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A retrospective review.The objective of this study was to determine whether fusing to touched vertebra (TV) on prone x-rays (XRs) with minimal rotation (Gd 0/1) allow for shorter fusion with optimal correction.Previous studies have shown risk of "adding on" when TV is not selected as lowest instrumented vertebra (LIV). Fusion proximal to TV leads to suboptimal results but fusing to TV on standing XRs can result in longer fusions. On lying down XRs, TV moves proximally, and its rotation decreases by a grade.TV patients with minimal rotation were selected on prone (TVP) or standing XRs (TVS). Patients fused to rotated (Gd 2+) TV on standing or prone XRs were considered touched vertebra rotated (TVR). In the non-TV (NTV) group, LIV was fused proximal to TV. Disk wedging ≥5° determined risk of "adding-on." To compare patients fused to minimally rotated TV, to those that were not, patients in group A (TVP + TVS) were compared with group B (TVR + NTV).In part II: TVP, TVS, TVR, and NTV patients were compared. Subanalysis compared levels saved as the difference between predicted and real LIV in TVP and TVS patients. Another subanalysis was carried out for Lenke 1+2 and Lenke 3, 4, 5.In part III: XRs of nonoperative adolescents idiopathic scoliosis patients with Cobb30 and Risser 4/5 were analyzed to determine "acceptable" end vertebra tilt and disc wedging and served as controls.There were a significantly greater number of patients in group B patients(TVR + NTV) with final disk wedging ≥5°, final LIV translation ≥1 and ≥2 cm ( P0.001).Utilizing prone XRs in TVP saved average 1 level, and 1.2 levels in TVS patients. TVP patients also had similar LIV tilt, disk wedging and coronal balance( P0.05) to controls.Choosing minimally rotated (Gd 0/1) TV on prone XR saves levels without sacrificing radiographic outcomes.

Retrospective review.The objective of this study was to evaluate and compare distribution of hospital and operating room charges and outcomes during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) patients by high-volume (HV) and standard-volume (SV) surgeons at one institution and examine potential cost savings.Increased surgical volume has been associated with improved perioperative outcomes after spinal deformity correction. However, there is a lack of information on how this may affect hospital costs.Retrospective study of AIS patients undergoing posterior spinal fusion between 2013 and 2019. Demographic, x-ray, chart review and hospital costs were collected and compared between HV surgeons (≥50 AIS cases/y) and SV surgeons (50/y). Comparative analyses were computed using Wilcoxon rank-sum, Kruskal-Wallis, and the Fisher exact tests. Average values with corresponding minimum-maximum rages were reported.A total of 407 patients (HV: 232, SV: 175) operated by 4 surgeons (1 HV, 3 SV). Radiographic parameters were similar between the groups. HV surgeons had significantly lower estimated blood loss (385.3 vs. 655.6 mL, P0.001), fewer intraoperative transfusions (10.8% vs. 25.1%, P0.001), shorter surgery time (221.6 vs. 324.9 min, P0.001), and lower radiation from intraoperative fluoroscopy (4.4 vs. 6.4 mGy, P0.001). HV patients had a significantly lower length of stay (4.3 vs. 5.3, P0.001) and complication rate (0.4% vs. 4%, P =0.04).HV surgeons had significantly lower total costs ($61,716.24 vs. $72,745.93, P0.001). This included lower transfusion costs ( P0.001), operative time costs ( P0.001), screw costs ( P0.001), hospital stay costs ( P0.001), and costs associated with 30-day emergency department returns ( P0.001).HV surgeons had significantly lower operative times, lower estimated blood loss and transfusion rates and lower perioperative complications requiring readmission or return to emergency department resulting in lower health care costs.Level III.

Previous reports identified minority race/ethnicity to be an independent risk factor for prolonged length of stay (LOS); however, these cohorts consisted of predominantly White patients. This study sought to evaluate minority status as an independent risk factor for prolonged LOS after primary total knee arthroplasty (TKA) in a predominantly Hispanic and Black cohort.This was a retrospective study using an institutional database of patients who underwent primary TKA between the years 2016 and 2019. Demographic and socioeconomic data, smoking, body mass index (BMI), medical comorbidities, discharge disposition, and 30-day readmission rates were collected. Patients were first categorized into racial/ethnic groups (Hispanic, Black, or White). An univariate analysis was performed comparing patient characteristics between racial/ethnic groups using the Wilcoxon rank sum, chi-squared, and Fisher exact tests. We then categorized patients into two groups-normal LOS (discharged on postoperative day 1 to 2) and prolonged LOS (discharged after postoperative day 2). An univariate analysis was again performed comparing patient characteristics between LOS groups using Wilcoxon rank sum, chi-squared, and Fisher exact tests. After identifying risk factors markedly associated with LOS, a multivariate logistic regression analysis was performed to identify independent risk factors for prolonged LOS.A total of 3,093 patients were included-47.9% Hispanic and 38.3% Black. Mean LOS was 2.9 ± 1.6 days. An univariate analysis found race/ethnicity, age, low socioeconomic status (SES), discharge disposition, insurance type, weekday of surgery, BMI40, smoking, increased American Society of Anesthesiologists (ASA)/Charlson Comorbidity Index (CCI) and several medical comorbidities to be associated with prolonged LOS (P0.05). A multivariate logistic regression analysis found Black and Hispanic patients were less likely to have prolonged LOS after adjusting for associated risk factors. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI40, and increased ASA and CCI were identified as independent risk factors for prolonged LOS (P0.05). The overall 30-day readmission rate was 3.6%, with no notable difference between racial/ethnic and LOS groups (P = 0.98 and P = 0.78).In contrast to previous reports, our study found that after adjusting for associated risk factors, minority patients do not have prolonged LOS after primary TKA in an urban, socioeconomically disadvantaged, predominantly minority patient cohort. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI40, increased CCI, and ASA were all found to be independent risk factors for prolonged LOS. These findings highlight the need to further investigate the role of race/ethnicity on LOS after primary TKA using large-scale, randomized controlled trials with equally represented patient cohorts.

Retrospective cohort study.This study aims to identify differences in perioperative outcomes between ambulatory patients with neuromuscular scoliosis (ANMS) and adolescent idiopathic scoliosis (AIS) following spinal fusion.NMS patients have severe curves with more comorbidities and procedural complexity. These patients require extensive fusion levels, increased blood loss, and suffer increased periop complications. However, NMS patients have a variable severity spectrum, including ambulation status.Chart and radiographic review of NMS and AIS patients undergoing PSF from 2005 to 2018. NNMS included NMS patients who were completely dependent (GMFCS IV-V). ANMS consisted of community ambulators without significant reliance on wheeled assistive devices (GMFCS I-III). Subanalysis matched by age, sex, levels fused and preoperative Cobb angle was conducted as well. Wilcoxon Rank-Sum, Kruskal-Wallis, χ2, and Fisher exact tests were performed.There were 120 patients in the NNMS group, 54 in ANMS and 158 in the AIS group. EBL was significantly lower for ANMS and AIS patients (P 0.001). Complications within 30 days were similar between ANMS and AIS (P = 1.0), but significantly higher for NNMS (P 0.001). Two (1.3%) AIS patients, (1.7%) nonambulatory NMS patients, and one (1.9%) ANMS patient required revision surgery (P = 1.0). However, all NMS patients had increased fusion levels, fixation points, and surgery time (P 0.05). NNMS had significantly longer ICU (P 0.001), hospital stay (P 0.001), intraoperative transfusions (P 0.001), and fewer patients extubated in the OR (P 0.001) than ANMS and AIS patients. In the subanalysis, ANMS had similar radiographic measurements, EBL, transfusion, surgery time, extubation rate, and complication rate (P 0.05) to AIS.Our data show radiographic outcomes, infections, revisions, and overall complications for ANMS were similar to the AIS population. This suggests that NMS patients who ambulate primarily without assistance can expect surgical outcomes comparable to AIS patients with further room for improvement in length of ICU and hospital stay.Level of Evidence: 4.

Database study.The purpose of this study was to use a large, nationwide database to determine prevalence of pediatric spine fractures in the United States, associated injuries, mechanisms of injury (MOI), use of safety devices, and mortality rates.Spinal fractures account for 1% to 2% of pediatric injuries. However, they are associated with significant comorbidities and complications. Motor vehicle accidents (MVAs) are most responsible for increased incidence observed.Retrospective review of National Trauma Data Bank between 2009 and 2014 (analysis in 2019) for all vertebral fractures in patients under 18 years of age. Subanalysis included those in MVAs where protective device use data were available. Patient demographics, MOI, geographical and anatomical region of injury, concomitant musculoskeletal/organ injury, protective device usage, hospital length of stay, surgical procedures, and mortality were all analyzed.A total of 34,563 patients with 45,430 fractured vertebrae included. Median age was 15 years. Most fractures (63.1%) occurred in patients aged 15 to 17 years, most frequent MOI was MVA (66.8%), and most common geographic location was the South (38%). Males sustained more spine fractures than females, overall (58.4% vs. 41.6%; P 0.001) and in MVAs (54.4% vs. 45.6%; P 0.001). Those in MVAs wearing seatbelts had lower odds of cranial (29.6% vs. 70.4%; odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.82-0.89; P 0.001) and thoracic (30.1% vs. 69.9%; OR = 0.88, 95% CI: 0.84-0.91; P 0.001) organ injury, multivertebral (30% vs. 70%; OR = 0.78, 95% CI: 0.73-0.83; P 0.001) and concomitant nonvertebral fractures (30.9% vs. 69.1%; OR = 0.89, 95% CI:0.73-0.83; P 0.001), and 21% lower odds of mortality (29.3% vs. 70.7%; OR = 0.79, 95% CI: 0.66-0.94; P = 0.009). Over 70% of drivers were not restrained during MVA, with majority of seatbelt violations incurred by males, ages 15 to 17, in the South.Over 60% of pediatric spinal fractures occur in children aged 15 to 17 years, coinciding with the beginning of legal driving. MVA is the most common cause and has significant association with morbidity/mortality. Nearly two- thirds pediatric spinal fractures sustained in MVAs occurred without seatbelts. Absence of seatbelts associated with20% greater odds of mortality. Ensuring new drivers wear protective devices can greatly reduce morbidity/ mortality associated with MVA.Level of Evidence: 3.

Single-center retrospective chart review with minimum 2-year follow up.To determine incidence of pulmonary hypertension in adolescent idiopathic scoliosis patients and to determine the effect of scoliosis surgery on pulmonary hypertension.Spinal deformity in adolescent idiopathic scoliosis can increase right atrial and ventricular pressures secondary to restrictive lung disease. Pulmonary hypertension leading to cor pulmonale is the most feared outcome, however mild pulmonary hypertension in adolescent idiopathic scoliosis (AIS) patients has been reported. No study has previously examined changes in the improvement of right heart function following scoliosis surgery.Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), pulmonary function tests (PFTs), arterial blood gas (ABG), and patient demographics reviewed. Right ventricular systolic pressure (RVSP) estimated using Bernoulli equation (4[TRV]2) and right atrial pressure. RVSP ≥36 mmHg is a surrogate marker for pulmonary hypertension. All echocardiograms were read by board certified Pediatric Cardiologists. Logistic regression used to assess for differences in TRV between groups.Mean preoperative RVSP was significantly elevated in AIS patients (26.9 ± 0.49; P 0.001) compared with controls (17.25 + 0.88). Only 47 (21%) Group 1 patients had elevated preoperative TRV (≥2.8 m/s) versus none in Group 2 (P 0.001). Additionally, logistic regression showed AIS patients have odds ratio of 3.29 for elevated TRV (P = 0.007)-an indirect measure of pulmonary hypertension. In all Group 3 patients, the cardiac function normalized postoperatively (mean TRV = 2.09 + 0.23; P 0.001). No association found between Cobb angle, aortic root parameters, or pulmonary function tests.This study found 13.9% of patients with adolescent idiopathic scoliosis had elevated TRV while controls had no TRV abnormalities. Additionally, RVSP measurements demonstrated mild pulmonary hypertension in AIS patients. These abnormal values normalized postoperatively, indicating the benefits of scoliosis surgery on cardiac function in adolescent idiopathic scoliosis.Level of Evidence: 3.

There has been increasing interest in the use of stemless humeral implants for total shoulder arthroplasty when compared with both short-stem (SS) and standard-length implants. Although evidence for decreased surgical time and blood loss exists for stemless versus standard-length stems, far less literature exists comparing these clinical parameters for stemless versus SS implants.A retrospective review of consecutive anatomic total shoulder arthroplasty (aTSA) cases conducted by a single, fellowship-trained shoulder surgeon was undertaken from January 2016 through January 2022 with the exception of March 2020 through January 2021 secondary to the COVID-19 pandemic. Demographic patient and surgical data, including age, sex, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder arthroscopy, surgical time, use of a Hemovac drain and/or tranexamic acid, hospital length of stay (LOS), and both postoperative day #1 (POD 1) and discharge visual analog scores. The use of a stemless or SS implant was recorded. Intraoperative total blood volume loss (TBVL) was calculated, in addition to the need for either intraoperative or postoperative transfusions. Nonparametric analysis of covariance was used to examine effects of stemless versus SS aTSA on surgical time and intraoperative TBVL adjusted for demographic, clinical, and surgical variables.There were 47 SS and 83 stemless anatomic implants included, of which 74 patients (57%) overall were women. The median surgical time for the stemless cohort was 111 minutes (IQR 96-130) versus 137 minutes (IQR 113-169) for the SS cohort (P0.00001). The median intraoperative TBVL for the stemless cohort was 298.3 mL (IQR 212.6-402.8) versus 359.7 mL (IQR 253.9-415.0) for the SS cohort (P = 0.05). After multivariable regression analysis, use of stemless humeral implants was independently associated with both decreased surgical time and intraoperative blood loss (P0.001 and P = 0.005, respectively). There was a shorter median hospital LOS in the stemless group (2 days [IQR 1-2] versus 2 days [IQR 2-3], P = 0.03). The visual analog score pain score at discharge was lower among the stemless cohort (0 [IQR 0-3] versus 4 [IQR 2-6], P0.00001). Increased surgical time was associated with intraoperative TBVL (r = 0.340, P0.0001).Stemless aTSA is associated with a markedly decreased surgical time and intraoperative TBVL when compared with a SS aTSA. Furthermore, the use of a stemless implant results in a shorter hospital LOS and lower discharge pain scores.

Short-term cancellation of elective ambulatory orthopaedic surgery can result in disruption to the process flow of the operating room, with resultant negative financial implications for the health system. The risk factors for patient-related short-term cancellations within 24 hours of the surgical date have not been well defined.A retrospective review of a single orthopaedic surgery electronic internal database was done to identify all cancellations from January 1, 2016, through December 31, 2019, which were made within 24 hours of the surgical date. Inclusion criteria included elective arthroscopic procedures canceled solely for patient-related issues. Any cancellation for surgeon-related or ambulatory center-related reasons was excluded. Demographic patient and surgical data, including insurance type, employment status, previous history of cancellation for the same surgery, socioeconomic status based on the Area Deprivation Index, and surgery type, were tabulated. Each cancellation was matched 1:2 with noncanceled cases based on the anatomic site of the arthroscopy scheduled. Multivariable logistic regression was used to examine associations of patient demographic and medical characteristics with surgical cancellation.There were 4,715 total arthroscopic procedures done during the study period, of which 126 (2.7%) were canceled within 24 hours of the surgery date. The mean age of the canceled cases was 44.9 ± 16.1 years (range, 14 to 77 years), with 46 females (43%) included. The presence of MRI of the involved joint within 6 months of surgery (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17 to 0.91) and current employment (aOR, 0.56, 95% CI, 0.33-0.94) were independently predictive of noncancellation. Current smokers were more likely to cancel within 24 hours of surgery (aOR, 2.63, 95% CI, 1.4-4.9). Finally, having previously canceled the same surgery was significantly associated with a current surgical cancellation (P = 0.004).Identification of the factors associated with short-term patient-related cancellation of elective arthroscopy may serve as the basis for preoperative interventions aimed specifically at those more likely to cancel. In turn, these interventions can minimize preventable cancellations.

STUDY DESIGN A retrospective chart review of prospectively collected data. OBJECTIVE The aim of this study was to determine whether back-to-back scoliosis surgeries can be performed safely without compromising outcomes and the reproducibility of the practice between institutions. SUMMARY OF BACKGROUND DATA During the summer, spinal surgeons will often book multiple cases in one day. The complexity and demands of spinal fusion surgery call into question the safety. Change of operating room staff including anesthesiologists, nurses, and neurologists may introduce new risks. METHODS From 2009 to 2018, index AIS surgeries were included. In Groups 1, 2, and 3, surgeries were performed by a single surgeon. In Group 4, they were performed by other institutional surgeons. Group 1: first surgery of the day, Group 2: second surgery of the day, Group 3: only surgery of the day, Group 4: only surgery of the day by different institutional surgeon. Additional analysis was done to determine reproducibility after a surgeon was moved from Institution 1 to Institution 2. RESULTS Five hundred sixty-seven AIS patients were analyzed. Group 1 patients had similar radiographic outcomes compared with Group 2 (P > 0.05). Surgical time was similar (P = 0.51), but significantly more levels fused (P = 0.01). Compared with Group 3, Group 2 had a smaller preoperative Cobb (P = 0.02), shorter surgeries (P

Retrospective review.The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA).Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication.AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared.There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly11.6% of PCA patients (P 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation.This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Multicenter retrospective review.This study aims to address major postoperative complications associated with Scheuermann kyphosis (SK) when compared with adolescent idiopathic scoliosis (AIS) in a large population matched by demographic characteristics, levels fused and operative technique.Prior studies have found that SK patients are 3.86 times more likely to experience major postoperative complications than in AIS. Historically, however, these studies have often had populations that were significantly different between the two groups in terms of disease severity, demographics, and small sample sizes.AIS patients were compared to SK patients between 2006 and 2018 contemporaneously. All surgeries were conducted by six surgeons among two institutions. Complications and revisions were calculated. A sub-analysis comparing SK and AIS patients by age, sex, and levels-fused in one-to-one matched pairs was performed as well as a sub-analysis matched by levels fused only in one-to-one matched pairs.One thousand three hundred twenty two patients were reviewed (1222 AIS; 100 SK). There were 52 (4.3%) complications in the AIS group compared with 20 (20%) complications in the SK group (P 0.001), with infections and revisions consisting of the majority of complication rates in both cohorts.When matched by age, sex, and levels fused, there were eight complications in the AIS group and 11 in the SK group (P = 0.63), with infection and revision rates being similar, (P = 0.29) and (P = 0.26) respectively.When matched by levels fused only, EBL, operative time and complication rates remained similar (P 0.05).Contrary to previously published literature, our analyses indicate that in a matched population, postoperative complication rates (i.e., infection and revision rates) are not significantly different between SK and AIS patients.Level of Evidence: 4.

STUDY DESIGN Retrospective review of prospective data from multicenter registry. OBJECTIVE Compare outcomes of posterior spinal fusion (PSF) versus magnetically controlled growing rods (MCGR) versus vertebral body tethers (VBT) in 8- to 11-year-old idiopathic early onset scoliosis (EOS) patients. SUMMARY OF BACKGROUND DATA In EOS, it is unclear at what age the benefit of growth-sparing strategies outweighs increased risks of surgical complications, compared with PSF. METHODS One hundred thirty idiopathic EOS patients, 81% female, aged 8-11 at index surgery (mean 10.5 yrs), underwent PSF, MCGR, or VBT. Scoliosis curve, kyphosis, thoracic and spinal height, complications, and Quality of Life (QoL) were assessed preoperatively and at most recent follow-up (prior to final fusion for VBT/MCGR). RESULTS Of 130 patients, 28.5% received VBT, 39.2% MCGR, and 32.3% PSF. The VBT cohort included more females (P

STUDY DESIGN Retrospective review of prospective case-control study. OBJECTIVE To compare minimally invasive scoliosis surgery (MIS) and posterior spinal fusion (PSF) in a large group of patients. SUMMARY OF BACKGROUND DATA MIS, has been shown to have benefits over standard PSF in adolescent idiopathic scoliosis (AIS). METHODS Radiographic, clinical, and operative review of a multi-institutional prospective database from 2013 to 2018. MIS patients with minimum 2-year XR follow up were compared with open PSF technique patients. RESULTS Four hundred eighty five patients were included; 192 MIS and 293 PSF. Preoperative Cobb (P = 0.231) and kyphosis were similar (P = 0.501). Cobb correction was comparable (P = 0.46), however percent improvement in thoracic kyphosis was significantly higher in MIS (P

Background:. With cost, size, and availability in mind, we developed a low-fidelity microsurgery anastomosis model for mastery of the tool skills needed to execute microsurgical procedures. The model combined the use of a cannulated Konnyaku Shirataki (KS) noodle with a low-cost, industrial inspection, trinocular stereo (IITS) microscope. The purpose of this study was to establish face and construct validity of this novel “combined” microsurgery training tool. Methods:. Fifteen participants, divided into 3 groups based on microsurgery experience, attempted microsurgical anastomoses of a cannulated KS noodle using the IITS microscope. Participants were asked to (1) manipulate the noodle ends adjacent to each other, (2) place a single 7-0 nylon suture through the opposed ends, and (3) complete the anastomosis. To determine construct validity, the performance of the microsurgical repair (maximum score 53 points) and time-to-anastomosis was assessed. To determine face validity, microsurgeons were given a 25-item, 5-point scale survey rating their experience with the model. Results:. Participants included 5 microsurgeons, 5 experienced trainees, and 5 novices. The microsurgeons judged the IITS microscope to be a close analog to an operating microscope (4.6/5 points), the combined model to have high educational value (4.7/5 points), and somewhat technical similarity with microsurgery in the operating room (OR) (3.7/5 points). The median technical score was 50 among microsurgeons, 40 among experienced trainees, and 27 among novices. Increased training level was associated with greater technical score among all 3 groups (p=0.002). The median time-to-anastomosis was 5.88 minutes for microsurgeons, 8.37 minutes for experienced trainees, and 17.10 minutes for novices. Increased training level was associated with shorter time-to-anastomosis (p=0.003). Conclusion:. The use of the KS noodle with a benchtop stereo microscope is a novel approach to microsurgical training. It is inexpensive, available, conducive to high-repetition training, and suited to many learning environments. Microsurgeons found that this combined model was representative of microsurgery in the OR, and we concluded face validity. Furthermore, an association was demonstrated between training level and performance on the model, suggesting construct validity.

The LigaSure system has been successfully used in thoracic and abdominal surgery. However, to date, its use in the resection of sarcomas has not been systematically studied. We aimed to determine whether the use of the LigaSure system reduces blood loss and blood transfusion volumes in sarcoma surgery.One hundred forty-two consecutive patients who underwent sarcoma surgeries between July 2010 and October 2016 were included. Conventional electrocautery alone (n = 91) and with LigaSure (n = 51) were compared. Case-matched samples (n = 46) from each group were additionally compared.The use of the LigaSure system resulted in a significant decrease in mean intraoperative blood loss (P = 0.02) and blood transfusion volume (P = 0.04). Likewise, a significant decrease in both mean and median intraoperative blood loss (P = 0.003; P0.0001) was seen with LigaSure in the case-matched analysis. In the soft-tissue sarcoma subgroup, a significant decrease was observed in mean hemoglobin reduction (P = 0.03) and mean intraoperative blood loss with LigaSure (P = 0.04). No adverse perioperative complications attributed to the LigaSure system were identified.The LigaSure vessel sealing and dividing system is a safe and effective hemostatic tool for deep dissection in bone and soft-tissue sarcoma surgery.Level III, therapeutic study.

Patient-reported outcome measures (PROMs) are commonly utilized to assess patient-derived orthopaedic health status and function. The prevalence of limited musculoskeletal health literacy (MHL) has been demonstrated to be high within the orthopaedic literature. The purpose of this study was to evaluate the association between MHL and upper extremity-specific PROMs and to determine which patient- and symptom-related factors affect baseline PROMs in patients with atraumatic shoulder pain.Patients with limited MHL would demonstrate lower median scores on baseline PROMs compared with those with adequate MHL.New patients with atraumatic shoulder pain presenting to an academic practice were administered the Literacy in Musculoskeletal Problems (LiMP), in addition to the American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Single Assessment Numeric Evaluation (SANE) questionnaires. A detailed physical exam and history was performed by a fellowship-trained shoulder surgeon. Demographic patient data, in addition to prior imaging and orthopaedic treatment, was tabulated. The association between demographics, pain-related variables, and MHL with the ASES, SANE, and QuickDASH scores were examined using Spearman correlation coefficients for continuous variables and Wilcoxon rank-sum tests for categorical variables. Non-parametric analysis of covariance (ANCOVA) was used to examine the independent association of predictor variables with PROMs.A total of 439 patients met the inclusion criteria and were enrolled. The mean age was 58.8±12.6years (range: 24-93) with 162 (37%) being men. Overall, 172 patients (39.2%) attained a college degree or higher and 183 (41.7%) were currently employed. MHL was significantly associated with ASES (p=0.03), but not with the QuickDASH (p=0.75) or SANE score (p=0.16). Similarly, age, having been in the medical profession or having previously visited an orthopaedist were not associated with PROMs, while employment status correlated to the SANE score (p=0.002). Visual Analogue Scale (VAS) pain level demonstrated varying strengths of association with each of the scores [ASES (r=-0.729, p0.001), QuickDASH (r=0.557, p0.001), and SANE (r=-0.430, p0.001)]. MHL demonstrated no association with initial patient-derived treatment selection.The SANE and QuickDASH may be administered to patients presenting for atraumatic shoulder pain in the outpatient setting regardless of MHL. Further research should be focused on the utility of the ASES instrument amongst patients with lower educational levels and/or limited MHL.II; diagnostic.

BACKGROUND CONTEXT When examined as a collective group, NMS has a worse prognosis and surgical outcomes than its AIS counterpart. However, not all operative patients with diagnoses of cerebral palsy, Duchenne muscular dystrophy or other NMS pathology necessarily suffer similar poor outcomes associated with the class. PURPOSE Our aim is to examine more mildly affected NMS patients to determine whether their surgical outcomes are comparable to AIS with regards to patient safety. STUDY DESIGN/SETTING Ambispective review PATIENT SAMPLE Radiograph and retrospective chart review of NMS and AIS patients undergoing PSF with pedicle screws from 2005-2018 were analyzed. OUTCOME MEASURES intraoperative parameters and radiographic measurements were collected at pre- and postoperatively. METHODS Group 1 included NMS patients who could ambulate without assistance (GMFCS I-III). Group 2 was AIS patients. Demographics, Wilcoxon rank sums tests and chi-square tests were performed. RESULTS Group 1 (n = 48) and Group 2 (n = 158) were similar in age, sex, preoperative kyphosis, pre- and postoperative Cobb angle, and Cobb correction. Additionally, EBL (p=0.143), postoperative transfusions (p=0.5), and perioperative complications within 30 days (p=0.5) were similar between groups. Infections (p = 0.592), DVT (p = 0.232), revisions (p = 1.0), and mortality (p = 1.0) were statistically similar. Group 2 NMS patients did have increased fusion levels (p CONCLUSIONS NMS inherently confers high risk of blood loss, longer surgeries and fusions, complications, ICU and hospitals stays. Our data confirms longer fusion levels, surgical time and hospital stay with lower extubation rates. Infection rate, revisions and overall complications were similar to AIS population as were the radiographic outcomes. This suggests that NMS patients who are ambulating can expect surgical outcomes quite comparable to AIS patients with further room for improvement in surgical duration and anesthesia protocols. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND DATA Pedicle screws placement remains technically demanding. The thoracic curve apex is considerably difficult due to its unique morphology and severe rotation. In comparison the upper end vertebrae have smaller pedicles and limited soft tissue exposure. This study seeks to evaluate the likelihood of screw misplacement at the end vertebra and apex. METHODS A retrospective review of preoperative and postoperative computed tomographic (CT) scans of spinal deformity patients who underwent posterior spinal fusion with pedicle screw constructs between 2004 and 2011 was performed. Pedicles located at the upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV), and the major and minor apices were evaluated. Pedicle morphology was studied on preoperative CT and screw placement on postoperative CT. RESULTS In total, 188 patients met the inclusion criteria, 172 had preoperative CT scans and 133 had postoperative CT scans. The UIV had a significantly lower percentage of normal pedicles (type A) compared with apex major, apex minor, or LIV (59.1% vs. 76.1% vs. 77.3% vs. 98.7%; P

Purpose To evaluate sensitivity, specificity and accuracy of a radiographic slipped capital femoral epiphysis (SCFE)-diagnosis among medical specialists. Methods Three paediatricians, three paediatric radiologists and three paediatric orthopaedic surgeons completed two rounds of a survey of anteroposterior and frog-leg lateral radiographs of patients with a diagnosis of SCFE (25), femoroacetabular impingement (four), Legg-Calvé-Perthes (11) or no hip pathology (ten). Intra- and interobserver agreement among specialties regarding the diagnosis of a SCFE were assessed using Cohen's kappa coefficient (κ). Diagnostic accuracy of SCFE relative to the benchmark, a combination of the radiographic diagnosis based on Klein's line, clinical symptoms and surgical treatment, was assessed computing sensitivity, specificity and accuracy. Results Intraobserver agreement between the surveys was moderate among paediatricians (κ-range, 0.44 to 0.52), moderate to almost perfect among orthopaedic surgeons (κ-range, 0.79 to 0.88) and almost perfect among paediatric radiologists (κ-range, 0.83 to 1.00). Interobserver agreement for survey 1 and 2 was slight among paediatricians (mean κ, 0.19), substantial among orthopaedic surgeons (mean κ, 0.77) and almost perfect among paediatric radiologists (mean κ, 0.86). Sensitivity of SCFE-diagnosis was high among radiologists and orthopaedic surgeons (88% to 100% for both specialties), but lower for paediatricians (24% to 76%). Specificity was high among radiologists and orthopaedic surgeons (72% to 84%), however, variable among paediatricians (56% to 80%). Accuracy of a SCFE-diagnosis was highest in radiologists (84% to 92%), followed by orthopaedic surgeons (80% to 88%) and paediatricians (48% to 78%). Conclusion SCFE can be detected on radiographs by different medical specialties. Intra- and interobserver agreement, specificity, sensitivity and accuracy for radiographic SCFE-diagnosis amongst paediatric radiologists and orthopaedic surgeons are better than that of general paediatricians. Level of Evidence II

BACKGROUND CONTEXT Neuromuscular scoliosis patients have a purportedly higher postoperative complication rate than those with adolescent idiopathic scoliosis. Of these, gastrointestinal (GI) issues are clinically well observed. However, there is limited data on the prevalence of postoperative GI complications, and the preoperative indicators that may predict them. PURPOSE The focus of this study is to determine the incidence and risk factors of gastrointestinal complications after neuromuscular scoliosis correction. STUDY DESIGN/SETTING Retrospective case review. PATIENT SAMPLE Inclusion criteria focused on pediatric scoliosis patients ( OUTCOME MEASURES Radiographic, clinical and hospital stay data was assessed. Patients were compared according to their postoperative gastrointestinal (GI) complication status. PO GI issues were described as either major or minor complications. Minor complications included continued nausea/vomiting, constipation, diarrhea and distention. Major complications included extended paralytic ileus, dysphagia, g-tube infections and gastroparesis based on literature and clinical experience. METHODS An IRB approved, retrospective case review of patient records from 2013 – 2019. Data was presented as median and interquartile values in order to avoid the effects of outsider values. Statistically, Fisher's Exact, Kruskal-Wallis and Chi-Squared tests were used. RESULTS We included a total of 69 patients, of which, 36 developed PO GI issues. Age and BMI values were similar for both groups of patients (p = 0.367, p = 0.371). Of the patients that developed PO GI complications, the overwhelming majority exhibited minor complications only (94.3%). PO GI patients had a significantly longer length of stay (9 vs 6 days, p = 0.004). While preoperative major Cobb angles were similar, patients that developed PO GI issues had a significantly higher preoperative pelvic obliquity (15.80 cm vs 7.55 cm, p = 0.040). Patients that developed PO GI issues were overwhelmingly classified with ASA scores of 3 or 4 (96.6%), were more likely to have a preoperative gastrostomy tube (p CONCLUSIONS Spasticity, the presence of a pre-existing GI issue, presence of a g-tube, and notable pelvic tilt appear to be significant risk factors for postoperative gastrointestinal complications in neuromuscular scoliosis patient. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Incidence of proximal junctional kyphosis (PJK) in Scheuermann's Kyphosis (SK) varies between 24–40%. Multiple factors have been implicated, including: overcorrection of kyphosis, failure to include the proximal end vertebra and choice of implants. Recently, studies have attempted to analyze pelvic parameters in SK, including lumbopelvic mismatch. However, the issue remains unresolved. PURPOSE This study aimed to determine the goal correction parameters based upon patients’ kyphosis, pelvic incidence, and UIV to prevent PJK in Scheuermann's Kyphosis. STUDY DESIGN/SETTING Retrospective Chart Review. PATIENT SAMPLE A total of 96 Sheuermann Kyphosis patients undergoing correction procedures with all pedicle screws (PS), hybrid fixation (HF) or anterior/posterior fusions with hybrid fixation (AP). OUTCOME MEASURES Kyphosis minus pelvic incidence > -10° was determined to be normal. T1/T2 were grouped together as proximal fusion group compared to T3 and distal group. METHODS X-ray and chart review of all SK patients analyzed and compared. RESULTS 96 total patients: PS (n=41), HF (n=24), and AP (n=31). Overall, at early postop 12/96 (12.5%) patients had PJK. At final follow-up 33/96 (34.4%) had PJK. There was no significant difference between groups at early postop (p = 0.86) or final follow-up (p = 0.67). When correcting Kyphosis-PI to > -10° and UIV was chosen to be T1 or T2, PJK developed in 6% of patients. When fusing to T1/T2 and having kyphosis-PI -10° but UIV chosen at T3 or below, 77.8% of patients developed PJK. When fusing to T3 or below and failing to correct kyphosis-PI to > -10°, 37% of patients developed PJK. CONCLUSIONS While surgical techniques and implants do not seem to have a substantial role in development of PJK, selecting proximal UIV and avoiding Kyphosis-PI mismatch can significantly decrease this possibility. Surgeons treating Scheuermann's Kyphosis should, therefore, aim to correct kyphosis closer to patient's pelvic incidence. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

MINI: The objective of this study was to evaluate the accuracy and reliability of pedicle screw placement using O-Arm at dosages below the manufactured recommended dose. O-Arm at reduced dose showed a 90% accuracy when compared with computed tomography; however, about 30% medial breaches were misclassified.Cadaveric study.The objective was to evaluate O-Arm's ability at low-dose (LD) settings to assess intraoperative screw placement.Accurate placement of pedicle screws is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intraoperative imaging of patient's anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structures. We hypothesize using LD or ultra-low doses (ULDs) to obtain intraoperative images allow for accurate assessment of screw placement, both minimizing radiation exposure and preventing screw misplacement.Eight cadavers were instrumented with pedicle screws bilaterally from T1 to S1. Screws were randomly placed using O-arm navigation into three positions: contained within the bone, OUT-anterior/lateral, and OUT-medial. O-arm images were obtained at three dosage settings: LD (kVp120/mAs125-lowest manufacturer recommended), very-low dose (VLD) (kVp120/mAs63), and ULD (kVp120/mAs39). Computed tomography (CT) scan was performed using institution's LD protocol (kVp100/mAs50) and gross dissection to identify screw positions.LD, VLD, ULD, and CT for identifying "IN" screws relative to gross dissection had, a mean (standard deviation) sensitivity of 84.2% (±5.7), specificity of 76.1% (±9.3), and accuracy of 79.9% (±3.1) from all three observers. Across the three observers, the interobserver agreement was 0.67 (0.61-0.72) for LD, 0.74 (0.69-0.79) for VLD, 0.61 (0.56-0.66) for ULD, and 0.79 (0.74-0.84) for CT. Effective doses of radiation (mSV) for LD O-arm scan was 2.16, VLD 1.08, ULD 0.68, and our LD CT protocol was 1.05.Accuracy of pedicle screw placement is similar for O-arm at all doses and CT compared to gross dissection. Interobserver reliability was substantial for VLD and CT. Approximately 30% of medial screw breaches are, however, misclassified. ULD and VLDs can be used for intraoperative navigation and evaluation purposes within these limitations.N/A.

BACKGROUND CONTEXT Increased surgical volume has been associated with improved perioperative outcomes after spinal deformity correction. However, there is a lack of information on how this may affect hospital costs. PURPOSE To determine whether high volume surgeons have lower costs than low-volume surgeons in spinal deformity surgery. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE This study included 335 AIS patients. OUTCOME MEASURES Age, BMI, Cobb, kyphosis, surgical time, anesthesia time, transfusion, blood products, overall hospital costs, extubation rate, return to ED. METHODS A retrospective study of adolescent idiopathic scoliosis (AIS) patients undergoing PSF from 2013 – 2019 was performed. Demographic, XR, chart review and hospital costs were collected and compared between high-volume (HV) surgeons (>50 AIS cases/yr) and low-volume (LV) surgeons (≤50/yr). Comparative analyses were computed using Wilcoxon Rank-Sum, Kruskal-Wallis, and Fisher's exact tests. Median values with corresponding IQRs were reported. RESULTS A total of 335 patients (HV: 198, LV: 137) operated by 4 surgeons (1 HV, 3 LV). Radiographic parameters were similar between the groups. HV surgeons had significantly lower EBL (325v600 mL, p CONCLUSIONS High volume surgeons had lower transfusion rates, shorter surgery time and were more likely to be extubated in the OR than their low volume counterparts. In addition, high volume surgeons had lower overall costs compared to low volume surgeons. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Studies have shown that narcotic substance addiction has been on a rise across all patient populations, including pediatrics. Narcotics have long been used in complex spine surgeries as a measure of pain control, and are often given in the form of patient-controlled analgesia (PCA) during postoperative recovery as well as take-home medication. PURPOSE The objective of this study was to report on one institution's use of single bolus microdose intrathecal morphine (ITM) during PSF for AIS and its comparison to patients whose pain was controlled with PCA. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE AIS patients undergoing PSF from 2011–2019 were reviewed. PCA patients were included in Group 1 and ITM in Group 2. OUTCOME MEASURES Intraoperative clinical data (operative time, estimated blood loss), postoperative hospital stay course, request for prescription refill, morphine equivalence. METHODS In 2018, we instituted an RRP for scoliosis patients undergoing PSF utilizing intrathecal micro dose ITM. Previously, PCA was the mainstay for postop pain management. In the ITM protocol, patients receive 1.5 mcg/kg ITM diluted in 1 cc saline administered preoperatively by anesthesiologists or intraoperatively by the surgeon. Postoperatively, patients received IV ketorolac at 0.5mg/kg Q6h, PO Tylenol (15 mg/kg q6h), PO oxycodone (0.1 mg/kg q4), and IV hydromorphone (15 mcg/kg) for breakthrough pain. At discharge, PCA patients received 14-day prescriptions for 5mg oxycodone q6 compared to just 7-day prescriptions in the ITM group. Charts from 2011 – 2019 were reviewed. PCA patients were included in Group 1 and ITM in Group 2. Periop data and patient requests for prescription refills were analyzed and compared using Kruskal-Wallis and chi-squared tests. RESULTS A total of 340 patients (PCA: 215; ITM:125). Levels fused (p = 0.325) and BMI (p = 0.746) were similar. Patients in Group 1 had a significantly higher median length of stay (p CONCLUSIONS This is the first study showing that use of microdose ITM with oral analgesics have significantly better postoperative pain control and perioperative outcomes to PCA in the AIS population following PSF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Hemivertebra excision in patients with congenital scoliosis is believed to give the best possible correction. It is, however, a technically challenging procedure and complications can include spinal cord injury, nerve root injury and CSF leak. We have utilized a hemivertebra-sparing approach in these patients alongside multi-level Ponte osteotomies and all pedicle screw constructs. PURPOSE To determine if this approach leads to similar perioperative correction and radiographic outcomes to AIS patients. STUDY DESIGN/SETTING A retrospective case-controlled matched study. PATIENT SAMPLE Twenty-four patients with congenital scoliosis and associated hemivertebra compared with the most recent 54 AIS correction surgeries with 2-year follow-up. OUTCOME MEASURES Curve correction, surgical time, blood loss, complications, length of stay, levels fused, fixation points. METHODS Twenty-four patients with congenital scoliosis and associated hemivertebra were included. These 24 patients were compared with the most recent 54 AIS correction surgeries with 2-year follow-up. An additional rigorous analysis was done to match hemivertebra patients from a database of 330 AIS patients. Patients were matched based on gender, age, BMI, and preop Cobb. Overall, 12 pairs (24 patients) were matched and analyzed. RESULTS When comparing hemivertebra to AIS patients, age (p=0.81), BMI (p=0.24) and preop Cobb (p=0.06) were similar. Postop Cobb (p=0.048) was significantly larger for AIS patients, however, overall Cobb correction was similar (p=0.29). Blood loss was similar (p=0.09) while surgical time (p CONCLUSIONS Patients with hemivertebra can benefit from hemivertebra sparing approach. The XR and periop outcomes were similar to AIS patients. This approach is safer compared to hemivertebra excision with similar or better curve correction than previously reported. Choosing fusion levels on similar principles akin to AIS leads to avoidance of hemivertebra excision in most cases including lumbosacral hemivertebra cases. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study design Retrospective chart review. Objective To determine if obtaining a prone computed tomography (CT)-scan can better delineate a questionable screw-aorta relationship. Summary of background data Pedicle screw misplacement rate is reported between 6% and 15%. Studies looking at misplacements on a per patient basis show up to 14% of patients have screws at risk (impinging vital structures). A screw abutting the aorta is a management challenge and often requires vascular surgery intervention. However, CT scans routinely done in supine position may overestimate screw-aorta relationship. Change in patient position may allow the aorta to roll away and, in most cases, reveal an uncompromised aorta. This will allow safe removal of pedicle screws without any vascular intervention. Methods One hundred eleven spinal deformity patients who underwent Posterior spinal fusion from 2004 to 2009 were evaluated. Patients with concerning screw-aorta relationship underwent additional prone CT scan. Mobility of the aorta was determined and distance was compared using prone and supine CT scans. Results Two thousand two hundred ninety five screws were reviewed, 36 screws in 18 patients were in proximity to the aorta. Fourteen screws (nine patients) appeared to be impinging the aorta. On prone CT, 13 out of the 14 instances the aorta moved away from the screw. The average distance at the screw level was 13.6 ± 4.8 mm in supine position and 8.9 ± 5.4 mm in prone position (P = 0.001). In one instance the relationship was unchanged on prone CT. No screw was noted to violate the lumen or distort the aorta. Conclusion Supine CT scan alone is not entirely accurate in determining screw-aorta relationship. Prone-CT scan provides additional information for better delineation. This additional diagnostic step can change the treatment option by limiting the need for vascular intervention. When in doubt, the additional use of an arteriogram can allow for improved visualization. Level of evidence 3.

Retrospective chart review of prospectively collected data. This study seeks to evaluate the effect of number of surgeons, surgeon experience, and surgeon volume on AIS surgery. Recent literature suggests that utilizing two surgeons for spine deformity correction surgery can improve perioperative outcomes. However, the surgeon’s experience and surgical volume are likely as important. AIS patients undergoing PSF from 2009 to 2019 were included. Patient demographics, X-ray and perioperative outcomes were collected and collated based on primary surgeon. Analysis was performed for single versus dual surgeons, surgeon experience (≤ 10 years in practice), and surgical volume (less/greater than 50 cases/year). Median (IQR) values, Wilcoxon Rank Sums test, Kruskal–Wallis test, and Fisher’s exact test were utilized. 519 AIS cases, performed by 4 surgeons were included. Two surgeons were highly experienced, 1 of whom was also high volume. Five cohorts were studied: a single senior high volume (S1) (n = 302), dual-junior surgeons (DJ) (n = 73), dual senior–junior (SJ) (n = 36), dual-senior (DS) (n = 21) and a single senior, standard-volume surgeon alone (S2) (n = 87). Radiographic parameters were similar between the groups (p > 0.05). Preoperative Cobb was significantly higher for DS compared to S1 (p = 0.034) Pre- and post-op kyphosis were similar (p > 0.05). Cobb correction was similar (p > 0.05). Levels fused, fixation points, anesthesia and surgical times were similar (p > 0.05). When the standard-volume surgeon operated with a second surgeon, radiographic parameters were similar (p > 0.05), but anesthesia time, surgical time, and hospital length of stay were significantly shorter (p

INTRODUCTION This study establishes the construct validity of a low-cost training platform designed for high-repetition training of the skills required for fluent use of the five specific tools described for free-hand pedicle screw placement and breach avoidance. METHODS A total of 19 participants were included and divided into three groups based on spine surgery experience. Participants were asked to place five pedicle screws into the model. The performance was assessed by recording breaches, technical criteria (0 to 44 points), time to completion, and angulation of the screws. Success (no breaches, no protrusions) frequency (success/time) was calculated and analyzed. RESULTS Participants included three spine surgeons, seven advanced trainees (who had placed >10 pedicle screws), and nine inexperienced trainees. None of the screws placed by the spine surgeons breached the pedicle wall. Eight of 35 screws placed by advanced trainees (22.9%) and 31 of 45 screws placed by inexperienced trainees (68.9%) had a pedicle breach. Spine surgeons had a higher median success frequency compared with inexperienced trainees and advanced trainees (P = 0.015). The time needed to place a screw decreased over time (P < 0.0001). There was a trend toward an association between increased training level and decreased time to place five screws (P = 0.076). Increased training level was associated with greater total points scored (P < 0.0001). More screws placed by inexperienced trainees were further away from the ideal pedicle axis compared with those placed by advanced trainees or spine surgeons. CONCLUSION An association exists between training level and performance on the pedicle screw model, which suggests construct validity when evaluating our model's use for teaching surgeon learners. The model is easily assembled and is an alternative spine surgery training tool that overcomes limited availability and considerable costs of other training platforms. It can be used in high repetition to establish tool-skill fluency. LEVEL OF EVIDENCE Level I.

Evaluation of a child's intoeing gait is one of the most common referrals made to a pediatric orthopedist. Families may have difficulty understanding the often transient and usually benign nature of intoeing. The purpose of this study was to investigate parental perceptions of an intoeing gait both before and after consultation with an orthopedic practitioner.48 parents of children referred to pediatric orthopedic surgeons for evaluation of intoeing gait completed a 22-item questionnaire that assessed demographics, anxiety, and parental perceptions of intoeing. Questionnaires were administered before and after visits. Statistical analysis was performed using Wilcoxon signed-rank tests and Fisher exact tests.Before their visits, parents reported similar levels of anxiety and understanding regarding intoeing, independent of their age or education. After the visits, anxiety decreased (P 0.001), and understanding increased (P 0.001) although younger parents (18-25 years) reported higher post-visit anxiety compared to parents older than 25 (P = 0.014). Similarly, parents with a high school degree or less reported higher post-visit anxiety compared to parents who attended college (P = 0.009). Post-visit understanding was inversely correlated with post-visit anxiety (r = -0.717; P 0.001). Additionally, parents who reported high anxiety post-visit stated they were more likely to seek additional care (P 0.001).Younger parents with lower education levels were more likely to leave visits with high anxiety and poor understanding. These parents were more likely to consider seeking further treatment for their child's intoeing, placing additional stress on their child, themselves and an overburdened healthcare system.

Retrospective review of magnetic resonance imaging (MRI) and computed tomographic (CT) scan imaging modalities.To determine MRI's capability of identifying pedicle morphology.Understanding pedicle morphology is important for accurate placement of pedicle screws. The gold standard modality to assess pedicle morphology is CT scan. However, CT scans carry the risk of radiation exposure. We have studied MRI as a potential alternative to CT scan.Nine hundred seventy pedicles in 33 spinal deformity patients were reviewed. Pedicle morphology was classified as follows: Type A (normal pedicle):4-mm cancellous channel; Type B: 2-4-mm channel; Type C: any size cortical channel; and Type D:2-mm cortical or cancellous channel. Pedicles in the same patients were classified on both low-dose CT scan and MRI. Concordance and discordance rates of MRI relative to CT scan in classification of pedicles into types A, B, C, and D were calculated for the entire length of the thoracolumbar spine and subgrouped into spinal sections. All images were evaluated by a single fellowship-trained musculoskeletal radiologist.CT scan had 809 Type A, 126 Type B, 29 Type C, and 6 Type D pedicles. Group II (MRI) had 735 Type A, 203 Type B, 30 Type C, and 2 Type D pedicles. Analysis of the entire spinal column showed a concordance rate of 86.7% in classification of the pedicles into the 4 types. In the upper thoracic region, the concordance rate was 77.1%, main thoracic 85.5%, thoracolumbar 96%, and lumbar 98.1%. MRI has a poor overall accuracy for detecting Type C pedicles, only a 44.8% concordance with CT scan. MRI overcalls Type B pedicles, often calling Type A pedicles Type B.MRI is an inferior alternative to CT scan as it has poor accuracy to properly detect pedicle abnormalities. The more severe the pedicle abnormality, the less diagnostic value the MRI has.Level III, diagnostic.

Study design A retrospective review of charts, x-rays (XRs) and computed tomography (CT) scans was performed. Objective To evaluate the accuracy of pedicle screw placement using a novel classification system to determine potentially significant screw misplacement. Summary of background data The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. Methods A retrospective review of charts, XRs and low-dose CT scans of 127 patients who underwent spinal fusion with pedicle screws for spinal deformity was performed. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). Results A total of 2724 screws were placed in 127 patients. A total of 2396 screws were placed accurately (87.96%). A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. Per-patient analysis showed 23 (18.11%) of patients had all screws AP. Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. Over 40% of patients had screws with either some/major concern. Conclusion Overall reported screw misplacement is low, but it does not reflect the potential impact on patient morbidity. Per-patient analysis reveals more concerning numbers toward screw misplacement. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. Better strategies need to be devised for evaluation of screw placement, including establishment of a national database of deformity surgery, use of intra-operative image guidance, and reevaluation of postoperative low-dose CT imaging. Level of evidence 3.

BACKGROUND CONTEXT Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is a complex procedure for which charges can exceed $150,000. Among the total costs, inpatient and intensive unit care contributed 22%. Many institutions have implemented rapid recovery pathways (RRP) to improve patient care following scoliosis surgery. This study aims to determine the effects of a multimodal RRP, utilizing intrathecal morphine (ITM) in combination with oral pain medication, on hospital costs and patient management. PURPOSE The purpose of this study was to determine whether a protocol that excludes postoperative patient care analgesia (PCA) with the utilization of preoperative/intraoperative ITM had similar or superior outcomes, including hospital costs. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE AIS patients undergoing PSF from 2013 – 2019. OUTCOME MEASURES Hospital stay data, requests for opioid refill and overall costs. METHODS AIS patients undergoing PSF from 2013 – 2019 were retrospectively reviewed. RRP patients received ITM as part of their multimodal analgesia. Fusion level-matched control patients received hydromorphone PCA for postoperative pain management. At discharge, PCA patients received 14-day prescriptions for oxycodone compared to 7-day prescriptions in the ITM group. Perioperative data, requests for opioid refill, and overall costs were analyzed. RESULTS A total of 363 patients were included (PCA: 255, RRP/ITM: 108). BMI (p=0.786) and preoperative Cobb (p=0.343) were similar. RRP patients had a significantly shorter length of stay (3 vs 5 days, p CONCLUSIONS With increasing concerns about opioid dependence and hospital costs, our RRP pathway, which incorporates microdose ITM injections, allows for optimum perioperative management, improved costs, with overall better outcomes than the traditional PCA. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Rett syndrome (RS) patients often present with scoliosis, which requires surgical correction. However, literature is limited and reports major surgical complications including respiratory failure, prolonged intubation, infections, significant blood loss, and prolonged hospital stay. Cerebral palsy (CP) patients undergoing scoliosis surgery may be comparable to RS patients. They are often nonverbal, nonambulatory with frequent respiratory and surgical complications. Most surgeons have comparatively more experience treating CP patients than RS. PURPOSE The objective of this study is to compare perioperative outcomes of RS and CP patients. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE A total of 27 RS and 78 CP patients undergoing PSF from 2005-2018. OUTCOME MEASURES Cobb, kyphosis, pelvic obliquity, coronal decompensation, extubation rate, complication rate, EBL, surgical time, anesthesia time, levels fused, fixation points, METHODS Patient demographics, perioperative parameters, and X-ray measurements were collected at pre, post, and follow-up. Furthermore, a subanalysis was performed comparing the nonambulatory patients. Wilcoxon rank sums test and chi-square tests were utilized. RESULTS No significant difference for preop Cobb angle (p=0.16), kyphosis (p=0.20), and pelvic obliquity (p=0.09). No significant difference for fixation points (p=0.42), levels fused (p=0.79), time to extubation (p=0.53), complication rate (p=0.66), length of ICU (p=0.07) or hospital stay (p=0.71). EBL was significantly higher in CP patients (p=0.006) as was duration of anesthesia (p=0.04), and transfusion volume (p=0.01). However, surgical time (p=0.07) was similar. Postop Cobb (p=0.008) was significantly higher for CP, but kyphosis (p=0.18) and pelvic obliquity (p=0.09) were similar. Significant difference was found between both preop (p=0.02) and postop (p=0.03) coronal decompensation. Subanalysis of nonambulatory Rett and CP patients showed no significant difference in outcomes. CONCLUSIONS RS patients are comparable to CP patients in terms of surgical, periop, and radiographic outcomes. CP patients had significantly more EBL, intraop transfusions, and longer anesthesia time. The subjects did not differ in their ICU or hospital stays, nor their complication rate. Outcomes and periop expectations of RS patients are similar to CP. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

STUDY DESIGN A retrospective study. OBJECTIVE To determine the incidence of pedicle screws close to vital structures and to identify patient or curve characteristics that increase the risk of screw misplacement. SUMMARY AND BACKGROUND Most pedicle screw misplacements are asymptomatic, thus they are frequently undetected. This study identifies the rate of screw placement in proximity to vital structures using postoperative computed tomography scans. METHODS A total of 2132 screws in 101 patients, who underwent posterior spinal fusion for spinal deformity, were reviewed. Screws adjacent to great vessels and viscera were identified and evaluated. Patients with screws at risk (group B) were compared with patients without screws at risk (group A). Patient and curve characteristics were analyzed to determine whether a correlation with screw misplacement exists. RESULTS A total of 40 at risk screws (∼2%) were identified in 25 patients (∼25%). These 40 screws were in proximity to the aorta (31), left subclavian artery (1), esophagus (3), trachea (3), pleura (1), and diaphragm (1). Of the 31 screws close to the aorta, 10 screws in 6 patients were impinging or distorting the aortic wall. One hundred percent of misplaced screws were in the thoracic spine, 50% were misplaced laterally, 50% were 35 mm long, 57.5% were in pedicles with normal morphology, and 75% were in curves between 40 and 70 degrees. Median screw misplacement rate was 10% in group A and 13% in group B. Adjusted for age and preoperative Cobb angle, patients with a higher misplacement rate were more likely to have screws adjacent to vital organs [adjusted odds ratio: 1.06 (95% confidence interval, 1.01-1.13), P=0.033]. CONCLUSIONS Although only a small number of screws were at risk, they occurred in a large percentage of patients (25%). A single at-risk screw causes a significant complication for the patient. Postoperative imaging beyond routine x-rays may be needed to detect at-risk screws in asymptomatic patients.

BACKGROUND CONTEXT PS misplacement rate is reported between 6-15%. Studies looking at misplacements on a per patient basis show up to 14% of patients have screws at risk (impinging vital structures). A screw abutting the aorta is a management challenge and often requires vascular surgery intervention. However, CT scans routinely done in supine position may overestimate screw-aorta relationship. Change in patient position may allow the aorta to roll away and, in most cases, reveal an uncompromised aorta. This will allow safe removal of pedicle screws without any vascular intervention. PURPOSE To assess whether prone CT helps delineate the aorta-pedicle screw relationship. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 111 patients with post-op CT, who underwent PSF for spinal deformity, from 2004-2009. OUTCOME MEASURES Distance of pedicle screw from posterior margin of Aorta. METHODS A total of 111 patients with post-op CT, who underwent PSF for spinal deformity, from 2004-2009, were evaluated. Patients with concerning screw-aorta relationship underwent a prone CT scan. Mobility of the aorta was determined by measuring between a line drawn from the posterior margin of the aorta, perpendicular to the long axis of the screw, and a parallel line passing through the anterior margin of the body of the vertebra (in mm). This distance was compared using prone and supine CT scans. Paired t-test and signed rank tests were utilized. RESULTS There were 2,295 screws were reviewed, 45 screws in 27 patients were in proximity to the aorta. Thirty-six of these were in close proximity, but not impinging (>1cm aorta-screw distance). Fourteen screws (7 patients) were impinging ( CONCLUSIONS Supine CT-scan alone is not entirely accurate in determining screw-aorta relationship. Prone-CT scan provides additional information for better delineation. This additional diagnostic step can change the treatment option by limiting the need for vascular intervention. When in doubt, the additional use of an arteriogram can allow for improved visualization. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Return to the ED continues to be a quality measure in health care. The purpose of this study was to describe one institution's experience with visits to the ED following spinal deformity surgery. There were 11.8% of patients returned to ED within 90 days mostly with medical complaints – more than half by 30 days. There were no risk factors identified, however, a majority of complaints appear to be preventable. PURPOSE Return to the hospital after surgery is frequently being used as a quality metric. The purpose of this study is to evaluate the reasons and risk factors for ED visits less than 90 days. STUDY DESIGN/SETTING Ambispective chart review. PATIENT SAMPLE A total of 346 patients were included: 274 idiopathic scoliosis, 48 neuromuscular, 10 Scheurmann's kyphosis, 3 spondylolisthesis (grade 4), and 11 other. OUTCOME MEASURES Return to ED with medical-related complaints, return to ED with surgical-related complaints, age, BMI, preoperative kyphosis, levels fused. METHODS A review of spinal deformity surgeries between 2011-2018 was performed. Radiographic, operative and hospital stay data was collected. Median and interquartile range (IQR) was with Wilcoxon-Signed Rank and Kruskal-Wallis tests. Patients who returned to the ED for any reason within 90 days were analyzed. ED visits were categorized as medical and surgical. Medical visits included but not limited to fever, pain, and seizures. Surgical visits included but not limited to wound infection, and surgical site infection. RESULTS A total of 346 patients were included: 274 idiopathic scoliosis, 48 neuromuscular, 10 Scheurmann's kyphosis, 3 spondylolisthesis (grade 4) and 11 other. Forty-one patients (11.8%) returned to the ED within 90 days; 32 (78%) returned with medical-related complaints: pain (n=14), fever (n=6), constipation (n=4), spasm/seizures(n=2), syncope (n=3), fall (n=1) and dysnea (n=2). Nine patients (22%) returned with surgical-related complaints: drainage from incision (n=6), wound infection (n=2), and baclofen pump failure (n=1); 65.8% (n=27) returned to the ED within 30 days. There was no significant difference in age (13.19 vs 12.42 years, p=0.27), BMI (18.27 vs 17.13, p=0.33) preoperative Cobb (47.30 vs 46.0, p=0.731), preoperative kyphosis (16 vs 17, p=0.971), and levels fused (10 vs 11,=0.359) between those did not return to the ED and those who did. Blood loss (300 vs 350ml,p=0.973), surgical time (230 vs 228,p=0.180), and length of stay (4 vs 4, p=0.94) were also similar between the two cohorts. Neuromuscular distribution was also similar (12.8% vs 21.9%). CONCLUSIONS A total of 11.8% of patients returned to ED within 90 days, mostly with medical complaints – more than half by 30 days. Although no risk factors were found in this study, the findings present an opportunity to better improve discharge planning and care coordination. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Narcotic substance addiction has been on a rise across all patient populations. Narcotics are often given in the form of patient controlled analgesic (PCA) during postoperative hospital stay as well as take-home medication. PURPOSE The objective of this study was to report on one institution's use of intrathecal single micro-dose duramorph during surgery and its comparison to patients that had undergone traditional PCA. STUDY DESIGN/SETTING Prospective study. PATIENT SAMPLE A total of 270 patients (209 PCA; 61 Duramorph). OUTCOME MEASURES Pain score, levels fused, Cobb angle, length of stay, refills, surgical time, anesthesia time, cardiac complications, respiratory complications, days to ambulation, days to first meal, transfusion rate. METHODS In 2018, we instituted RRP for scoliosis patients undergoing PSF utilizing intrathecal micro dose duramorph. PCA used to be the mainstay for postop pain management. In the duramorph protocol, patients receive 1mcg/kg intraspinal morphine diluted in 1 cc saline administered preop by anesthesiologists or intraop by surgeon. AIS patients undergoing PSF from 2011 – 2018 were reviewed. PCA patients were included in Group 1(G1) and Duramorph in Group 2(G2). Periop data were analyzed. Fisher's exact test and Wilcoxon tests were utilized. RESULTS A total of 270 patients (PCA: 209;Duramorph:61). Median Cobb in G1 was 54° and 50° in G2(p CONCLUSIONS Using single use micro-dose Duramorph can eliminate the need for PCA with similar postoperative outcomes in a RRP. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Spinal deformity in asolescent idiopathic scoliosis (AIS) can increase right atrial and ventricular pressures secondary to restrictive lung disease. Pulmonary hypertension leading to cor pulmonale is the most feared outcome. However, mild pulmonary hypertension in AIS patients has been reported in the past. No study has examined these changes including the improvement of right heart function following scoliosis surgery. PURPOSE To determine if scoliosis repair resolves cardiac function abnormalities. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 363 patients: 184 AIS patients undergoing PSF, 179 healthty age-matched controls. OUTCOME MEASURES Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), PFTs, ABG, and patient demographics reviewed. Right ventricular systolic pressure (RVSP) was estimated using Bernoulli's equation (4[TRV]2) and right atrial pressure. METHODS Retrospective chart review. Group 1: 184 AIS patients, 10-22 years of age, undergoing PSF from 2009-2013 at a single institution. Group 2 control patients: 179 healthy, age-matched adolescents. Cobb angle, 2D-echo signs of structural heart disease, aortic root dimensions, tricuspid regurgitant jet velocity (TRV), PFTs, ABG, and patient demographics reviewed. Right ventricular systolic pressure (RVSP) was estimated using Bernoulli's equation (4[TRV]2) and right atrial pressure. RVSP ≥25 mmHg is a surrogate marker for pulmonary hypertension. All echocardiograms were read by board certified pediatric cardiologists. Group 3: 39 AIS patients from Group 1 with elevated preoperative TRV underwent corrective PSF. Logistic regression was used to assess for differences in TRV between groups. RESULTS Mean preop RVSP was significantly elevated in AIS patients (25.7 vs 17.3; p CONCLUSIONS This study found that 21% of patients with AIS had elevated TRV while age-matched controls had no TRV abnormalities. Additionally, RVSP measurements demonstrated mild pulmonary hypertension in AIS patients. These abnormal values normalized postop, indicating the benefits of scoliosis surgery on cardiac function in AIS. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Minimizing the fusion levels in PSF for AIS is important. Previous studies have shown good results utilizing TV as the lowest instrumental vertebrae (LIV). TV is the ‘touched’ vertebra determined by central sacral vertical line on standing AP XRs (TVS). We have found that TV moves proximally on supine/prone radiographs. Thus utilizing TV on prone XR (TVP) in LIV decision making may allow even shorter fusion. PURPOSE To assess whether the use of TVP to determine LIV saves fusion levels while maintaing good correction and coronal balance. STUDY DESIGN/SETTING Ambispective cohort study. PATIENT SAMPLE Group I contained 102 patients, undergoing PSF, in who TVP was used to determine LIV. Group II contained 26 patients, undergoing PSF, in who TVS was used to determine LIV. Group III contained 132 nonoperative AIS patients. Patients with only thoracic fusion were excluded. OUTCOME MEASURES Cobb angle, coronal balance (CB), LIV tilt angle and translation, and disc wedging were collected preoperatively and postoperatively. METHODS There were three groups. Group I: patients where TVP was used to determine LIV. Group II: patients where TVS was used to determine LIV. Group III: nonoperative AIS (Risser 4/5, Cobb RESULTS The control group had 132 patients with a median (IQR) Cobb of 20° (16-26), age of 16 (14.8-17), coronal balance 1.4 (0.5-2.2), disc wedging of 4° (2-5), and LIV tilt of 10° (7-13). In Group I (n=102), median preoperative Cobb was 53.8° and coronal balance was 1.8. Final Cobb was 12.4° and coronal balance was 0.9. Compared to controls, Group I patients had significantly less coronal imbalance (p =0.023), lower disc wedging (p>0.001) and LIV tilt (p 5° (p CONCLUSIONS In AIS, using TVP to determine LIV allows for shorter fusion. LIV tilt and disc wedging is also within ‘acceptable’ levels determined on controls. TVP is an effective and better way to determine the lowest instrumented vertebra. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study Design Retrospective case series. Objective The objective of this study was to determine the safety of postoperative radiographs to assess screw placement. Summary of Background Data Previously defined criteria are frequently employed to determine pedicle screw placement on intraoperative supine radiographs. Postoperatively, radiographs are typically used as a precursor to identify screws of concern, and a computed tomographic (CT) is typically ordered to confirm screw safety. Methods First, available postoperative PA and lateral radiographs were reviewed by 6 independently blinded observers. Screw misplacement was assessed using previously defined criteria. A musculoskeletal radiologist assessed all CT scans for screw placement. Pedicle screw position was classified either as acceptable or misplaced. Misplacements were subclassified as medial, lateral, or anterior. Results One hundred four patients with scoliosis or kyphosis underwent posterior spinal fusion and had postoperative CT scan available were included. In total, 2,034 thoracic and lumbar screws were evaluated. On CT scan, 1,772 screws were found to be acceptable, 142 were laterally misplaced, 30 medially, and 90 anteriorly. Of the 30 medially placed screws, 80% to 87% screws were believed to be in positions other than medial, with a median of 73% (63% to 92%) of these screws presumed to be in normal position. Similarly, of the 142 screws placed laterally, 49% to 81% screws were identified in positions other than lateral, with a median of 77% (59% to 96%) of these screws felt to be in normal position. Of the 90 anteriorly misplaced screws, 16% to 87% screws were identified in positions other than anterior, with 72% (20% to 98%) identified as normal. The criteria produced a median 52% sensitivity, 70% specificity, and 68% accuracy across the 6 observers. Conclusion Radiograph is a poor diagnostic modality for observing screw position. Level of Evidence Level IV.