Acute Flaccid Myelitis

BACKGROUND

Acute flaccid myelitis (AFM) is an anterior horn disorder that manifests as rapid onset muscle weakness or paralysis. Development of scoliosis in pediatric AFM patients has been anecdotally reported, but associated risk factors or incidence have yet to be determined.

METHODS

Pediatric AFM patients treated over a 10-year period at a tertiary care center were identified. Patients were considered to have scoliosis if there was radiographic evidence of coronal curvature ≥15 degrees. Number of limbs affected, independent ambulation and head control, ventilator requirement at initial admission, and long-term ventilatory support (≥1 year) were recorded. Muscle strength and functional status were assessed by manual muscle testing (MMT) and Physical Abilities and Mobility Scale (PAMS), respectively. Areas of spinal cord lesion on initial MRI were recorded. Bivariate analyses were performed, with alpha set to 0.05.

RESULTS

Fifty-six AFM patients (27 scoliosis, 29 no scoliosis) were identified. Mean time from AFM presentation to scoliosis diagnosis was 0.93 years. Mean major Cobb angle at first radiograph was 31.7 ± 14.3 degrees. Lack of independent ambulation, ventilator dependence at time of admission or long term, number of limbs affected, and decreased MMT and PAMS scores were more common in patients who developed scoliosis (all, p < .05). Patients who developed scoliosis had more extensive thoracic spinal cord involvement on initial MRI (p = .03).

CONCLUSION

AFM patients who develop scoliosis are more likely to be ventilator dependent, lack independent ambulation, and have more extensive thoracic SCI.

Spine Surgery and Preoperative Hemoglobin, Hematocrit, and Hemoglobin A1c: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Synthesize previous studies evaluating clinical utility of preoperative Hb/Hct and HbA1c in patients undergoing common spinal procedures: anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), posterior lumbar fusion (PLF), and lumbar decompression (LD).

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on preoperative Hb/Hct and HbA1c and post-operative outcomes in adult patients undergoing ACDF, PCF, PLF, or LD surgeries.

RESULTS

Total of 4,307 publications were assessed. Twenty-one articles met inclusion criteria.

PCF AND ACDF

Decreased preoperative Hb/Hct were significant predictors of increased postoperative morbidity, including return to operating room, pulmonary complications, transfusions, and increased length of stay (LOS). For increased HbA1c, there was significant increase in risk of postoperative infection and cost of hospital stay.

PLF

Decreased Hb/Hct was reported to be associated with increased risk of postoperative cardiac events, blood transfusion, and increased LOS. Elevated HbA1c was associated with increased risk of infection as well as higher visual analogue scores (VAS) and Oswestry disability index (ODI) scores.

LD

LOS and total episode of care cost were increased in patients with preoperative HbA1c elevation.

CONCLUSION

In adult patients undergoing spine surgery, preoperative Hb/Hct are clinically useful predictors for postoperative complications, transfusion rates, and LOS, and HbA1c is predictive for postoperative infection and functional outcomes. Using Hct values <35-38% and HbA1c >6.5%-6.9% for identifying patients at higher risk of postoperative complications is most supported by the literature. We recommend obtaining these labs as part of routine pre-operative risk stratification.

LEVEL OF EVIDENCE

III.

Progress in Cheerleading Safety: Update on the Epidemiology of Cheerleading Injuries Presenting to US Emergency Departments, 2010-2019

Background

Although the athleticism required of cheerleaders has increased, the risks of cheerleading have been less studied as compared with other sports.

Purpose

To update our understanding of the epidemiology of cheerleading-related injuries.

Study Design

Descriptive epidemiology study.

Methods

We analyzed the National Electronic Injury Surveillance System (NEISS) for cheerleading-related injuries presenting to nationally representative emergency departments (EDs) in the United States from January 2010 through December 2019. Extracted data included patient age and sex, injury characteristics (diagnosis, body region injured, time of year, and location where injury occurred), and hospital disposition. Using patient narratives, we recorded the cheerleading skills, settings, and mechanisms that led to injury. NEISS sample weights were used to derive national estimates (NEs) from actual case numbers.

Results

From 2010 to 2019, a total of 9868 athletes (NE = 350,000; 95% CI, 250,000-450,000) aged 5-25 years presented to US EDs for cheerleading injuries. The annual number of injuries decreased by 15%, from 982 (NE = 35,000; 95% CI, 27,000-44,000) to 897 (NE = 30,000; 95% CI, 18,000-42,000) (P = .048), corresponding to a 27% decline in the injury rate per 100,000 cheerleaders (P < .01). The annual number of injuries caused by performing stunts decreased by 24%, from 240 (NE = 8700; 95% CI, 6700-11,000) to 216 (NE = 6600; 95% CI, 4000-9200) (P = .01), with a 36% decline in the corresponding injury rate per 100,000 cheerleaders (P < .01). Despite these decreases, annual incidence of concussions/closed head injuries increased by 44%, from 128 (NE = 3800; 95% CI, 2900-4700) to 171 (NE = 5500; 95% CI, 3400-7700) (P = .02), and patients requiring hospital admission increased by 118%, from 18 (NE = 330; 95% CI, 250-410) to 24 (NE = 720; 95% CI, 440-1000) (P < .01). The hospital admission rate increased by 9.0% (P = .02).

Conclusion

The number of cheerleading-related injuries presenting to US EDs decreased from 2010 to 2019. However, the incidence of concussions/closed head injuries and hospital admissions increased, suggesting that further measures are needed to improve safety for cheerleaders.

Preoperative Hyponatremia is an Independent Risk Factor for Prolonged Hospital Stay Following Anterior Cervical Discectomy and Fusion

OBJECTIVE

To determine the effects of preoperative hyponatremia on short-term postoperative complications and healthcare utilization (length of stay, readmissions) following anterior cervical fusion and discectomy (ACDF).

METHODS

Patients who underwent ACDF were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients who had revision surgery, trauma, vertebral malignancy, or infection were excluded. Eunatremia was defined as sodium (Na) level between 135 and 145 mEq/L, whereas hyponatremia was defined as Na < 135 mEq/L. Preoperatively hyponatremic patients were matched 1:1 with eunatremic patients using propensity-score matching based upon age, gender, American Society of Anesthesiology (ASA) score, and baseline comorbidities. Minor adverse events included superficial infection, dehiscence, urinary tract infection, pneumonia, and renal insufficiency or failure. Serious adverse events included deep wound infection, reintubation, pulmonary embolism, cerebrovascular accident, cardiac arrest, deep vein thrombosis, sepsis, return to operating room, and death within 30 days. Complications were analyzed using bivariate and logistic analysis with significance set at p<0.05.

RESULTS

Of the 9,094 patients undergoing ACDF, 3.64% (331 patients) were preoperatively hyponatremic. Preoperative hyponatremia was an independent risk factor for postoperative pneumonia following ACDF (OR=4.47; p=0.020) as well as extended length of hospital stay greater than one standard deviation above the mean (OR=1.71; p=0.042). Preoperative hyponatremia was an independent risk factor for having a serious adverse event (OR=2.40; p=0.005), as well as any adverse event (OR=2.44; p=0.009).

CONCLUSION

Preoperative hyponatremia is an independent risk factor for pneumonia and prolonged length of stay following ACDF.

Spinal Fusion with Sacral Alar Iliac Pelvic Fixation in Severe Neuromuscular Scoliosis

Neuromuscular scoliosis is characterized by rapid progression of curvature during growth and may continue to progress following skeletal maturity. Posterior spinal fusion in patients with cerebral palsy and severe scoliosis results in substantial improvements in health-related quality of life¹. Correction of pelvic obliquity can greatly improve sitting balance, reduce pain, and decrease skin breakdown. The sacral alar iliac (SAI) technique has key advantages over prior techniques, including the Galveston and iliac-screw techniques. The SAI technique eliminates the need for subcutaneous muscle dissection over the iliac crest, does not require the use of connectors from the rod to the iliac screw, and decreases the risk of implant prominence².

Description

We demonstrate how to perform posterior spinal fusion with SAI pelvic fixation in a patient with cerebral palsy. In correcting the scoliosis, we utilize the segmental 3-dimensional technique, which includes compression, distraction, transverse approximation to 1 rod at a time, and derotation around 2 rods. We also demonstrate SAI pelvic fixation with identification of the screw starting point on the lateral-caudal border of the first sacral foramen and trajectory toward the anterior inferior iliac spine.

Alternatives

Nonoperative alternatives include bracing, trunk support, contouring of sitting surfaces (such as wheelchairs), and physical therapy to slow curve progression during growth periods and delay the need for surgical treatment^3,4. Decision-making is shared with the family following education about the risks and benefits. Families who are satisfied with the function of the child at baseline should not be persuaded into pursuing surgical treatment.

Rationale

Neuromuscular scoliosis can include difficulty sitting secondary to increased pelvic obliquity, along with poor trunk control and balance. Surgical intervention is considered in patients with curves exceeding approximately 50°, as these curves will often continue to progress even after maturity⁵. In patients with neuromuscular scoliosis, indications for pelvic fixation include pelvic obliquity of >15°, poor control of the trunk as indicated by lack of independent sitting or standing, and location of the apex of the curve in the lumbar spine. SAI screws are utilized as a low-profile option for pelvic fixation to avoid implant prominence and an increased risk of skin breakdown and infection, which are associated with traditional sacroiliac screws^2,6.

Expected Outcomes

Miyanji et al. reported quality outcomes in patients with cerebral palsy and Gross Motor Function Classification Scores of ≥4¹. In that study, caregivers completed a validated disease-specific questionnaire grading the health-related quality of life of the patient preoperatively and at 1, 2, and 5 years postoperatively. Complication data were prospectively collected for each patient and preoperative outcome scores were compared at each of the postoperative time points. Survey scores at 1, 2, and 5 years postoperatively were significantly higher compared with baseline preoperative values.Sponseller et al. compared the 2-year postoperative radiographic parameters of 32 pediatric patients who underwent SAI fixation and 27 patients who underwent pelvic fixation with the sacroiliac technique². Among patients who underwent SAI fixation, the mean correction of pelvic obliquity was 20° ± 11° (70% correction) and the mean Cobb angle 42° ± 25° (67%). Among patients who underwent pelvic fixation with the sacroiliac technique, those values were 10° ± 9° (50%) and 46° ± 16° (60%), respectively. SAI screws provided significantly better pelvic obliquity correction (p = 0.002) but no difference in Cobb correction or complications compared with other traditional techniques.

Important Tips

Family discussion prior to surgical treatment is paramount.Perform preoperative neurologic examination⁷.Examine the cranium carefully for a ventriculoperitoneal shunt or prior cranial reconstruction prior to cranial traction.Transcranial neuromonitoring may be useful. Use descending neural motor evoked potentials when no signals from transcranial monitoring are obtained⁸.Sink the SAI screw until it lines up with the S1 screw. Bury the SAI screw so it is not prominent.Measure rods longer in order to ensure adequate length for compression and distraction in correction of the pelvic obliquity.Use a T-square to verify adequate spinopelvic alignment⁹.Postoperatively, the use of incisional vacuum-assisted closure can decrease soiling in these patients.

Acronyms and Abbreviations

SAI = Sacral alar iliacCP = Cerebral palsyAIS = Adolescent idiopathic scoliosisSMA = Spinal muscular atrophyIONM = Intraoperative neuromonitoringGMFCS = Gross Motor Functional Classification SystemDNMEP = Descending neural motor evoked potentialTXA = Tranexamic acidFFP = Fresh frozen plasmaASIS = Anterior superior iliac spineAIIS = Anterior inferior iliac spinePJK = Proximal junctional kyphosis.

Patient-reported outcomes after operative versus nonoperative treatment of pediatric lateral humeral condyle fractures

Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires).We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (<2-mm displacement), moderate (isolated, 2- to 5-mm displacement), or severe (isolated, >5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05.No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P < .001). The overall complication rate for our cohort was low, with no differences by treatment type or fracture severity.In our cohort, patient-reported outcomes were similar across fracture severity categories, irrespective of treatment or fixation type. Patients who underwent internal fixation with cannulated screws experienced significantly higher rates of return to the operating room compared with those treated with Kirschner wires but otherwise had similar complication rates and patient-reported outcomes.Level of Evidence: 3.

Interlocking Fixation in Fassier-Duval Rods: Performance and Success Factors

INTRODUCTION

Pediatric patients with osteogenesis imperfecta (OI) can be treated with intramedullary Fassier-Duval rod (FDR) systems for limb deformity or recurrent fractures. Single-interlocking pins can improve epiphyseal fixation, but there is a paucity of literature examining incidence of rod migration or pin backout long-term. The purpose of this study is to quantify rates of rod migration and pin backout in OI patients treated with single-interlocking FDRs.

METHODS

A retrospective chart review was performed on pediatric patients treated at a tertiary care center across a 15-year period. Inclusion criteria to select patients was: (1) Pediatric patients (below 18 y of age); (2) Patients with confirmed OI; and (3) Patients with lower extremity fractures or deformity treated with FDRs with distal interlocking pins. Age at time of surgery, rates of obturator migration and pin backout and prominence were collected. We recorded if pin tips were bent by the surgeon during the procedure. Bivariate statistics were used to analyze risk factors for pin backout and prominence.

RESULTS

Twenty-four single-interlocking pin FDRs (21 tibia, 3 femur) were identified. The mean age at index surgery was 5.7±3.4 years, with the mean follow-up time of 7.2±4.7 years. Fourteen (58%) rods underwent revision surgery. Obturator proximal migration was observed in 3/24 rods (13%). No cases of obturator distal migration were observed (0/24, 0%). Mean proximal obturator migration was 2.16±1.8 cm. Revision for pin backout was observed in 10 (42%) rods and pin prominence in 11 (46%) extremities. Bending interlocking pins on at least 1 end was associated with decreased pin backout (P=0.01) and prominence (P=0.04).

CONCLUSIONS

Even with distal interlocking pins, the obturator of FDRs can still migrate over time. Pin backout is a common indication for revision surgery. Bending interlocking pins can decrease rates of pin backout and prominence.

LEVEL OF EVIDENCE

Level III.

Early-Onset Spinal Deformity in Neurofibromatosis Type 1: Natural History, Treatment, and Imaging Surveillance

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Early-onset scoliosis (EOS) or kyphosis is common in patients with neurofibromatosis (NF) and is characterized by rapid progression of deformity.

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Traditional growing rods provide good functional and deformity outcomes in patients with NF and EOS; magnetically controlled growing rods (MCGRs) also provide good deformity correction, although high rates of revision have been reported after their use.

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Among patients with NF type 1 (NF1), morphologic characteristics of the spinal deformity are different in those with paraspinal neurofibromas than in those without paraspinal tumors.

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Patients with NF1 are at low risk for developing malignant peripheral nerve sheath tumors during childhood (<1%) and their lifetime (8% to 12%), and routine imaging surveillance for malignancy in the absence of symptoms should be clinically directed.

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Further investigation is needed to standardize screening for EOS in children with NF1 and to develop guidelines for ideal imaging modalities, including their frequency and a timeline.

Surgical Treatment of Unstable Pelvic Ring Injury in a Young Child: A Case Report

CASE

We describe an anterior and posterior pelvic ring construct, with emphasis on the posterior construct, to treat a vertical displacement fracture in a 2-year-old girl who was struck by a motor vehicle. Eighteen months after her injury, radiographs showed intact sacroiliac joints and symmetrical pubic symphysis.

CONCLUSION

Although commonly performed in adults, pelvic fixation is challenging in children because of the small size of the child's pelvis and osseous fixation pathways. However, this approach enabled successful vertical stabilization of the pelvis, complete resolution of symphyseal diastasis, and recovery of function and mobility.

Traumatic bone cyst of an anterior mandible with previous symphyseal fracture in a pediatric patient: a rare finding and etiopathologic correlation

Traumatic bone cysts (TBCs) are uncommon intraosseous lesions, classified as pseudocysts because they lack an epithelial membrane lining. The etiology of a pseudocyst has not been determined. Various hypotheses have been put forward to explain its pathogenesis, of which the traumatic-hemorrhagic theory is the most commonly accepted. Minor trauma, insufficient to cause fracture or iatrogenic injury, is commonly implicated as the stimulus initiating cyst formation. A TBC presenting after jaw fracture has been rarely reported in the literature. This article presents a case of a TBC of the anterior mandible in a child with a previous history of trauma and fracture of the symphysis. The article also reviews the literature to corroborate the possible role of major trauma in the pathogenesis of TBC.

Follicular Adenomatoid Odontogenic Tumor in Mandible: A Rare Case Report

Adenomatoid odontogenic tumor (AOT) is a relatively rare, benign, hamartomatous, and cystic odontogenic neoplasm that was first described more than a century ago. The lesion still continues to intrigue experts with its varied histomorphology and controversies regarding its development. The present article describes a case of cystic AOT with an unusual histomorphology associated with an impacted 44 in a 21-year-old male.

Implementation of Oral Health Education to Orphan Children

OBJECTIVE

To determine the knowledge and oral hygiene status of orphanage children in Pune and changes in them after health education.

STUDY DESIGN

Interventional study.

PLACE AND DURATION OF STUDY

Centers for Orphan Children in Pune, India, from April to June 2014.

METHODOLOGY

A specially designed questionnaire was used to assess the dental problems and existing oral hygiene maintenance practice among children between 5 - 12 years of age (n=100) in an orphanage center. Pre- and postinterventional intra-oral examination was carried out to check their oral hygiene status which included DMFS [Decayed Missing Filled Tooth Surfaces index (for permanent teeth)], OHIS (Simplified Oral Hygiene Index) and gingival indices. Intervention was in the form of oral health education, demonstration of correct brushing technique, diet counselling and maintenance of overall oral hygiene.

RESULTS

Present study shows that the orphans had multiple dental problems along with improper oral hygiene practices and careless attitude towards oral health. Pre- and post-interventional DMFS was compared using Wilcoxon sign rank test, which was not significant; while OHIS and gingival indices were compared by using repeat measures ANOVA(p < 0.001) which was significant for each, respectively.

CONCLUSION

There was considerable improvement in the oral hygiene status of orphans due to educational intervention. Oral health education at right age can help to cultivate healthy oral hygiene practices in orphans which will benefit them for lifelong. Caretakers should be educated and trained about oral hygiene practices so that they can implement it and supervise the orphan children.

Enhancing the Dental Professional's Responsiveness Towards Domestic Violence; A Cross-Sectional Study

BACKGROUND

Dentists may be the first health care professionals to treat patients who have experienced Oro-facial trauma resulting from Domestic violence (DV). Hence, as a national health concern, it challenges the social responsibility of a dentist in bringing down its prevalence.

OBJECTIVE

To assess the knowledge of Domestic violence among dentists of Karnataka.

MATERIALS AND METHODS

A cross-sectional questionnaire survey was conducted among dentists of Karnataka to know their knowledge, its relation to dentistry and measures they practice to bring down the prevalence of DV victims.

RESULTS

Overall knowledge about DV was very less among the dentists & out of 64% who said the dentist has a role in bringing down the prevalence, 28% reported the need for training.

CONCLUSION

Based on analysis of the data, dentists were interested and would benefit from additional education opportunities concerning recognizing, referring and managing patients who may be the victim of domestic violence in order to enhance their role.

Psychosocial characteristics of oromucosal diseases in psychiatric patients: observational study from Indian dental college

Background:

Psychiatric diseases like anxiety, depression, schizophrenia and bipolar disorders can affect the mental and physical statuses of an individual.

Aim:

The study was to investigate the different oromucosal diseases (OMD) in psychiatric patients and to evaluate the correlation between these OMD to severity of anxiety and depression.

Materials and Methods:

A cross-sectional study was carried out during a six-month period. Patients reporting to psychiatry department with anxiety, depression, schizophrenia and bipolar disorder as diagnosed by an experienced psychiatrist, were subjected to complete oral examination by a skilled oral diagnostician to check for OMD like oral lichen planus (OLP), aphthous stomatitis (AS) and burning mouth syndrome (BMS). During the above mentioned time interval, 1320 patients with any of the above mentioned psychiatric diseases were included in this study. Of these, 278 had anxiety, 398 had depression, 295 had schizophrenia and 349 had bipolar disorder. Equal number of individuals reported to the Oral Medicine and Radiology department for routine oral screening with no mucosal diseases were included as control group.

Results:

In this study, statistically significant increase in the OMD of the psychiatric patients was recorded when compared with the control group. The OMD were significantly higher in patients with anxiety (20.86%) followed by patients with depression (9.04%), schizophrenia (7.7%), bipolar disorder (7.4%) and control group (5.17%), respectively. Most prevalent OMD in patients with anxiety was AS (12%) followed by OLP (5.7%), and BMS (2.87%) respectively. Patients with moderate to severe anxiety and depression showed significantly higher prevalence of these OMD compared to the ones with mild anxiety and depression. The AS and OLP were significantly more in the younger age group (18-49 year) and BMS was higher in 50-77 year age group in both the study and control groups.

Conclusion:

A positive association was established between psychological alterations and OMD. Emotional alterations may act as a precipitating factor that could influence the initiation and development of different OMD. Hence, better harmonization is essential between dentist and psychiatrists for comprehensive management of psychosomatic disorders of the oral mucosa.