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Background: Although elective surgical procedures in the United States have been suspended because of the coronavirus disease 2019 (COVID-19) pandemic, orthopaedic surgeons are being recruited to serve patients with COVID-19 in addition to providing orthopaedic acute care. Older individuals are deemed to be at higher risk for poor outcomes with COVID-19. Although previous studies have shown a high proportion of older providers nationwide across medical specialties, we are not aware of any previous study that has analyzed the age distribution among the orthopaedic workforce. Therefore, the purposes of the present study were (1) to determine the geographic distribution of U.S. orthopaedic surgeons by age, (2) to compare the distribution with other surgical specialties, and (3) to compare this distribution with the spread of COVID-19.Methods: Demographic statistics from the most recent State Physician Workforce Data Reports published by the Association of American Medical Colleges were extracted to identify the 2018 statewide proportion of practicing orthopaedic surgeons ≥60 years of age as well as age-related demographic data for all surgical specialties. Geospatial data on the distribution of COVID-19 cases were obtained from the Environmental Systems Research Institute. State boundary files were taken from the U.S. Census Bureau. Orthopaedic workforce age data were utilized to group states into quintiles.Results: States with the highest quintile of orthopaedic surgeons ≥60 years of age included states most severely affected by COVID-19: New York, New Jersey, California, and Florida. For all states, the median number of providers ≥60 years of age was 105.5 (interquartile range [IQR], 45.5 to 182.5). The median proportion of orthopaedic surgeons ≥60 years of age was higher than that of all other surgical subspecialties, apart from thoracic surgery.Conclusions: To our knowledge, the present report provides the first age-focused view of the orthopaedic workforce during the COVID-19 pandemic. States in the highest quintile of orthopaedic surgeons ≥60 years old are also among the most overwhelmed by COVID-19. As important orthopaedic acute care continues in addition to COVID-19 frontline service, special considerations may be needed for at-risk staff. Appropriate health system measures and workforce-management strategies should protect the subset of those who are most potentially vulnerable.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Systematic review.The objectives of this systematic review were to determine whether sociologic and demographic factors modify the effect of fusion versus nonoperative management in patients with chronic low back pain.Chronic low back pain is among the most common symptoms leading patients to seek medical care and presents significant challenges in treatment decision making. This is due to the wide array of pathologic conditions causing back pain, the multitude of patient variables (i.e., litigation, psychologic issues, social issues) that are thought to influence the perception of back pain, and the wide variation in treatment response. Sociodemographic factors are thought to play a role in pain perception and treatment response, though this has been poorly assessed in the literature.Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of sociodemographic factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain.The only sociologic factors evaluated in randomized controlled trials adequate to assess heterogeneity of treatment effect are pending litigation, worker's compensation, sick leave, and heavy labor job type. Litigation patients, although thought to do poorly with treatment of chronic low back pain in general, responded more favorably to fusion than nonoperative care. Likewise, patients with lighter jobs and those patients who were not on sick leave did better with fusion than nonoperative care. No demographic factors were observed to respond more favorably to one treatment over the other.Sociodemographic factors are not well studied in the literature, but are assumed to affect treatment outcomes. After rigorous review, few studies held up to the standards required for defining the comparative treatment effect of these factors. Pending litigation may negatively impact outcomes of patients with chronic low back pain; however, those who underwent fusion had better outcomes than those with nonoperative management in two European studies. There is no evidence to suggest that sociodemographic factors alone should preclude surgery. Well-constructed prospective randomized studies with predefined subgroup analyses are required to further understand the impact of sociodemographic factors in the treatment of chronic low back pain.Sociodemographic factors should be considered when making treatment decisions for patients with chronic low back pain, but alone do not preclude fusion for chronic low back pain. Strength of recommendation: Weak. [ABSTRACT FROM AUTHOR]

The article presents a study which identifies the complications in patients following the use of bone morphogenetic proteins (BMP) in spinal fusion surgery. The study conducted a systemic review of literatures published from 1990 to June 2009 in the Cochrane Collaboration Library, EMBASE and MEDLINE. Results show that multiple complications including resorption, subsidence and dysphagia are associated following the use of recombinant BMP-2 in lumbar and cervical spinal fusion surgery.

An introduction to a series of articles on value-based spine care is presented.

Study Design: Retrospective review., Objective: The objective of the study was to determine the morbidity and mortality rate associated with same day versus staged cervical circumferential approach., Summary of Background Data: A combined approach to the cervical spine is often indicated for complex cervical pathologies. Previous studies suggested superior results associated with same day combined surgery for thoracolumbar patients. This study examines the usefulness of p-Physiological and Operative Severity Score for enumeration of Morbidity and Mortality (POSSUM), an estimated mortality risk assessment for cervical spine patients and will compare same day surgery to staged procedures., Methods: This is a retrospective chart review including patients who underwent ventral and dorsal approach within 2 weeks. Estimated mortality was calculated using p-POSSUM. The cohort was divided into same day surgery group and staged group. Risk factors were compared between groups. Mean p-POSSUM was calculated and compared with the actual mortality rate. Univariate analysis was used to compare the risk factors between groups and the groups' outcomes. Multivariable analysis was used to adjust for risk factor differences when comparing group outcomes., Results: One hundred thirty-five patients were included, 106 patients were in the same day surgery group whereas 29 patients were in the staged group. Mean p-POSSUM was 2.8% predicted mortality with a 95% confidence interval of 1.6% to 4.1%. The actual mortality rate was 3.7%. The groups did not vary in most risk factors assessed. Univariate analysis demonstrated a statistically significantly higher rate of major complications (0.62 vs. 0.34, P=0.0369), infection (41.4% vs. 9.4%, P<0.0001), and length of hospital stay (9.3 vs. 6.8 d, P=0.0120) in the staged group. Multivariable analysis demonstrated significantly higher infection rate in the staged group., Conclusions: P-POSSUM mortality estimate may serve as a useful and valid tool for spine surgery studies. Staged combined cervical surgery harbors a higher complication rate and may be associated with lengthier hospitalization.

Study Design: A prospective clinical research article., Objective: The primary goals were to determine (1) radiation exposure to the spine surgeon with the use of an intraoperative 3-dimensional imaging system and (2) to define the safe distance from the computed tomographic scanner., Summary of Background: Intraoperative radiation exposure to the spinal surgeon has been assessed during 2-dimensional fluoroscopy but has not been investigated during intraoperative 3-dimensional imaging., Methods: Ten patients undergoing lumbar or thoracolumbar fusion were enrolled in a prospective trial to determine the radiation exposure to a spine surgeon standing in the substerile room, with the use of the O-ARM Imaging System (Medtronic, Memphis, TN). A thermolucent digital dosimeter was worn at chest level without a lead apron. Dosimeter readings and distance from the spine surgeon were recorded. RESULTS.: Average surgeon exposure was 44.22 ± 17.4 μrem (range: 17.71-70.76 μrem). The mean distance from the O-ARM was 4.56 ± .32 m, and the surgeon was exposed for an average of 19.6 ± 5.7 seconds (range: 8.05-28.7 s). The annual number of necessary procedures required to surpass the exposure limit, according to the data presented here, would be 113,071 operations using O-ARM. Hence, the number of necessary procedures for O-ARM use is predicted to be 1,130,710 annual procedures to reach the occupational exposure limits for extremity, skin, and all other organs and 339,213 procedures to reach the limits for the lens of eye., Conclusion: Radiation exposure is minimal to the surgical team during routine use of the O-ARM imaging system. The number of procedures required to surpass occupational exposure limits is high if using appropriate distance from the O-ARM.

Study Design: Review of literature., Objective: To evaluate the available literature supporting the use of lumbar fusion extenders in clinical practice., Summary of Background Data: Because of the morbidity associated with the harvest of autologous iliac crest bone grafts, the search for lumber fusion extenders and replacements has accelerated. Many formulations of lumbar fusion extenders have been developed, and it is essential to evaluate clinical literature and available outcome metrics of these extenders., Methods: A review of English-language literature was performed between 1990 and January of 2010 for all literature presenting clinical outcomes of lumbar fusion extenders. After controlling for inclusion and exclusion criteria and assigning levels of evidence, 19 clinical studies were fully reviewed including those for demineralized bone matrix, recombinant human bone morphogenetic protein 2 (rhBMP-2), β-tricalcium phosphate, and calcium sulfate., Results: The most extensively studied of the lumbar fusion extenders is β-tricalcium phosphate, especially with regard to its use in adolescent scoliosis correction. The use of rhBMP-2 and demineralized bone matrix is supported only by two and three clinical studies, respectively. Calcium sulfate and other miscellaneous extenders are not conclusively or consistently supported by available clinical studies., Conclusion: Calcium phosphate is the most supported of the lumbar fusion extenders. rhBMP-2 and demineralized bone matrix are supported by smaller bodies of evidence. These formulations are supported by these initial studies but in some cases need to be better examined with regard to side effect profiles.