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Background: There has been an increase in posterior-based interbody fusions over the past two decades. Our objective was to evaluate trends in interbody fusion use among the American Board of Orthopedic Surgery (ABOS) Part II candidates. Methods: The ABOS database from 2003 to 2012 was queried for common procedural terminology (CPT) codes indicating lumbar interbody fusion (22,558 anterior lumbar interbody fusion [ALIF] and 22,630 and 22,633 posterior lumbar interbody fusion [PLIF] or transforaminal lumbar interbody fusion [TLIF]). Trends in the use of interbody fusion technique, associated complications, and geographical variation were evaluated. We also queried utilization of the anterior and posterior interbody fusions by the International Classification of Diseases-9 code. Results: 6841 interbody fusion cases were identified (2329 ALIF and 4512 PLIF/TLIF). There was a significantly higher use of PLIF/TLIF than ALIF over the study period (P < 0.001). As compared to patients in the Midwest, those in the Northwest had significantly higher odds of undergoing PLIF/TLIF (odds ratio [OR]: 4.79, 95% confidence interval [CI]: 3.61-6.35, P <0.001), and those in the Southwest had significantly lower odds of PLIF/TLIF (OR: 0.81, 95% CI: 0.69-0.95, P = 0.01). The overall complication rate was 22.2% (n = 1,519). Vascular-related complications were significantly higher among patients undergoing ALIF (31 vs. 1, P <0.001), while those undergoing TLIF/PLIF were more likely to experience unspecified medical complications. On multivariate analysis, patients undergoing PLIF/TLIF had lower odds of experiencing a complication (P = 0.03, OR 0.87, CI 95%). Conclusion: Over the 10-year study period, there has been a significantly increased rate of posterior interbody fusion among candidates taking part II ABOS examination.

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Rotator cuff tears with anterior cable disruption show a more detrimental natural history than tears with an intact cable. Anterior cable reconstruction in the setting of such tears provides a potential avenue to improve tissue quality of the repaired construct and enhance repair longevity. Cadaveric studies investigating anterior cable reconstruction have shown biomechanical advantages. We present an arthroscopic surgical technique for rotator cuff anterior cable reconstruction using long head of the biceps tendon autograft in the setting of repairable large-to-massive rotator cuff tears with poor anterior cable tissue quality.

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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To identify prevalence of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine in a large sample, to characterize spinal involvement, and to identify associations with patient characteristics. METHODS: Computed tomography (CT) scans of all patients receiving cervical spine CT imaging in a level-1 emergency department from January 1, 2014 to December 31, 2014 were reviewed. Diagnosis and classification of OPLL was performed, and data for associated patients was obtained (age, sex, race, ethnicity, body mass index, diabetes). US Census data was referenced for the sample population. Statistical analysis included t test and chi-square testing, with significance cutoff P < .05. RESULTS: There were no significant differences between the sample and population data. Of 2917 patients reviewed, 74 exhibited OPLL (2.5%). Age distribution between OPLL and non-OPLL cohorts was significantly different (P < .01), with highest prevalence of OPLL between ages 40 to 49 and 50 to 59 years. Comorbid diabetes also differed between groups (27% OPLL, 13% non-OPLL, P < .01). There was no difference in distribution of sex, race, or ethnicity. For OPLL, segmental type is most common (67.6%), involving on average 3.4 levels. OPLL involvement begins at any level, but ends most commonly at C6 (40.5%) or C7 (36.5%). Among OPLL patients, 18 (24.3%) demonstrated concurrent ponticulus posticus. CONCLUSIONS: This review of 2917 patients reaffirms previous data, with OPLL prevalence of 2.5%. In asymptomatic patients, incidental diagnosis is frequently seen as early as ages 40 to 49 years. OPLL is better characterized with a significant association with diabetes, segmental type being the most common, and the caudal extent typically involving C6-7 (77%).

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BACKGROUND: The identification of surgical site infections for infection surveillance in hospitals depends on the manual abstraction of medical records and, for research purposes, depends mainly on the use of administrative or claims data. The objective of this study was to determine whether automating the abstraction process with natural language processing (NLP)-based models that analyze the free-text notes of the medical record can identify surgical site infections with predictive abilities that match the manual abstraction process and that surpass surgical site infection identification from administrative data. METHODS: We used surgical site infection surveillance data compiled by the infection prevention team to identify surgical site infections among patients undergoing orthopaedic surgical procedures at a tertiary care academic medical center from 2011 to 2017. We compiled a list of keywords suggestive of surgical site infections, and we used NLP to identify occurrences of these keywords and their grammatical variants in the free-text notes of the medical record. The key outcome was a binary indicator of whether a surgical site infection occurred. We estimated 7 incremental multivariable logistic regression models using a combination of administrative and NLP-derived variables. We split the analytic cohort into training (80%) and testing data sets (20%), and we used a tenfold cross-validation approach. The main analytic cohort included 172 surgical site infection cases and 200 controls that were repeatedly and randomly selected from a pool of 1,407 controls. RESULTS: For Model 1 (variables from administrative data only), the sensitivity was 68% and the positive predictive value was 70%; for Model 4 (with NLP 5-grams [distinct sequences of 5 contiguous words] from the medical record), the sensitivity was 97% and the positive predictive value was 97%; and for Model 7 (a combination of Models 1 and 4), the sensitivity was 97% and the positive predictive value was 97%. Thus, NLP-based models identified 97% of surgical site infections identified by manual abstraction with high precision and 43% more surgical site infections compared with models that used administrative data only. CONCLUSIONS: Models that used NLP keywords achieved predictive abilities that were comparable with the manual abstraction process and were superior to models that used administrative data only. NLP has the potential to automate and aid accurate surgical site infection identification and, thus, play an important role in their prevention. CLINICAL RELEVANCE: This study examines NLP's potential to automate the identification of surgical site infections. This automation can potentially aid the prevention and early identification of these surgical complications, thereby reducing their adverse clinical and economic impact.

Asunto(s)

Procesamiento de Lenguaje Natural , Procedimientos Ortopédicos/efectos adversos , Infección de la Herida Quirúrgica/diagnóstico , Adulto , Anciano , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Infección de la Herida Quirúrgica/etiología , Adulto Joven

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Background. Elective surgical procedures necessitate careful patient selection. Insurance level has been associated with postoperative outcomes in trauma patients. This study evaluates the relationship insurance level has with outcomes from elective foot and ankle surgery. Methods. Retrospective chart review was performed on patients who underwent elective surgery at a single center with 1-year follow-up. Patients were classified by insurance: under-/uninsured (Medicaid, Option plans) versus fully insured. Outcomes included narcotic refills, patient-reported outcomes (PROMIS) of pain, function, and mood, and compliance with follow-up visits. Statistical analysis involved mean comparison and multivariate regression modeling, with significance P < .05. Results. Cohort groups included 220 insured and 47 under-/uninsured. Outcomes between the insured and under-/uninsured groups differed significantly in narcotic refills (0.72 vs 1.74 respectively, P < .01), missed appointments (0.13 vs 0.62, P < .01), and PROMIS results (pain 54.5 vs 60.2; function 44.3 vs 39.5; mood 44.6 vs 51.3; P < .01). The change in PROMIS scores from preoperative to 1-year postoperative were different in pain (-7.3 vs -2.5, P = .03) and function (+6.3 vs +1.3, P = .04). Regression results confirm insurance as a significant factor (coefficient 0.27, P < .01). Conclusion. These results establish that under-/uninsured patients have worse pain, patient-reported outcomes, and functional outcomes after elective foot and ankle surgery, which may inform patient selection. Levels of Evidence: Level III: Retrospective cohort study.

Asunto(s)

Procedimientos Quirúrgicos Electivos , Predicción , Seguro , Procedimientos Ortopédicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento

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STUDY DESIGN: Retrospective evaluation of prospectively collected data. OBJECTIVE: In spine tumor patients: i) to assess the correlation of Patient-reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores; and ii) to assess ceiling and floor effects of PROMIS PF, PI, and Depression domains and the ODI/NDI. SUMMARY OF BACKGROUND DATA: There remains no widely used patient-reported outcome (PRO) instrument for spine tumor patients. PROMIS, a universal PRO tool, may add notable value to patient care. A paucity of work exists comparing PROMIS to legacy PRO tools in primary and metastatic spine tumor patients. METHODS: Patients confirmed to have a primary or metastatic spine tumor were asked to complete PROMIS PF, PI, and Depression domains and either an ODI or NDI questionnaire between May 2015 and December 2017. Pearson correlation coefficients (r) were calculated. Ceiling and floor effects were determined. P < 0.05 was significant. RESULTS: Eighty unique visits from 51 patients with spine tumors (44 metastatic/67 visits; 7 primary/13 visits) met our inclusion criteria. A strong correlation existed between PROMIS PI and the ODI/NDI in both primary and metastatic tumor patient subgroups (range, r = 0.75-0.86, P < 0.05). PROMIS PF and the ODI/NDI demonstrated a strong correlation among all patients (r = -0.75, P < 0.05) and in the metastatic disease subgroup (r = -0.78, P < 0.05). A strong correlation existed between PROMIS Depression and the ODI/NDI in the primary tumor subgroup (r = 0.79, P < 0.05). PROMIS Depression demonstrated the largest floor effect (13.6%); there were similar ceiling effects. CONCLUSION: PROMIS PF and PI domains correlate well with the ODI/NDI in spine tumor patients and have a similar ceiling effect but decreased floor effect. PROMIS Depression was not as well captured, except in the primary tumor subgroup. LEVEL OF EVIDENCE: 2.

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Medición de Resultados Informados por el Paciente , Neoplasias de la Columna Vertebral , Encuestas y Cuestionarios/normas , Dolor en Cáncer , Depresión , Humanos , Estudios Retrospectivos , Neoplasias de la Columna Vertebral/epidemiología , Neoplasias de la Columna Vertebral/patología , Neoplasias de la Columna Vertebral/fisiopatología , Neoplasias de la Columna Vertebral/psicología

RESUMEN

OBJECTIVE: To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome. METHODS: This retrospective cohort study reviewed hip MRI images of all patients seen by a single surgeon between January 2015 and March 2016. The comparison group included all patients with clinical internal hip snapping, versus the control group that did not. MRI images were processed using minimum intensity projection. Measurements obtained of the pelvis and course of the iliopsoas tendon included: pelvic incidence, coronal angle, and sagittal opening angle (SOA). Comparison of measurements between the groups was performed with Mann-Whitney U analysis and receiver operator curve (ROC) plotting, with a significance cutoff of p = 0.05. RESULTS: The control group (n = 85) and comparison group (n = 48) demonstrated no difference in age or gender. Pelvic incidence was similar [51.3 (± 10.7) degrees control versus 52.2 (± 7.7) degrees comparison (p = 0.36)], as was coronal angle [13.9 (± 4.6) degrees control versus 14.8 (±4.8) degrees comparison (p = 0.15)]. There was a significant difference in SOA [137.0 (± 5.9) degrees control versus 141.9 (± 6.5) degrees comparison (p < 0.01)]. ROC analysis revealed SOA threshold of 140 degrees for clinical IP hip snapping (p < 0.01), with odds ratio 5.2 (2.4-11.3) for SOA > 140 degrees. CONCLUSIONS: Iliopsoas hip snapping is often part of a more complex disease process. While challenging to diagnose, advanced imaging parameters, like the sagittal opening angle, relate with clinical pathology. The SOA offers diagnostic value, with a threshold of greater than 140 degrees significantly correlating with clinical presentation.

Asunto(s)

Articulación de la Cadera/diagnóstico por imagen , Aumento de la Imagen/métodos , Artropatías/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Músculos Psoas/diagnóstico por imagen , Tendinopatía/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Articulación de la Cadera/patología , Humanos , Artropatías/patología , Masculino , Persona de Mediana Edad , Músculos Psoas/patología , Estudios Retrospectivos , Tendinopatía/patología

RESUMEN

The shoulder is a complex joint, with a wide range of motion and functional demands. An understanding of the intricate network of bony, ligamentous, muscular, and neurovascular anatomy is required in order to properly identify and diagnose shoulder pathology. There exist many articulations, unique structural features, and anatomic relationships that play a role in shoulder function, and therefore, dysfunction and injury. Evaluation of a patient with shoulder complaints is largely reliant upon physical exam. As with any exam, the basic tenets of inspection, palpation, range of motion, strength, and neurovascular integrity must be followed. However, with the degree of complexity associated with shoulder anatomy, specific exam maneuvers must be utilized to isolate and help differentiate pathologies. Evaluation of rotator cuff injury, shoulder instability, or impingement via exam guides clinical decision-making and informs treatment options.

Asunto(s)

Examen Físico , Hombro/anatomía & histología , Humanos , Inestabilidad de la Articulación/diagnóstico , Ligamentos/anatomía & histología , Músculo Esquelético/anatomía & histología , Rango del Movimiento Articular , Lesiones del Manguito de los Rotadores/diagnóstico , Hombro/irrigación sanguínea , Hombro/inervación

RESUMEN

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine the prevalence of KFS in asymptomatic patients in New York State. SUMMARY OF BACKGROUND DATA: Klippel-Feil syndrome (KFS) is characterized by congenitally fused cervical vertebrae and may not be diagnosed clinically because most patients do not have the classic triad of short neck, low posterior hairline, and decreased neck range of motion. KFS may be associated with abnormalities such as congenital scoliosis and deafness, and patients are at higher risk for neurologic injury following cervical spine trauma. The prevalence of KFS has not been evaluated in a large series but is estimated to occur every 40,000 births. METHODS: A total of 3,534 cervical computed tomography (CT) scans at the emergency department of a level I trauma center were obtained during a one-year period. Duplicate scans and outside hospital imaging were excluded, resulting in 2,917 cervical CT scans for review. Demographic information was collected, and if KFS was present, level(s) fused, Samartzis classification type, and presence of cervical scoliosis and cervical spine fractures were recorded. RESULTS: The prevalence of KFS was 0.0058% (1 in 172). Of the 17 subjects with KFS, 8 were female and 9 were male. The most commonly fused levels were C5-C6 and C2-C3. All 17 subjects were classified as Samartzis type I, with a single congenitally fused cervical segment. None of the subjects had cervical scoliosis or cervical spine fractures. CONCLUSIONS: The prevalence of KFS in our series is much higher than previously described. Because clinical diagnosis may not be reliable, it is likely that this condition is underreported and may only be found incidentally on imaging. LEVEL OF EVIDENCE: Level III.

Asunto(s)

Síndrome de Klippel-Feil/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Lactante , Síndrome de Klippel-Feil/diagnóstico por imagen , Masculino , Persona de Mediana Edad , New York/epidemiología , Prevalencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto Joven

RESUMEN

STUDY DESIGN: A computed tomography (CT) study of the morphology of the C1 vertebra. OBJECTIVE: Is to determine the prevalence of ponticulus posticus (PP) by analyzing CT scans performed on a large, diverse population in the northeast United States. This study also proposes a CT-based classification system both to aid in unifying the description of PP, and to aid in future research. SUMMARY OF BACKGROUND DATA: The prevalence of PP varies from 5% to 68% in published studies. There may be geographic variation in the prevalence of PP. Our objective was to establish the prevalence of PP in the general population, and to develop a comprehensive classification system to describe PP. METHODS: We evaluated cervical spine CT scans performed on patients in the emergency room of a level I trauma center over a 1-year period (January 1, 2014-December 31, 2014). The CT images were evaluated for the presence of a PP, and if present the following demographic data were collected: age, sex, race/ethnicity, and body mass index (BMI). We propose a novel classification system to standardize the description of PP identified on CT scan. RESULTS: Two thousand, nine hundred and seventeen cervical spine CT scans were reviewed in this study. The prevalence of PP was 22.5%. Men had a higher prevalence of PP than women (53.5% male vs. 46.5% female P ≤ 0.01). When compared with the overall population, African-Americans were more likely to have a PP (P ≤ 0.01), while Caucasian patients were less likely (P ≤ 0.01). The novel classification consisted of a two letter designation for each patient, with the first letter denoting the right sided arch and the second letter the left sided arch. Each side of the arch described as an A, B, or C type. The A type had no presence of a PP, B type had in incomplete PP, and C type had a complete PP. The most common type of a PP was CC encompassing 25% of the patients. The presence of a PP was more common in the left sided arch than the right side (B and C type Left 89.2% vs. B and C type Right 84.7%, P = 0.02). CONCLUSION: We found a 22.5% prevalence of PP in 2917 patients undergoing a cervical spine CT. This is the largest study to evaluating the prevalence of PP. LEVEL OF EVIDENCE: 4.

Asunto(s)

Atlas Cervical/diagnóstico por imagen , Tomografía Computarizada por Rayos X/clasificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Servicio de Urgencia en Hospital/clasificación , Etnicidad , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Factores Sexuales , Tomografía Computarizada por Rayos X/métodos , Adulto Joven

RESUMEN

PURPOSE: To compare clinical efficacy and complication rate as measured by postoperative falls and development of peripheral neuritis between intra-articular blockade and femoral nerve block in patients undergoing arthroscopic hip surgery. METHODS: An institutional review board approved retrospective review was conducted on a consecutive series of patients who underwent elective arthroscopic hip surgery by a single surgeon, between November 2013 and April 2015. Subjects were stratified into 2 groups: patients who received a preoperative femoral nerve block for perioperative pain control, and patients who received an intra-articular "cocktail" injection postoperatively. Demographic data, perioperative pain scores, narcotic consumption, incidence of falls, and iatrogenic peripheral neuritis were collected for analysis. Postoperative data were then collected at routine clinical visits. RESULTS: A total of 193 patients were included in this study (65 males, 125 females). Of them, 105 patients received preoperative femoral nerve blocks and 88 patients received an intraoperative intra-articular "cocktail." There were no significant differences in patient demographics, history of chronic pain (P = .35), worker's compensation (P = .24), preoperative pain scores (P = .69), or intraoperative doses of narcotics (P = .40). Patients who received preoperative femoral nerve blocks reported decreased pain during their time in PACU (P = .0001) and on hospital discharge (P = .28); however, there were no statistically significant differences in patient-reported pain scores at postoperative weeks 1 (P = .34), 3 (P = .64), and 6 (P = .70). Administration of an intra-articular block was associated with a significant reduction in the rate of postoperative falls (P = .009) and iatrogenic peripheral neuritis (P = .0001). CONCLUSIONS: Preoperative femoral nerve blocks are associated with decreased immediate postoperative pain, whereas intraoperative intra-articular anesthetic injections provide effective postoperative pain control in patients undergoing arthroscopic hip surgery and result in a significant reduction in the rate of postoperative falls and iatrogenic peripheral neuritis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Asunto(s)

Artroscopía/efectos adversos , Nervio Femoral/cirugía , Articulación de la Cadera/cirugía , Bloqueo Nervioso/métodos , Dolor Postoperatorio/terapia , Accidentes por Caídas/estadística & datos numéricos , Adolescente , Adulto , Anciano , Amidas/administración & dosificación , Anestésicos Locales/administración & dosificación , Antiinflamatorios no Esteroideos , Artroscopía/métodos , Combinación de Medicamentos , Epinefrina/administración & dosificación , Femenino , Humanos , Inyecciones Intraarticulares , Ketorolaco/administración & dosificación , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Narcóticos/administración & dosificación , Neuritis/epidemiología , Neuritis/etiología , Dimensión del Dolor , Dolor Postoperatorio/epidemiología , Estudios Retrospectivos , Ropivacaína , Resultado del Tratamiento , Adulto Joven

RESUMEN

BACKGROUND: The Granulicatella and Abiotrophia species are streptococci and natural inhabitants of the oral and urogenital flora. They are uncommonly associated with human pathology, although they can cause septicemia, endocarditis, or bacteremia. These microorganisms are difficult to culture and identify due to particular microenvironment requirements. Rarely, presentation is osteomyelitis or infections of the spine. CASE DESCRIPTION: The case report referenced patient notes, laboratory values, and imaging from the electronic health record. In this 48-year-old male with a history of hepatitis C and intravenous drug use, back pain was a relatively common presentation of an uncommon infection. His hospital course was significant for low back pain that did not resolve with conservative measures. Imaging was concerning for infection of the lumbar spine. Biopsies, negative early on, were ultimately positive for Granulicatella and Abiotrophia species, a rare infectious etiology. This infection uncommonly affects the lumbar spine and has not been previously documented in IV drug users. Intravenous antibiotics were prescribed for 6 weeks, after which the patient demonstrated significant clinical improvement. CONCLUSION: With such an uncommon pathogen, there are no universal protocol changes indicated. However, awareness of such unusual microbes and their potential role as the etiology of more common infections, such as lumbar osteomyelitis, is crucial in developing a thorough infectious workup in cases resistant to treatment targeting typical microorganisms.

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Abiotrophia , Absceso Epidural/microbiología , Infecciones por Bacterias Grampositivas/microbiología , Osteomielitis/microbiología , Antibacterianos/uso terapéutico , Absceso Epidural/diagnóstico por imagen , Absceso Epidural/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/complicaciones , Infecciones por Bacterias Grampositivas/diagnóstico por imagen , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Hepatitis C Crónica/complicaciones , Humanos , Dolor de la Región Lumbar/etiología , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Osteomielitis/complicaciones , Osteomielitis/diagnóstico por imagen , Osteomielitis/tratamiento farmacológico , Infecciones Estreptocócicas/complicaciones , Infecciones Estreptocócicas/diagnóstico por imagen , Infecciones Estreptocócicas/tratamiento farmacológico , Infecciones Estreptocócicas/microbiología , Abuso de Sustancias por Vía Intravenosa/complicaciones

RESUMEN

Study Design Retrospective study. Objective Cervical scoliosis is a rare condition that can arise from various etiologies. Few reports on the surgical management of cervical scoliosis exist. Our objective was to evaluate clinical and radiographic outcomes following surgical management of cervical scoliosis. Methods We evaluated our cervical spine surgical database for patients with cervical scoliosis (Cobb angle > 10 degrees) from 2005 to 2010. Demographic data including age, gender, diagnoses, and primary versus revision surgery was collected. Surgical data including procedure (anterior versus posterior), estimated blood loss (EBL), length of surgery, length of hospitalization, and complications was recorded. Preoperative and postoperative Cobb angle measurements and Neck Disability Index (NDI) scores were recorded. Results Cervical scoliosis was identified in 18 patients. We excluded 5, leaving 5 men and 8 women with an average age of 50.7 (median 52, range 25 to 65). The average follow-up was 40 months (median 36.5, range 5 to 87). An anterior-only approach was used in 6 cases (average 4 levels fused), 5 cases were posterior-only approach (average 8.7 levels fused), and 2 cases were combined anterior-posterior approach. The EBL was an average of 286 mL (median 150, range 50 to 900), the average surgical time was 266 minutes (median 239, range 136 to 508), and the average hospital stay was 2.7 days (median 2, range 1 to 7). Complications occurred in 7 patients, and 2 developed adjacent segment pathology. The average coronal Cobb angle preoperatively was 35.1 degrees (median 31, range 13 to 63) and corrected was 15.7 degrees (median 10.5, range 2 to 59) postoperatively (p < 0.005). The average NDI preoperatively was 24.9 (median 26, range 6 to 37) and was reduced to 17.8 (median 18, range 7 to 30) postoperatively (p < 0.02). Conclusion Surgical management of cervical scoliosis can result in deformity correction and improvement in patient outcomes. Higher rates of complications may be encountered.

RESUMEN

INTRODUCTION: Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches. METHODS: A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05. RESULTS: Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45). CONCLUSION: In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint.

Asunto(s)

Fijación Intramedular de Fracturas , Articulación de la Rodilla/cirugía , Dolor Postoperatorio/cirugía , Fracturas de la Tibia/cirugía , Adulto , Clavos Ortopédicos , Bases de Datos Factuales , Femenino , Fijación Intramedular de Fracturas/efectos adversos , Humanos , Articulación de la Rodilla/fisiopatología , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Rango del Movimiento Articular , Fracturas de la Tibia/complicaciones , Fracturas de la Tibia/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiología

RESUMEN

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1-L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patient's persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis.

Asunto(s)

Vértebras Lumbares/microbiología , Infecciones por Mycobacterium no Tuberculosas/diagnóstico , Mycobacterium kansasii , Osteomielitis/microbiología , Sarcoidosis/complicaciones , Adulto , Antituberculosos/uso terapéutico , Diagnóstico Diferencial , Discitis/tratamiento farmacológico , Discitis/microbiología , Discitis/patología , Quimioterapia Combinada , Etambutol/uso terapéutico , Fiebre/etiología , Fracturas por Compresión/diagnóstico , Humanos , Huésped Inmunocomprometido , Isoniazida/uso terapéutico , Vértebras Lumbares/patología , Imagen por Resonancia Magnética , Masculino , Infecciones por Mycobacterium no Tuberculosas/tratamiento farmacológico , Osteomielitis/tratamiento farmacológico , Osteomielitis/patología , Fracturas de la Columna Vertebral/diagnóstico

RESUMEN

Online ratings of orthopedic surgeons have not been studied. We conducted a study to evaluate the online ratings of orthopedic surgeons in a major metropolitan region, to identify trends in ratings of orthopedic surgeons, and to analyze ratings to identify variables of significance in determining overall rating. Website traffic was used to identify the 8 busiest physician rating websites: AngiesList.com, EverydayHealth.com, Thirdage.com, Yelp.com, HealthGrades.com, Vitals.com, UCompareHealthcare.com, and RateMDs.com. These websites were consulted for data regarding orthopedic surgeons in a major metropolitan region with a population of 1.3 million in September 2012. Surgeon ratings were scaled from 0 to 100 for homogeneity. Of the 8 websites considered, 4 were excluded because of inaccessible or unreliable data. The qualifying sites were HealthGrades.com, Vitals.com, UCompareHealthcare.com, and RateMDs.com, with 2185 reviews total. Across these websites, mean overall rating of orthopedic surgeons was 81.8 (between 100, definitely recommend, and 80, mostly recommend). Five variables were statistically significant (Ps < .01) for higher ratings: ease of scheduling, time spent with patient, wait time, surgeon proficiency/knowledge, and bedside manner.

Asunto(s)

Internet , Satisfacción del Paciente , Cirujanos , Competencia Clínica , Humanos , Relaciones Médico-Paciente

RESUMEN

BACKGROUND: Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥ 40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. METHODS: Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. RESULTS: On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. CONCLUSIONS: This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found.

Asunto(s)

Proteína Morfogenética Ósea 2/efectos adversos , Vértebras Lumbares/cirugía , Complicaciones Posoperatorias/inducido químicamente , Proteínas Recombinantes/efectos adversos , Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/efectos adversos , Vértebras Torácicas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Proteína Morfogenética Ósea 2/uso terapéutico , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Proteínas Recombinantes/uso terapéutico , Estudios Retrospectivos , Fusión Vertebral/métodos

RESUMEN

STUDY DESIGN: Case report. OBJECTIVE: To report the clinical and imaging findings of a patient with arachnoiditis ossificans (AO) 22 years after revision surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: To our knowledge, there are no reports in the literature that describe AO developing after primary or revision surgery for AIS. Ararchnoiditis ossificans is a rare finding and we provide a review of its presentation and management. METHODS: We report the patient's history, physical examination, radiographical findings, and management in addition to providing a literature review. RESULTS: A 43 year-old-male who underwent revision surgery for AIS due to intradural migration of a laminar hook presented 22 years after surgery with subjective leg weakness. On physical examination, no weakness was elicited and radiographs demonstrated the instrumentation to be intact. Computed tomographic imaging was performed to assess for adjacent segment disease and diffuse ossification or AO of the thecal sac from L3 to S1 was noted. We recommended observation and nonoperative management because the patient's symptoms were relatively mild. CONCLUSION: To our knowledge, this is the first report of AO after surgical management of primary or revision AIS. A discussion on the management of AO and a literature review is presented.

Asunto(s)

Aracnoiditis/diagnóstico por imagen , Osificación Heterotópica/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Escoliosis/diagnóstico por imagen , Escoliosis/cirugía , Adolescente , Adulto , Aracnoiditis/etiología , Estudios de Seguimiento , Humanos , Masculino , Osificación Heterotópica/etiología , Complicaciones Posoperatorias/etiología , Radiografía , Reoperación/efectos adversos , Reoperación/tendencias , Factores de Tiempo , Resultado del Tratamiento