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The substantial risk for medical complication after adult spinal deformity (ASD) surgery is well known. However, the timing of medical complications during the inpatient stay have not been previously described. Accurate anticipation of complications and adverse events may improve patient counseling and postoperative management.(1) Describe the rate of medical complication and adverse events by postoperative day after ASD surgery and (2) determine whether early ambulation is protective for complications.Single institution retrospective cohort study.Two hundred thirty-five patients with ASD who underwent posterior-only fusion of the lumbar spine (≥5 levels to the pelvis) between 2013 and 2020.Medical complications, categorized per the International Spine Study Group-AO system (cardiopulmonary [CP], gastrointestinal [GI], central nervous system [CNS], infectious [nonsurgical site], and renal) and adverse events (postoperative blood transfusion, urinary retention, and electrolyte abnormalities).Patients were identified from an institutional ASD database. Outcome measures were classified by the first postoperative day the event was recognized. Demographics, year of surgery, surgical factors, radiographic parameters, surgical invasiveness (ASD-S Index), frailty (Modified Frailty Index-5 [mFI-5]), Charlson Comorbidity Index (CCI), obstructive sleep apnea (OSA), smoking, preoperative opioid use, depression, and post-operative day of ambulation were assessed as risk factors for inpatient medical complications.After exclusions of patients with incomplete medical chart data, 191 patients were available for analysis, mean age 66±10 y, BMI 28±5 kg/m2, PI-LL 24±20°, T1PA 28±13°. Inpatient medical complications occurred in 55 (28.8%) patients; adverse events occurred in 137 (71.7%). Length of stay was higher in patients with medical complications (mean 8.5±3.8 vs. 5.8±2.3 days, p.001). However, for patients who had an adverse event, but no medical complication, LOS was comparable (p.05). Most medical complications occurred by POD3 (58% of all complications). Risk (defined as the proportion of patients with that complication out of all inpatients that day) of CNS, CP, and GI complication peaked early in the postoperative course (CNS on POD1 [2.1% risk]; GI on POD2 [3.7%]; CP on POD3 [2.7%]). Risk for infectious and renal complications (infectious POD8 [2.7%]; renal POD7 [0.9%]) peaked later (Figure 1). On univariate analysis, patients with medical complications had higher rates of OSA (9.1% vs. 2.2%, p=.045), ASD-S (45.9 vs. 40.8, p=.04), max coronal cobb (46.9 vs. 36.7°, p=.003), ASA class (2.5 vs. 2.3, p=.01), and POD of ambulation (1.9 vs. 1.3, p=.01). On multivariate logistic regression (c-statistic 0.78), larger coronal cobb and later POD of ambulation were independent risk factors for complications (OR 1.04, 95% CI 1.01-1.07 and OR 2.3, 95% CI 1.2-4.7, respectively).Our data may inform peri-operative management and patient expectations for hospitalization after ASD surgery. Early ambulation may reduce the risk of complications.

Glass-embedded into the PDMS microchannel of the sound activated nanosieve enabled high-efficiency capture of 500 nm nanoparticles at dramatically higher flow rates due to high acoustic reflectivity and energy retention within the fluid.

Retrospective review.To analyze if shoulder balance continues to change in the postoperative period in patients undergoing selective lumbar fusion for adult spinal deformity (ASD), and secondarily, analyze if shoulder balance correlates with health-related quality of life (HRQOL) outcomes.Shoulder balance in patients with ASD is poorly understood and has largely been extrapolated from adolescent scoliosis literature.Adult patients who underwent selective lumbar fusion (upper instrumented vertebra: Τ9-Τ12, lower instrumented vertebra: L4-Pelvis) for thoracolumbar or lumbar scoliosis (cobb angle30°) or sagittal plane deformity with thoracic compensatory curves (cobb angle10°) were identified. The clavicular angle (CA) was used to quantify shoulder balance. Shoulder balance was categorized into three groups postoperatively (balanced: CA2°, mild imbalance: CA 2°-4°, severe imbalance: CA4°). The average CA and proportion of patients in each shoulder balance group were compared at each postoperative period. Patients with 1-year postoperative HRQOL scores were identified.Eighty-six patients were included. The preoperative CA was 2.7 ± 2.3° and did not significantly change at discharge (2.9 ± 2.4°), 6-weeks (2.5 ± 2.1°), 6-months (2.4 ± 2.2°), 1-year (2.4 ± 2.5°), or 2-years (2.3 ± 1.5°) postoperatively. The proportion of patients in each shoulder balance group did not significantly change from discharge to 6-weeks, 6-months, 1-year or 2-years postoperatively (P 0.1). At 1-year follow-up, the CA demonstrated no significant correlation with Oswestry Disability Index, Scoliosis Research Society (SRS)-22 score, or SRS-22 subscores. There was no significant association between shoulder balance group and Oswestry Disability Index, SRS-22 score, or SRS-22 subscores.In patients with ASD undergoing selective lumbar fusion, shoulder balance did not change over the postoperative period. From a functional standpoint, shoulder balance demonstrated no correlation with HRQOL scores. In patients undergoing selective lumbar fusion for ASD, shoulder balance may not spontaneously correct over the postoperative period, but this may not be of functional consequence.Level of Evidence: 4.

Study Design Retrospective cohort study. Objectives To determine if standing pre-discharge radiographs can predict the development of junctional complications. Materials and methods Adult spinal deformity patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) were included. All patients underwent full-length standing radiographs before hospital discharge. Outcomes of interest included 2-year radiographic PJK and proximal junctional failure (PJF). Patients were stratified into 3 exclusive groups: No PJK, PJK, and PJF. Chi-square automatic interaction detection (CHAID) decision tree analysis was utilized to identify pre-discharge proximal junctional angle (PJA) thresholds associated with increased risk of PJK or PJF. Results The 117 study patients had a mean age 65.8 ± 8.5, BMI 27.2 ± 4.9, PI-LL 23.3 ± 17.4, TPA 27.2 ± 11.5. Sample was stratified into 64 (54.7%) No PJK, 39 (33.3%) PJK, 14 (12.0%) PJF. No differences were detected between cohorts in discharge alignment, preop-discharge change, or offset from age-adjusted alignment targets ( P > .005). Decision tree analysis showed that the first branch point depended on the UIV, as most patients with an UT UIV did not develop PJK or PJF (no PJK, 67.4%). For patients with an LT UIV, a second branch point occurred based on the ΔPJA. 89.5% of LT patients with a ΔPJA < 4.3° were free of radiographic PJK and PJF. The third branch point occurred based on the PJA at discharge. Thus, the highest risk group was comprised of ΔPJA ≥4.3° and PJA > 15.5°, as 57.1% of developed PJF and 28.6% PJK. Conclusion Most patients with a lower thoracic UIV, preop-discharge ΔPJA ≥4.3°, and discharge PJA > 15.5° develop PJF.

Background and Aims Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States and is closely associated with obesity and insulin resistance (IR). Weight loss is the best treatment for NAFLD. Endoscopic sleeve gastroplasty (ESG) is a promising endoscopic procedure for treatment of obesity. Our aim is to evaluate the change in IR and estimated hepatic steatosis and fibrosis after ESG. Methods One hundred eighteen patients with obesity and NAFLD underwent ESG and were followed for 2 years. Weight loss was evaluated as % total body weight loss. IR was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). The previously validated hepatic steatosis index and NAFLD fibrosis score were used to estimate hepatic steatosis and risk of fibrosis. Results Patients' mean body mass index was 40 ± 7 kg/m2 at baseline. Eighty-four percent of patients completed 2 years of follow-up. At 2 years, the mean total body weight loss was 15.5% (95% confidence interval, 13.3%-17.8%). Patients' HOMA-IR improved significantly from 6.7 ± 11 to 3.0 ± 1.6 after only 1 week from ESG (P = .019) with continued improvement up to 2 years (P = .03). Patients' hepatic steatosis index score improved significantly, decreasing by 4 points per year (P for trend, Conclusions Our results suggest a significant and sustained improvement in estimated hepatic steatosis and fibrosis after ESG in patients with NAFLD. Importantly, we showed an early and weight-independent improvement in insulin resistance, which lasted for 2 years after the procedure.

Study Design: Single-center retrospective analysis of prospectively collected data. Objective: Our aim was to compare the correction capacity in 3 planes of the VCA technique versus the AD technique in neuromuscular scoliosis patients. Methods: We analized patients with neuromuscular scoliosis that underwent posterior spinal fusion from 2013 to 2017 using 2 different techniques for correction: vertebral coplanar alignment (VCA) that takes into consideration the fact that the medial cortex is more resistant than the lateral cortex, with more anchor points for better distribution of forces and ligamentotaxis and the more widely spread apical derotation (AD) technique. Clinical, surgical, and radiographic information of patients operated on with the AD technique were compared to those operated on with the VCA technique in the coronal, sagittal and axial plane at pre-op, immediate post-op, and 2 year follow-up. Results: 64 patients met inclusion criteria, 34 patients underwent the VCA technique and 30 patients underwent the AD technique. The 2 cohorts did not differ in terms of demographics, clinical presentation or preoperative alignment. There were no significant differences in the correction ability between both techniques regarding curve magnitude, apical vertebral rotation, or pelvic obliquity. There was a significant decrease in thoracic kyphosis in the AD group compared to the VCA group in the immediate postop period (4.2 ± 26.6º for VCA and 13.2 ± 21.3º for AD (p = 0.048)). Conclusion: Both apical derotation technique and vertebral coplanar alignment allow for correction in the 3 planes for patients with neuromuscular scoliosis. VCA is a less hypokyphosing technique than AD.

STUDY DESIGN Retrospective review of prospective multicenter database. OBJECTIVE The aim of this study was to investigate how preoperative mental status affects preoperative and postoperative disability and health scores in adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA The relationship between health-related quality of life (HRQOL) and depression has previously been documented. However, the influence of depression on clinical outcomes among ASD patients is not well understood. METHODS ASD patients with minimum 2-year follow-up were stratified based on preoperative mental health measured by Short Form 36 (SF-36) mental component score (MCS). Patients with MCS in the 25th and 75th percentile of the cohort were designated as having low and high MCS, respectively. After matching by preoperative demographics and deformity, pre- and post-HRQOL were compared between the two groups. Further analysis was performed to identify individualized questions on the SF-36 that could potentially screen for patients with low MCS. RESULTS Five hundred thirteen patients were assessed (58.4 years' old, 79% women, mean MCS 45.5). Thresholds for low and high MCS cohorts were 35.0 and 57.3, respectively. After matching by preoperative alignment, low MCS patients had worse Oswestry Disability Index (ODI) (52.3 ± 17.0 vs. 35.7 ± 14.6, P

Study Design Retrospective cohort study. Objective Compare the supine vs standing radiographs of patients with adult spinal deformity against ideals defined by healthy standing alignment. Methods 56 patients with primary sagittal ASD (SRS-Schwab Type N) and 119 asymptomatic volunteers were included. Standing alignment of asymptomatic volunteers was used to calculate PI-based formulas for normative age-adjusted standing PI–LL, L4–S1, and L1–L4. These formulas were applied to the supine and standing alignment of ASD cohort. Analyses were repeated on a cohort of 25 patients with at least 5 degrees of lumbar flexibility (difference between supine and standing lordosis). Results The asymptomatic cohort yielded the following PI-based formulas: PI–LL = −38.3 + .41*PI + .21*Age, L4–S1 = 45.3–.18*Age, L1–L4 = −3 + .48*PI). PI–LL improved with supine positioning (mean 8.9 ± 18.7°, P < .001), though not enough to correct to age-matched norms (mean offset 12.2 ± 16.9°). Compared with mean normative alignment at L1–L4 (22.1 ± 6.2°), L1–L4 was flatter on standing (7.2 ± 17.0°, P < .001) and supine imaging (8.5 ± 15.0°, P < .001). L4-S1 lordosis of subjects with L1-S1 flexibility >5° corrected on supine imaging (33.9 ± 11.1°, P = 1.000), but L1–L4 did not (23.0 ± 6.2° norm vs 2.2 ± 14.4° standing, P < .001; vs 7.3 ± 12.9° supine, P < .001). Conclusions When the effects of gravity are removed, the distal portion of the lumbar spine (i.e., below the apex of lordosis) corrects, suggesting that structural lumbar deformity is primarily proximal.

Study Design: Retrospective cohort study. Objective: To investigate correlations between preoperative supine imaging and postoperative alignment. Methods: A retrospective review was conducted of a single-institution database of patients with adult spinal deformity (ASD). Patients were stratified by fusion location in the lumbar or thoracic spine. Outcomes of interest were postoperative lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal alignment parameters were compared and correlation analyses were performed. Multilinear stepwise regression was conducted to identify independent predictors of postoperative LL or TK. Regression analyses were repeated within the lumbar and thoracic fusion cohorts. Results: A total of 99 patients were included (mean age 63.2 years, 83.1% female, mean body mass index 27.3 kg/m2). Scoliosis Research Society classification demonstrated moderate to severe sagittal and/or coronal deformity (pelvic tile modifier, 18.2% ++; sagittal vertical axis, 27.3% ++, pelvic incidence minus lumbar lordosis mismatch, 29.3% ++, SRS type, 29.3% N type curve and 68.7% L or D type curve). A total of 73 patients (73.7%) underwent lumbar fusion and 50 (50.5%) underwent thoracic fusion. Correlation analyses demonstrated a significant association between pre- and postoperative LL and TK. Multilinear regression demonstrated that LL supine and pelvic incidence were significant predictors of postoperative LL ( r2 = 0.568, P < .001). LL supine, TK supine, and age were significant predictors of postoperative TK ( r2 = 0.490, P < .001). Conclusion: Preoperative supine films are superior to standing in predicting postoperative alignment at 1-year follow-up. Anticipation of undesired alignment changes through supine imaging may be useful in mitigating the risk of iatrogenic malalignment.

Study Design: Retrospective cohort study. Objectives: The identification of case types and institutional factors associated with reduced length of stay (LOS) is a key initial step to inform the creation of clinical care pathways that can assist hospitals to maximize the benefit of value-based payment models. The objective of this study was to identify preoperative, intraoperative, and postoperative factors associated with shorter than expected LOS after adult spinal deformity (ASD) surgery. Methods: A retrospective cohort study was performed of 82 patients with ASD who underwent ≥5 levels of fusion to the pelvis between 2013 and 2018. A LOS Results: A total of 35 patients were in group S (42.7%). Gender, age, body mass index, ASA (American Society of Anesthesiologists) class, and use of preoperative narcotics, revision surgery, day of admission, and surgical complications did not vary between the cohorts ( P > .05). Mild-moderate preoperative sagittal deformity (sagittal Schwab modifiers 0 or +), lower estimated blood loss (Conclusions: This study identifies the ASD “case phenotype,” intra-, and postoperative benchmarks associated with shorter LOS, providing targets for pathways designed to reduce LOS.

Study Design: Retrospective single-center study. Objective: Investigate the effect of posterior instrumentation on the relationship between lordosis and kyphosis. Methods: Surgically treated patients with a minimum of 6 months of follow-up were analyzed. Asymptomatic volunteers served to show the normal anatomical relationship between thoracic and lumbar curves. Patients were stratified based on postoperative instrumentation: “Thoracic Fusion” = complete fusion of thoracic spine; “Lumbar Fusion” = complete fusion of lumbar spine; and “Complete Fusion” = fusion from sacrum to at least T5. Bivariate correlations and regression analysis were used to evaluate the relationship between change in thoracic kyphosis (ΔTK) and change in spinopelvic mismatch (ΔPI-LL; pelvic incidence-lumbar lordosis) before and after fusion. Analyses were repeated in “Lumbar Fusion” patients with flexible preoperative thoracic spines. Results: For asymptomatic volunteers, the natural anatomical relationship between TK and LL was found to be TK = 41% of LL ( r = 0.425, P < .001). A total of 153 of 167 adult spinal deformity patients were included (62 years old, 26.7 kg/m2, 78% female). Mean follow-up was 11.5 ± 6.8 months. “Thoracic Fusion” group showed no alteration in the natural relationship between TK and LL (ΔTK = 39% ΔPI-LL), whereas “Lumbar Fusion” group had a reduction in reciprocal change (ΔTK = 34% ΔPI-LL) although a subanalysis of patients in the “Lumbar Fusion” group with flexible thoracic spines showed a marked compensation in reciprocal change with (ΔTK = 58% ΔPI-LL). Conclusion: The relationship between ΔTK and ΔPI-LL is dependent on level instrumented. “Thoracic Fusion” drives change in LL while this relationship is affected by TK’s natural stiffness in “Lumbar Fusion” patients.

The cartilage of joints, such as meniscus and articular cartilage, is normally long lasting (i.e., permanent). However, once damaged, especially in large animals and humans, joint cartilage is not spontaneously repaired. Compensating the lack of repair activity by supplying cartilage-(re)forming cells, such as chondrocytes or mesenchymal stromal cells, or by transplanting a piece of normal cartilage, has been the basis of therapy for biological restoration of damaged joint cartilage. Unfortunately, current biological therapies face problems on a number of fronts. The joint cartilage is generated de novo from a specialized cell type, termed a 'joint progenitor' or 'interzone cell' during embryogenesis. Therefore, embryonic chondroprogenitors that mimic the property of joint progenitors might be the best type of cell for regenerating joint cartilage in the adult. Pluripotent stem cells (PSCs) are expected to differentiate in culture into any somatic cell type through processes that mimic embryogenesis, making human (h)PSCs a promising source of embryonic chondroprogenitors. The major research goals toward the clinical application of PSCs in joint cartilage regeneration are to (1) efficiently generate lineage-specific chondroprogenitors from hPSCs, (2) expand the chondroprogenitors to the number needed for therapy without loss of their chondrogenic activity, and (3) direct the in vivo or in vitro differentiation of the chondroprogenitors to articular or meniscal (i.e., permanent) chondrocytes rather than growth plate (i.e., transient) chondrocytes. This review is aimed at providing the current state of research toward meeting these goals. We also include our recent achievement of successful generation of "permanent-like" cartilage from long-term expandable, hPSC-derived ectomesenchymal chondroprogenitors.

PRCIS Combined phacoemulsification and trabeculectomy is able to achieve greater reduction in intraocular pressure (IOP), higher rates of complete surgical success and fewer postoperative manipulations and visits compared with combined phacoemulsification and Xen implantation in glaucomatous eyes. PURPOSE Our study aims to compare and understand the differences between the efficacy and safety of XEN45 implantation and trabeculectomy in Asian eyes with glaucoma. MATERIALS AND METHODS This was a retrospective, single-center, comparative study of consecutive patients who underwent combined phacoemulsification and trabeculectomy (Phaco-Trab) from January 2013 to June 2014 and combined phacoemulsification and XEN45 implantation (Phaco-Xen) from May 2017 to September 2018 in a tertiary Ophthalmology center in Singapore. Outcome measures included IOP, number of anti-glaucoma eyedrops, success rate, factors leading to success/failure, number of postoperative interventions and visits required, and surgical complications. RESULTS A total of 137 eyes (91 Phaco-Trab, 46 Phaco-Xen) were included. Phaco-Trab group had greater mean IOP reduction at all time points beyond postoperative month (POM) 1 (mean difference 2.9 to 3.8 mm Hg; P

Objectives: Chondrogenic mesenchymal cells have been developed from human pluripotent stem cells (hPSCs) as a human model of embryonic chondrogenesis. These cells are expandable in the presence of fibroblast growth factor (FGF), and the types of cartilage they tend to generate have been characterized in vitro and in vivo. Resistance to endochondral ossification is one of the most important characteristics of the tissue engineered cartilage for cartilage regenerative therapy. Despite some reports on directed derivation of endochondral ossification resistant chondrocytes from hPSCs, their precursors (chondrogenic mesenchymal cells) have been poorly characterized. We have developed methods to generate two types of chondrogenic mesenchymal cells that lead to cartilage pellets expressing high or very low levels of hypertrophic chondrocyte markers in vitro. These cartilage pellets, when transplanted, became either fully mineralized bony tissue or remained unmineralized, respectively. Here, we present results from cell-type analyses of the two types of mesenchymal cells using the genome-wide RNA-seq technology, aiming to provide mechanistical insights into how the two types of mesenchymal cells prefer to form different types of cartilage. Methods: Human PSC lines were differentiated toward paraxial mesodermal progeny in a chemically-defined medium (CDM) as previously described (1, 2), and mesodermal cells were isolated by cell sorting (2, 3). The isolated cells were then cultured in CDM containing FGF2, platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-beta) inhibitor and glycogen synthase kinase (GSK) inhibitor (1), which were then subjected to CDM containing FGF2, TGFbeta inhibitor and GSK inhibitor (FSbC medium) as well as to CDM containing PDGF and BMP inhibitor (PN medium) to generate mesenchymal cells of distinct size and shape. The resulting cells were subjected to RT-PCR and bulk RNA-seq analyses for cell-type determination. Chondrogenesis was done by pellet culture using PDGF, TGF-beta3 and bone morphogenetic proteins, as described previously (1, 2). Some cartilage pellets were fixed, sectioned, and stained with Toluidine Blue and von Kossa, or immunostained with anti-collagen type I, II and X (COL1, 2, 10) antibodies. DNA, RNA, and sulfated glycosaminoglycan were isolated and quantified from unfixed cartilage pellets. Some cartilage pellets were also subcutaneously transplanted into NSG (severely immunocompromised) mice and the recovered cartilage pellets were similarly analyzed. All the methods involved were previously described in detail (1, 2). Results: The PN cultured mesenchymal cells (Fig. 1) developed COL2+ cartilage pellets that expressed COL10A1 at 10 to 100-fold lesser levels and PRG4 (Lubricin gene) at higher levels than those derived from the FSbC cultured mesenchymal cells, and were resistant to endochondral ossification after subcutaneous transplantation for 8 weeks (Fig. 2) (1, 2). In contrast, the FSbC cultured mesenchymal cells (Fig. 1) developed cartilage pellets that expressed COL10A1 at higher levels than those derived from the PN cultured mesenchymal cells, and were readily mineralized after subcutaneous transplantation (Fig. 2) (1, 2). The comparative RNA-seq analyses of the two mesenchymal cell populations showed that the FSbC cells resembled ectomesenchymal cells derived from neural crest progeny of hPSCs (1, 2) and the PN cells consisted of cells resembling mesenchymal stromal cells and ligament/tendon progenitors (Fig. 3). Conclusions: From hPSCs, chondrogenic mesenchymal cells of distinct chondrogenesis activity can be generated in vitro in a controlled fashion. One type leads to chondrocytes prone to endochondral ossification, and the other type leads to rather stable cartilage that seems to resist endochondral ossification. Our results suggest that the fate of hPSC-derived chondrocytes can be controlled at the mesenchymal cell (i.e., chondrocyte precursor)-stage, which seems to be dependent on how the mesenchymal cells are generated from hPSCs and maintained in culture. Further biological studies on these cells will not only enable hPSC-derived chondrocytes/chondroprogenitors to be used directly for cartilage regenerative therapy, but also may lead to a critical mechanism that allows therapeutically relevant adult chondrogenic cells such as skeletal stem cells to reproducibly regenerate hyaline permanent cartilage during cartilage repair. [Figure: see text][Figure: see text][Figure: see text]

Purpose: To evaluate the safety and efficacy of the iStent inject device combined with phacoemulsification in Asian eyes with primary open angle glaucoma. Methods: A retrospective study of combined phacoemulsification and iStent inject surgeries performed in a single institution from July 2017 to August 2019 on patients with co-existing cataracts and primary open angle glaucoma (POAG). Outcome measures included best-corrected visual acuity, intraocular pressure (IOP), number of glaucoma eyedrop medications, and surgical complications. Results: A total of 95 eyes were included. Majority of subjects were male (59, 62.1%) and Chinese (83, 87.4%). Mean age was 74.7 ± 8.7 years. Pre-operatively, mean IOP was 16.2 ± 4.3 mmHg and number of medications was 1.9 ± 0.9. Significant post-operative reduction in mean IOP was observed at all timepoints – post-operative month (POM)1: 3.0 ± 5.6 mmHg reduction ( n = 95, p Conclusion: Asian eyes undergoing combined phacoemulsification and iStent inject surgery demonstrate a significant and sustained reduction in both IOP and number of glaucoma medications. Overall, there is a good safety profile for iStent inject.

Background The independent prognostic value of troponin and other biomarker elevation among patients with coronavirus disease 2019 (COVID‐19) are unclear. We sought to characterize biomarker levels in patients hospitalized with COVID‐19 and develop and validate a mortality risk score. Methods and Results An observational cohort study of 1053 patients with COVID‐19 was conducted. Patients with all of the following biomarkers measured—troponin‐I, B‐type natriuretic peptide, C‐reactive protein, ferritin, and d ‐dimer (n=446) —were identified. Maximum levels for each biomarker were recorded. The primary end point was 30‐day in‐hospital mortality. Multivariable logistic regression was used to construct a mortality risk score. Validation of the risk score was performed using an independent patient cohort (n=440). Mean age of patients was 65.0±15.2 years and 65.3% were men. Overall, 444 (99.6%) had elevation of any biomarker. Among tested biomarkers, troponin‐I ≥0.34 ng/mL was the only independent predictor of 30‐day mortality (adjusted odds ratio, 4.38; P 2 T 2 ) ≥3 had a 30‐day mortality of 43.7% while those with a score 2 T 2 score was 0.834 for the derivation cohort and 0.784 for the validation cohort. Conclusions Elevated troponin and other biomarker levels are commonly seen in patients hospitalized with COVID‐19. High troponin levels are a potent predictor of 30‐day in‐hospital mortality. A simple risk score can stratify patients at risk for COVID‐19–associated mortality.

BACKGROUND CONTEXT Bone density in the lumbar spine is variable by level and can impact surgical strategy. In the cervical spine, low Hounsfield units (HU) have been associated with cage subsidence. The distribution of HU in the cervical spine has not been established. PURPOSE To define level-specific cervical HU reference values and the relationship between cervical bone density, age, BMI, comorbidities and alignment. STUDY DESIGN/SETTING Retrospective review at a single center from May 2015 to December 2019. PATIENT SAMPLE A total of 224 patients, 18 excluded for previous hardware and 5 for known osteoporosis. OUTCOME MEASURES Hounsfield units. METHODS Patients who presented with neck symptoms and had a cervical spine CT for evaluation of pathology or surgical planning were included. Exclusions were hardware on CT, osteoporosis, or cervical deformity. Measurements were performed in 5 regions of each vertebral body (VB) (C2-T1; mid-axial, anterior-axial, posterior-axial, mid-coronal, and mid-sagittal) and 2 regions of the lateral masses (LMs) (C3-C6; mid-cor, mid-sag). The VB measurements were averaged at each level to obtain a composite value of each vertebral body (TotalVB), similarly the mid-cor and mid-sag values were averaged at each LM (TotalLatM). Outliers were excluded pairwise. To evaluate reliability, 6 observers each measured 355 HU values (71 over 5 patients), inter-relater reliability assessed with intraclass correlation coefficients (ICCs). Correlations of composite HU with age, BMI, Charlston Comorbidity Index (CCI) and cervical alignment were evaluated. RESULTS Average age 57±12 years, mean BMI 28±6 kg/m2, 63.5% male, 90.1% white. Diagnoses included radiculopathy (45.8%), myelopathy (37.9%) and facet arthropathy (46.3%). ICC for HU measurements were as follows: VB, 0.82 mid-axial, 0.59 ant-axial, 0.77 post-axial, 0.88 mid-cor, 0.88 mid-sag; LM, 0.46 mid-sag, 0.61 mid-cor. C4 VB and C4 LM had the highest HU (383.6±71.9 and 480.0±103, respectively) while T1 VB and C6 LM had the lowest (232.3±46.5 and 398.3±98.2, respectively). No significant correlations were found between LM HU and age, BMI, CCI, or alignment. Increased kyphosis was weakly correlated with VB HU at all levels (except C2) strongest correlations at C7 (0.25) and weakest correlation at C3 (0.16). Age and CCI showed weak-moderate correlations with VB HU at all levels (age, r= -0.20 to -0.35; CCI r= -0.28 [C2, C7, T1] to -0.17 [C4]). CONCLUSIONS Our level-specific cervical HU values may be referenced when evaluating cervical BMD. The most reliable measurement technique is on the mid-sag or mid-cor VB, measurement of LMs is less reliable. Bone is least dense in the lower cervical spine, which may influence instrumentation strategies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P.001) and mean number of publications (79.1 vs 35.9, P.001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P.001) and mean number of publications (294.5 vs 36.8, P.001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.

Study Design Retrospective cohort study Objective Given changes in bone density induced by degenerative disease, general measures of bone health (ie DEXA) are inadequate to evaluate bone density in surgical areas of interest. Regional differences in HU in the cervical spine may influence surgical strategies. The purposes of our study were to determine whether cervical Hounsfield units (HU) vary by level, examine their relationship with age, comorbidities, and alignment, and propose a technique to measure HU in the lateral masses. Methods Two hundred twenty-four patients with degenerative spine pathology with a cervical computed tomography were included (2015-2019). Measurements were performed in each vertebral body (C2-T1; mid-axial, anterior-axial, posterior-axial, mid-coronal, and mid-sagittal) and 2 regions of the lateral masses (C3-C6; mid-cor, mid-sag). To evaluate reliability, 6 observers each measured 355 HU values, inter-relater reliability assessed with intraclass correlation coefficients Correlations of HU with age, BMI, comorbidities, and cervical alignment were evaluated. Results Bone density differed by level, with the lowest HU scores in the lower cervical spine (C6-T1) ( P < .001). No correlations were found between LM HU and age, BMI, CCI, or alignment ( P > .05). Increased kyphosis was weakly correlated with VB HU, while age and CCI showed moderate correlations with VB HU at all levels (PConclusion Bone is least dense in the lower cervical spine. HU scoring is not reliable in the lateral masses. We recommend that a level-specific approach to bone density is considered in surgical planning.

OBJECTIVE Supine radiographs have successfully been used for preoperative planning of lumbar deformity corrections. However, they have not been used to assess thoracic flexibility, which has recently garnered attention as a potential contributor to proximal junctional kyphosis (PJK). The purpose of this study was to compare supine to standing radiographs to assess thoracic flexibility and to determine whether thoracic flexibility is associated with PJK. METHODS A retrospective study was conducted of a single-institution database of patients with adult spinal deformity (ASD). Sagittal alignment parameters were compared between standing and supine and between pre- and postoperative radiographs. Thoracic flexibility was determined as the change between preoperative standing thoracic kyphosis (TK) and preoperative supine TK, and these changes were measured over the overall thoracic spine and the fused portion of the thoracic spine (i.e., TK fused). A case-control analysis was performed to compare thoracic flexibility between patients with PJK and those without (no PJK). The cohort was also stratified into three groups based on thoracic flexibility: kyphotic change (increased TK), lordotic change (decreased TK), and no change. The PJK rate was compared between the cohorts. RESULTS A total of 101 patients (mean 63 years old, 82.2% female, mean BMI 27.4 kg/m2) were included. Preoperative Scoliosis Research Society–Schwab ASD classification showed moderate preoperative deformity (pelvic tilt 27.7% [score ++]; pelvic incidence–lumbar lordosis mismatch 44.6% [score ++]; sagittal vertical axis 42.6% [score ++]). Postoperatively, the average offset from age-adjusted alignment goals demonstrated slight overcorrection in the study sample (−8.5° ± 15.6° pelvic incidence–lumbar lordosis mismatch, −29.2 ± 53.1 mm sagittal vertical axis, −5.4 ± 10.8 pelvic tilt, and −7.6 ± 11.7 T1 pelvic angle). TK decreased between standing and supine radiographs and increased postoperatively (TK fused: −25.3° vs −19.6° vs −29.9°; all p < 0.001). The overall rate of radiographic PJK was 23.8%. Comparisons between PJK and no PJK demonstrated that offsets from age-adjusted alignment goals were similar (p > 0.05 for all). There was a significant difference in the PJK rate when stratified by thoracic flexibility cohorts (kyphotic: 0.0% vs no change: 18.4% vs lordotic: 35.0%; p = 0.049). Logistic regression revealed thoracic flexibility (p = 0.045) as the only independent correlate of PJK. CONCLUSIONS Half of patients with ASD experienced significant changes in TK during supine positioning, a quality that may influence surgical strategy. Increased thoracic flexibility is associated with PJK, possibly secondary to fusing the patient’s spine in a flattened position intraoperatively.

Background And Aims The growing burden of obesity as a chronic disease necessitates a multifaceted approach to management. There has been an increase in the number of available endoscopic therapies for weight management with endoscopic sleeve gastroplasty (ESG) proving to be one of the best options. The long-term efficacy of ESG for management of obesity is not known. This study sought to assess the long-term safety and efficacy of ESG for treatment of obesity. Methods This was a prospective cohort study. Participants underwent ESG in a single academic center, and were prospectively enrolled. All procedures were performed by the same therapeutic endoscopist. Patients with a body mass index of >30 kg/m2 (or >27 with comorbidities), who underwent ESG from August 2013 to August 2019 for treatment of obesity were enrolled. Patients were followed for up to 5 years after their procedure. The primary outcome was weight loss at 5 years after the procedure (% total body weight loss, TBWL) Results 216 patients (68% female) with a mean age of 46±13 years, and mean BMI of 39±6 kg/m2 underwent ESG. Out of 216 patients, 203, 96, and 68 patients were eligible for a 1-, 3-, and 5-year follow up, with complete follow-up rates of 70%, 71%, and 82%, respectively. At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p Conclusions Our results suggest that ESG is safe and effective for treatment of obesity, with durable long-term results for at least up to 5 years after the procedure. This procedure should be considered as a reliable option for treatment of obesity.

Study Design: Single-center, retrospective cohort study conducted from 2013 to 2017.Purpose: To determine the risk factors for surgical complications in neuromuscular scoliosis based on known patient comorbidities. Overview of Literature: The concept of neuromuscular scoliosis includes a wide variety of pathologies affecting the neuromuscular system. Complications are numerous and are often difficult to predict.Methods: A retrospective analysis of a single-center database was conducted from 2013 to 2017. Inclusion criteria were patients aged

BackgroundThe 2019 novel coronavirus disease (COVID-19) has created unprecedented medical challenges. There remains a need for validated risk prediction models to assess short-term mortality risk among hospitalized patients with COVID-19. The objective of this study was to develop and validate a 7-day and 14-day mortality risk prediction model for patients hospitalized with COVID-19.MethodsWe performed a multicenter retrospective cohort study with a separate multicenter cohort for external validation using two hospitals in New York, NY, and 9 hospitals in Massachusetts, respectively. A total of 664 patients in NY and 265 patients with COVID-19 in Massachusetts, hospitalized from March to April 2020.ResultsWe developed a risk model consisting of patient age, hypoxia severity, mean arterial pressure and presence of kidney dysfunction at hospital presentation. Multivariable regression model was based on risk factors selected from univariable and Chi-squared automatic interaction detection analyses. Validation was by receiver operating characteristic curve (discrimination) and Hosmer-Lemeshow goodness of fit (GOF) test (calibration). In internal cross-validation, prediction of 7-day mortality had an AUC of 0.86 (95%CI 0.74-0.98; GOF p = 0.744); while 14-day had an AUC of 0.83 (95%CI 0.69-0.97; GOF p = 0.588). External validation was achieved using 265 patients from an outside cohort and confirmed 7- and 14-day mortality prediction performance with an AUC of 0.85 (95%CI 0.78-0.92; GOF p = 0.340) and 0.83 (95%CI 0.76-0.89; GOF p = 0.471) respectively, along with excellent calibration. Retrospective data collection, short follow-up time, and development in COVID-19 epicenter may limit model generalizability.ConclusionsThe COVID-AID risk tool is a well-calibrated model that demonstrates accuracy in the prediction of both 7-day and 14-day mortality risk among patients hospitalized with COVID-19. This prediction score could assist with resource utilization, patient and caregiver education, and provide a risk stratification instrument for future research trials.

Summary Cartilage pellets generated from ectomesenchymal progeny of human pluripotent stem cells (hPSCs) in vitro eventually show signs of commitment of chondrocytes to hypertrophic differentiation. When transplanted subcutaneously, most of the surviving pellets were fully mineralized by 8 weeks. In contrast, treatment with the adenylyl cyclase activator, forskolin, in vitro resulted in slightly enlarged cartilage pellets containing an increased proportion of proliferating immature chondrocytes that expressed very low levels of hypertrophic/terminally matured chondrocyte-specific genes. Forskolin treatment also enhanced hyaline cartilage formation by reducing type I collagen gene expression and increasing sulfated glycosaminoglycan accumulation in the developed cartilage. Chondrogenic mesoderm from hPSCs and dedifferentiated nasal chondrocytes responded similarly to forskolin. Furthermore, forskolin treatment in vitro increased the frequency at which the cartilage pellets maintained unmineralized chondrocytes after subcutaneous transplantation. Thus, the post-transplantational fate of chondrocytes originating from hPSC-derived chondroprogenitors can be controlled during their genesis in vitro., Graphical Abstract, Highlights • Forskolin/cAMP suppresses/delays BMP-induced chondrocyte maturation in vitro • Forskolin supports chondrocyte proliferation and hyaline chondrogenesis in vitro • Forskolin suppresses osteogenesis and BMP signaling gene expression in cartilage • In vitro forskolin treatment improves in vivo maintenance of uncalcified cartilage, In this article, Naoki Nakayama and colleagues show that suppression of hypertrophic differentiation and terminal maturation of chondrocytes by forskolin/cAMP treatment during in vitro chondrogenesis from human pluripotent stem cell-derived chondroprogenitors leads to the formation of cartilage consisting of an increased proportion of proliferating, immature chondrocytes with significantly improved ability to be maintained in an unmineralized state in vivo.

BACKGROUND CONTEXT The Hounsfield unit (HU) is a measurement of X-ray beam attenuation in computer tomography (CT) scans and have shown strong correlation to Dual-energy X-ray absorptiometry (DEXA), the current standard for measurement of bone density. Unlike DEXA, Hounsfield units may be opportunistically assessed on preoperative CT scans for osteoporosis screening. While the lumbar spine has been well studied using this technique, difference in the biomechanics of loading between the cervical spine and lumbar spine poses the question of whether lumbar HU can be correlated to cervical HU. PURPOSE To investigate associations between lumbar and cervical Hounsfield unit measurements. STUDY DESIGN/SETTING Retrospective single center study. PATIENT SAMPLE A total of 182 patients. OUTCOME MEASURES Hounsfield units. METHODS In addition to basic demographics and clinical information, HU measurements were collected by three independent reviewers at C2, C4, C7, T1, L1, L2, L3, L4 and S1 within a sagittal region of interest (ROI) in the vertebral body. These were compared and correlated to BMD as measured by DEXA scans. RESULTS There were 182 patients included. Interrater reliability was excellent between the three reviewers for all measurements. Linear regression analysis showed a significant association between lumbar and cervical HU (r-square: 0.436; std error: 37.3). Hounsfield units of the spine were strongly associated with DEXA of the spine, however not to the radius or hip. Interestingly 92% of patients with an osteoporotic cervical spine have a non-osteoporotic lumbar spine while only 1.3% of patients that have a non-osteoporotic cervical spine have an osteoporotic lumbar spine. CONCLUSIONS A region of the spine can be a good predictor of overall bone quality; however, it is not specific enough to predict the bone quality in another spinal region. The lumbar spine cannot be used as a predictor of bone quality in the cervical spine. However, if the cervical spine is normal, it is likely that the lumbar spine is normal as well. Planned fusion surgeries on the cervical spine should not use lumbar DXA or HU as a surrogate for cervical bone quality. Finally, future studies should evaluate if the cervical spine can be used as an early indicator for osteoporosis screening. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Pseudarthrosis with distal mechanical failure is a common complication after long constructs in adult spinal deformity (ASD). Multiple strategies have been proposed to improve fusion rates and reduce the rate of rod fracture, including the use of interbody fusion (IBF) and multi-rod (≥3) techniques. Whether rod fracture rates are lower with the utilization of IBF versus multi-rod constructs remains unknown. PURPOSE To assess for any difference in rod fracture rate between constructs with IBF and multiple rods up to 2 years postoperatively. STUDY DESIGN/SETTING Retrospective Cohort. PATIENT SAMPLE ASD patients undergoing fusion of ≥6 levels to ilium and a minimum follow-up of 24 months. OUTCOME MEASURES Rate of postoperative rod fracture. METHODS ASD patients undergoing fusion of ≥6 levels to ilium and a minimum follow-up of 24 months were included. Patients with a history of prior fusion to L4 or below, and those with neuromuscular disease, inflammatory arthritis, or skeletal dysplasia were excluded. Patients were grouped by construct types: 2 rods w/ IBF (IBF) and w/o IBF (2R) and ≥3 rods w/o IBF (3R). Demographics, perioperative and radiographic data, and evidence of rod fracture were collected. ANOVA, chi-square and Fisher exact tests were used to compare across construct types. RESULTS Seventy-one patients were included, with mean age 65.0 years (±8.5) and BMI 26.7 kg/m2 (±5.4). In total, 20 patients had 2R constructs, 12 had IBF, and 39 had 3R. There were no significant differences in sagittal or coronal parameters at baseline or 2 years, or in OR time, EBL, or number of levels fused across groups. There were 76.1% of patients with posterior column osteotomy (2R 75.0%, IBF 50.0%, 3R 84.6%; p=0.063) and 9.9% had 3 column osteotomy. There were 12 total rod fractures (15.2%) with no significant difference between groups (2R 25.0%, IBF 16.7%, 3R 12.8%; p=0.423) and no differences in revision rate for rod fracture. CONCLUSIONS Compared to multi-rod techniques, the addition of IBF does not reduce the rate of rod fracture at two years after long constructs for ASD. These findings suggest that increasing the rigidity of the construct with the addition of a third rod may be sufficient to prevent rod fractures while IBF may provide no additional benefit at 2 years follow-up. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Flattening of the thoracic spine is a common biomechanical compensatory mechanism for adult spinal deformity (ASD). The literature shows that younger ASD patients recruit more thoracic flattening than older patients. It is hypothesized that differences in muscle quality between younger and older ASD patients explains this difference in the recruitment of thoracic compensation. PURPOSE Investigate the relationship between paraspinal muscle degeneration and recruitment of thoracic compensation. STUDY DESIGN/SETTING Retrospective review of a prospective database. PATIENT SAMPLE ASD patients from a prospective database. OUTCOME MEASURES Posterior paraspinal muscle fat infiltration, thoracic kyphosis between T4 and T12 (TK) and pelvic retroversion (PT). METHODS ASD patients with spino-pelvic deformity (defined as SRS-Schwab PI-LL modifier of + or ++) and available pre-op CT imaging were identified from a retrospective database. Patients with previous fusion of the thoracic spine were excluded. Erector spinae and multifidus measurements were manually contoured on CT imagesat three vertebral levels (T2, T10, and L3), at three locations per level: immediately inferior to the superior end plate, in the middle of the vertebral body, and superior to the inferior end plate. Fat infiltration (Fat) within each muscle was defined as the number of voxels with a Hounsfield unit (HU) corresponding to fat (-190 to 0) divided by the total number of voxels. The maximum fat infiltration (MaxFat) was determined by taking the muscle with the highest percentage of Fat. After a Pearson correlation analysis, the cohort was separated into 2 groups: high Fat (HFat) and Low Fat (LFat) based on MaxFat threshold of 35%. Demographics and radiographic parameters including TK and PT were compared between groups. RESULTS Of the 57 patients (mean age 61 yrs, 75% F, BMI 28) that met inclusion, 26% had a fused lumbar spine. Assessed by +/++ SRS-Schwab modifiers, 90% of patients had severe PT malalignment and 75% a severe SVA malalignment. Breakdown of Fat and area by vertebral level was: T2 (35% and 1332mm²), T10 (30% and 1910mm²), L3 (38% and 3915mm²). TK correlated significantly with Fat at all levels from T2 to L3 (r=-0.498, r=-0.519, r=-0.472), FatMax (r=-0.470) and area at T10 (r=-0.341). PT correlated significantly with FatMax (r=0.333) and T10 Fat(r=0.548). After grouping, 31 pts were HFat, and 25 pts were LFat. HFat pts were older (64.2 vs 56.3, p=0.047) and had a greater BMI (30.1 vs 25, p=0.002). The groups did not differ in sex or rates of lumbar fusion. In terms of spinal alignment, HFat pts had a higher T1 pelvic angle (30.7° vs 23.7°), a higher TK (-34.6° vs -22.9°), and a higher PT (30.1° vs 25.2°), without difference in lumbar deformity or other sagittal parameters. CONCLUSIONS Patients with higher fat infiltration in paraspinal muscles show less compensation with the thoracic spine than patients with leaner musculature, despite having similar lumbar deformities. Consequently, patients with degenerative paraspinal musculature have more pelvic retroversion, causing greater gait disruption due to limitation in hip extension. The assessment of fatty infiltration in posterior paraspinal muscles could help identify patient compensatory profile and aid in surgical planning. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Several guidelines for target-selection in the literature utilize pelvic incidence (PI) as a marker for lumbar correction. In practice, postoperative alignment is highly affected by preoperative data, including demographics and spinal flexibility. Preoperative supine radiographs allow for early visualization of patient alignment in the intraoperative position. Our objective was to determine the strongest predictor of postoperative alignment among PI, age and preoperative supine alignment using a retrospective, single center database of adult spinal deformity (ASD) patients. PURPOSE Identify independent predictors of postoperative curvatures (LL and TK) using preoperative data only. STUDY DESIGN/SETTING Retrospective review of a single-center database of ASD patients. PATIENT SAMPLE A total of 99 surgically treated ASD patients with minimum 1 year follow-up. OUTCOME MEASURES L1-S1 lordosis, T4-T12 kyphosis. METHODS Pre- to postoperative analysis was conducted using paired t-test sampling. Patients were stratified by region of fusion postoperative: complete lumbar fusion (from L1 to S1) and/or complete thoracic fusion (from T4 to T12). Pearson's r correlation analysis was performed on postoperative curvatures (LL and TK) with preoperative alignment in both standing and supine positions. Correlation analysis was repeated for LL in patients with complete lumbar fusion and for TK in patients with complete thoracic fusion. Lastly, a multilinear stepwise regression was conducted to identify independent predictors of LL or TK post-op. RESULTS A total of 99 patients were included in the analysis (63.2yo, 83.1%F, 27.3kg/m2, mean f/u 21 months±.9.8). Preoperative SRS classification demonstrated a moderate to severe sagittal and/or coronal deformity (PT modifier: 18.2% ++, SVA: 27.3% ++, PI-LL: 29.3% ++, SRS type: 29.3% N and 68.7% L or D). Sagittal alignment significantly improved between pre- and postoperative (all p CONCLUSIONS Preoperative supine alignment is one of the best predictors of postoperative alignment at 1 year. When controlling for fusion location, results show an even greater importance of supine alignment, especially regarding thoracic alignment. Specific attention is required when performing thoracic fusion to avoid thoracic flattening FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: The magnetic resonance observation of cartilage repair tissue (MOCART) scoring system was developed and modified to allow for assessment of articular cartilage repair tissue in the foot and ankle. The purpose of this study was to evaluate the intra- and inter-rater reliability of the MOCART score following a variety of surgical procedures to repair chondral injuries within the ankle joint as well as to correlate these scores to clinically relevant functional outcomes scores. By correlating functional outcome scores with each variable evaluated by the MOCART scoring system as well as the presence of edema and cysts postoperatively, we aimed to identify the radiographic parameters most closely associated with clinical outcomes. Methods: Patients treated for a chondral injury after August 2006 by a fellowship-trained foot and ankle surgeon at our institution were included if their postoperative MRI and Foot and Ankle Outcome Score (FAOS) were completed within 5 months of one another. Surgical interventions used to stimulate reparative cartilage formation included osteochondral graft transplantation, debridement, microfracture, microfracture augmented by bone marrow aspirate concentrate (BMAC), juvenile particulate cartilage implantation, or another adjunctive therapy like micronized allogenic cartilage extracellular matrix. Two radiologists (R1-R2) independently reviewed and scored each MRI using the MOCART system. A total MOCART score ranging between 0 and 100 was calculated for each patient. In addition, the presence or absence of postoperative cysts and edema was documented. Inter- and intra- rater reliability were calculated using Intraclass Correlation Coefficients (ICC), and MOCART scores were correlated with FAOS to test for relative functional and clinical relevance. Correlations were calculated as Pearson Correlation Coefficients. Results: Forty-six patients (average age 35 +/- 13.49) under the care of nine different surgeons met inclusion criteria. Average follow-up was 18 months. For overall MOCART score, intra-rater ICC = 0.87 (pConclusion: Intra-rater reliability for an overall MOCART score was relatively strong for each rater while the correlation between raters ranged from strong to moderate. As such, an overall MOCART score appears to be a somewhat reproducible measure. Weak to moderate negative correlational coefficients between the overall MOCART score and postoperative FAOS scores and changes in FAOS scores indicated the MOCART score may be limited in its ability to predict clinical outcomes. Finally, presence or absence of a postoperative cyst may be a useful category that significantly helps predict changes in FAOS pain as well as the size of the lesion preoperatively.

Periorbital necrotizing fasciitis is a potentially fatal disease, and early surgical debridement has been advocated to minimize the risk of blindness and mortality. The authors report a case of an 18-year-old man who presented with isolated, unilateral group A Streptococcus eyelid necrotizing fasciitis. The patient responded to intravenous antibiotics alone, and no surgical debridement was needed. Skin reconstructive surgery was carried out after resolution of the acute infection. The clinical and cosmetic outcome was good. This case report supports limited but growing evidence that potentially disfiguring surgical debridement may be avoided in selected cases of eyelid necrotizing fasciitis and that uncomplicated periorbital necrotizing fasciitis can be treated conservatively with good results.