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BACKGROUND Intraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture. PURPOSE The purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes. PATIENT SAMPLE Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis. OUTCOME MEASURES The primary outcome was unintended VI during anterior lumbar spine surgery. METHODS Manual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes. RESULTS In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI ( https://sorg-apps.shinyapps.io/lumbar_vascular_injury/ ). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64. CONCLUSION Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting.

Understanding practice-based differences in treatment of lumbar disc herniations (LDHs) is vital for reducing unwarranted variation in the delivery of spine surgical health care. Identifying factors that influence surgeons’ decision-making will offer useful insights for developing the most cost-effective and safest surgical strategy as well as developing surgeon education materials for common lumbar pathologies. This study was to capture any variation in techniques used by surgeons in Australia and New Zealand (ANZ) region, and perceived complications of different surgical procedures for primary and recurrent LDH (rLDH). Web-based survey study was emailed to orthopaedic and neurosurgeons who routinely performed spinal surgery in ANZ from Decmber 20, 2018 to February 20, 2020. The response data were analyzed to assess for differences based on geography, practice setting, speciality, practice experience, practice length, and operative volume. Invitations were sent to 150 surgeons; 96 (64%) responded. Most surgeons reported microdiscectomy as their surgical technique of choice for primary LDH (73%) and the first rLDH (72%). For the second rLDH, the preferred choice for most surgeons was fusion surgery (82%). A surgeon’s practice setting (academic/private/hybrid) was a statistically significant factor in what surgical procedure was chosen for the first rLDH (P = 0.014). When stratifying based on surgeon experience, there were statisfically significant differences based on the annual volume of spine surgeries performed (perceived reherniation rates following primary discectomy, P = 0.013; perceived reherniation rates following revision surgeries, P = 0.017; perceived intraoperative complications rates following revision surgeries, P = 0.016) and based on the annual volume of lumbar discectomies performed (perceived reherniation rates following revision surgeries, P = 0.022; perceived intraoperative complications rates following revision surgeries, P = 0.036; perceived durotomy rates following primary discectomy, P = 0.023). Surgeons’ annual practice volume and practice setting have significant influences in the selection of surgical procedures and the perception of surgical complications when treating LDHs.

BACKGROUND CONTENT Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States. PURPOSE To determine the percentage of patients with CSM who are radiographically candidates for LP. STUDY DESIGN Retrospective comparative cohort study. PATIENT SAMPLE Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019. OUTCOME MEASURES Candidacy for LP based on radiographic criteria. METHODS Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2–C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated. RESULTS One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2–C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability. CONCLUSIONS In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM.

BACKGROUND CONTEXT Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level. PURPOSE The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression. PATIENT SAMPLE This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included. OUTCOME MEASURES The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores. METHODS Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID. RESULTS Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46–70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4–31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15–0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID. CONCLUSIONS In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis. Level of Evidence 2

BACKGROUND Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy. PATIENT SAMPLE Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation. OUTCOME MEASURES Reoperation for wound infection within 90 days after surgery METHODS Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection. RESULTS Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88. CONCLUSION Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting.

Study Design: Retrospective study. Objective: Multiple studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications, making optimal management of these patients challenging. The purpose of this study was to determine the relationship between patient age and the likelihood of surgical complications, mortality, and 30-day readmission rates following surgery for osteoporotic vertebral compression fractures (OVCFs). Methods: A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR), with corresponding P values and 95% confidence intervals, of the relationship between age (treated as a continuous variable) and perioperative mortality, surgical complications, and 30-day readmission rates. Results: Younger patients were statistically more likely to endure a minor (OR = 0.98; P = .002) or major complication (OR = 0.97; P = .009). The older a patient was, on the other hand, the higher the likelihood that patient would be readmitted within 30 days of surgery (OR =1.02; P = .004). Mortality within the 30-day perioperative period was not statistically correlated with age. Conclusions: The impact of age on adverse outcomes following surgery for OVCF is mixed. While younger patients are more likely to endure complications, older patients are more likely to be readmitted within 30 days following surgery. Patient age showed no correlation with mortality rates. In the setting of surgical treatment for an OVCF, a patient’s age can help determine the risk of complications and the rate of readmission following intervention.

IMPORTANCE Preoperative determination of the potential for postoperative opioid dependence in previously naive patients undergoing elective spine surgery may facilitate targeted interventions. OBJECTIVE The purpose of this study was to develop supervised machine learning algorithms for preoperative prediction of prolonged opioid prescription use in opioid-naive patients following lumbar spine surgery. DESIGN Retrospective review of clinical registry data. Variables considered for prediction included demographics, insurance status, preoperative medications, surgical factors, laboratory values, comorbidities, and neighborhood characteristics. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis. SETTING One healthcare entity (two academic medical centers, three community hospitals), 2000 to 2018. PARTICIPANTS Opioid-naive patients undergoing decompression and/or fusion for lumbar disk herniation, stenosis, and spondylolisthesis. MAIN OUTCOME Sustained prescription opioid use exceeding 90 days after surgery. RESULTS Overall, of 8,435 patients included, 359 (4.3%) were found to have prolonged postoperative opioid prescriptions. The elastic-net penalized logistic regression achieved the best performance in the independent testing set not used for algorithm development with c-statistic=0.70, calibration intercept=0.06, calibration slope=1.02, and Brier score=0.039. The five most important factors for prolonged opioid prescriptions were use of instrumented spinal fusion, preoperative benzodiazepine use, preoperative antidepressant use, preoperative gabapentin use, and uninsured status. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/lumbaropioidnaive/ . CONCLUSION AND RELEVANCE The clinician decision aid developed in this study may be helpful to preoperatively risk-stratify opioid-naive patients undergoing lumbar spine surgery. The tool demonstrates moderate discriminative capacity for identifying those at greatest risk of prolonged prescription opioid use. External validation is required to further support the potential utility of this tool in practice.

Study Design: Retrospective study. Objectives: We examined the impact that location of a lumbar disc herniation has on the likelihood that a patient will require surgery after at least 6 weeks of nonoperative management. Methods: Using ICD-10 codes M51.26 and M51.27, we identified patients at a single academic institution from 2015 to 2016 who received a diagnosis of primary lumbar radicular pain, had magnetic resonance imaging confirming a lumbar disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome or progressive motor deficits were excluded. Results: Five hundred patients met inclusion/exclusion criteria. Twenty-nine (5.8%) had L3-L4 herniations, 245 (49.0%) had L4-L5 herniations, and 226 (45.2%) had L5-S1 herniations. Overall, 451 (90.2%) patients did not undergo surgery within 1 year of diagnosis. Nonsurgical patients had an average herniation size occupying 31.2% of the canal, compared with 31.5% in patients who underwent surgery. While herniation size, age, sex, and race failed to demonstrate a statistical association with the likelihood for surgery, location of disc herniation demonstrated a strong association. L3-L4 and L4-L5 herniations had odds ratios of 0.19 and 0.45, respectively, relative to L5-S1 herniations ( P = .0047). Patients were more than twice as likely to require a surgery on an L5-S1 herniation in comparison with an L4-L5 herniation ( P < .05). L3-L4 herniations rarely required surgery. Conclusions: Patients with caudal lumbar disc herniations were more likely to require surgery after at least 6 weeks of conservative management than those with disc herniations in the mid-lumbar spine.

BACKGROUND Adult spinal deformity (ASD) is a debilitating condition that commonly requires surgical intervention. However, ASD patients may also present with osteoporosis, predisposing them to surgical complications and failure of instrumentation. As a result, proper detection of low bone mineral density (BMD) is critical in order to ensure proper patient care. Typically dual-energy x-ray absorptiometry (DEXA) scans are performed on the hip and spine. Unfortunately, in ASD patients, the latter is often inaccurate PURPOSE In this study, we consider the value of obtaining a forearm DEXA scan in addition to a hip scan in patients suffering from ASD and osteoporosis in order to accurately detect low BMD. STUDY DESIGN Retrospective study. PATIENT SAMPLE Patient data between 2016 and 2018 from a single academic medical center was utilized. Two hundred eighty-six patients met the initial search criteria. OUTCOME MEASURES No outcomes measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included T-scores across various anatomic locations and diagnoses relating to low bone density (ie, osteopenia and osteoporosis). METHODS This retrospective study examines patients that underwent DEXA studies between 2016 and 2018 and were previously diagnosed with both osteoporosis and adult spinal deformity. For each patient, age, gender, body mass index, and smoking history were noted, as well as whether there was long-term prednisone use. T-scores from both the forearm and hip were recorded and analyzed. Diagnoses from hip DEXA scans were compared with those obtained from forearm scans to identify which region was more sensitive in detecting low BMD. From this data, the frequency of a missed diagnosis, due to reliance on hip or spine T-scores for detection of low BMD, was extrapolated. No external funding source was received in support of this study. RESULTS Two hundred eighty-six patients matched the initial search criteria. Only 68% had one T-score value. However, 24.8% of patients had data for both the hip and forearm, whereas 7.1% had data for the forearm, hip, and spine. Among the 85 patients with more than one anatomical site of study, the forearm was more sensitive than the hip in its ability to detect osteopenia or osteoporosis 41.2% of the time. A two-tailed t test showed no statistically significant difference between hip T-scores and forearm T-scores. However, for more than 17% of patients, the forearm allowed clinicians to detect osteoporosis or osteopenia in a setting where using only the hip data would have missed such a diagnosis. CONCLUSIONS Clinicians need to ensure they survey at least two locations when conducting DEXA studies before precluding a diagnosis of osteopenia or osteoporosis. All ASD patients being evaluated for low bone density should receive DEXA scans that survey at least the hip and the forearm. Misdiagnoses can be costly in the setting of ASD. They occur frequently when only a single hip scan is relied upon to assess BMD.

Study Design: Retrospective study. Objective: In this study, we examined whether the size of a lumbar disc herniation (LDH) is predictive of the need for surgical intervention within 2 years after obtaining an initial magnetic resonance imaging (MRI) scan. We hypothesized that a fragment that occupied a larger percentage of the spinal canal would not predict which patients failed conservative management. Methods: Using the ICD-10 code M51.26, we identified patients at a single academic institution, across the 2-year period from 2015 to 2016, who received a diagnosis of primary lumbar radicular pain, had MRI showing a disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome and those with progressive motor neurological deficits were excluded from analysis, as were patients exhibiting “hard” disc herniations. Within the axial view of an MRI, the following measurements were made on AGFA-IMPACS for a given disc herniation: the length of both the canal and the herniated disc along the anterior-posterior axis, the average width of the disc within the canal; the total canal area, and the area of the disc herniation. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach’s alpha as a measure of reliability was obtained. Results: A total of 368 patients met the inclusion and exclusion criteria for this study. Of these, 14 (3.8%) had L3-L4 herniations, 185 had L4-L5 herniations (50.3%), and 169 had L5-S1 herniations (45.9%). Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the LDH diagnosis. Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average. A Cronbach’s alpha of .992 was observed overall across interobserver measurements. After controlling for age, race, gender, and location of herniation through a logistic regression, it was found that the size of the herniation and the percentage of the canal that was occupied had no predictive value with regard to failure of conservative management, generating an odds ratio for surgery of 1.00. Conclusions: The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.

Retrospective cohort study of patients from the National Spinal Cord Injury Statistical Center (NSCISC).The aim was to compare the outcomes of patients with gunshot-induced spinal injuries (GSIs) treated operatively and nonoperatively.The treatment of neurological deficits associated with gunshot wounds to the spine has been controversial. Treatment has varied widely, ranging from nonoperative to aggressive surgery.Patient demographics, clinical information, and outcomes were extracted. Surgical intervention was defined as a "laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine." The primary outcome was the American Spinal Injury Association (ASIA) Impairment Scale. Statistical comparisons of baseline demographics and neurological outcomes between operative and nonoperative cohorts were performed.In total, 961 patients with GSI and at least 1-year follow-up were identified from 1975 to 2015. The majority of patients were Black/African American (55.6%), male (89.7%), and 15-29 years old (73.8%). Of those treated surgically (19.7% of all patients), 34.2% had improvement in their ASIA Impairment Scale score at 1 year, compared with 20.6% treated nonoperatively. Overall, surgery was associated with a 2.0 [95% confidence interval (CI): 1.4-2.8] times greater likelihood of ASIA Impairment Scale improvement at 1 year. Specifically, benefit was seen in thoracic (odds ratio: 2.5; 95% CI: 1.4-4.6) and lumbar injuries (odds ratio: 1.7; 95% CI: 1.1-3.1), but not cervical injuries.While surgical indications are always determined on an individualized basis, in our review of GSIs, surgical intervention was associated with a greater likelihood of neurological recovery. Specifically, patients with thoracic and lumbar GSIs had a 2.5 and 1.7-times greater likelihood of improvement in their ASIA Impairment Scale score 1 year after injury, respectively, if they underwent surgical intervention.

Introduction: When the COVID-19 pandemic forced the cancellation of visiting subinternships, we pivoted to create a virtual orthopaedic rotation (VOR). The purpose of this study was to assess the effect of the VOR on the residency selection process and determine the role of such a rotation in the future. Methods: A committee was convened to create a VOR to replace visiting orthopaedic rotations for medical students who are interested in pursuing a career in orthopaedic surgery. The VOR was reviewed and sanctioned by our medical school, but no academic credit was granted. We conducted three 3-week VOR sessions. During each session, virtual rotators participated in regularly scheduled educational conferences and attended an invitation-only daily conference in the evenings that was designed for a medical student audience. In addition, students were paired with faculty and resident mentors in a structured mentorship program. Students' orthopaedic knowledge was assessed using prerotation and postrotation tests. Results: From July to September 2020, 61 students from 37 distinct medical schools participated in the VOR. Notable improvements were observed in prerotation and postrotation orthopaedic knowledge test scores. In postrotation surveys, both students and faculty expressed high satisfaction with the curriculum but less certainty about how well they got to know each other. In the subsequent residency application cycle, 27.9% of the students who participated in the VOR were selected to interview, compared with 8.7% of the total application pool. Discussion: The VOR was a valuable substitute for in-person clinical rotations during the COVID-19 pandemic. Although not likely to be a replacement for conventional away rotations, the VOR is a possible adjunct to in-person clinical rotations in the future.

Background Adult spinal deformity (ASD) patients may have osteoporosis, predisposing them to an increased risk for surgical complications. Prior studies have demonstrated that treating osteoporosis improves surgical outcomes. In this study we determine the prevalence of osteoporosis in ASD patients undergoing long spinal fusions and the rate at which osteoporosis is treated. Methods ASD patients who frequented either of two major academic medical centers from 2010 through 2019 were studied. All study participants were at least 40 years of age and endured a spinal fusion of at least seven vertebral levels. Medical records were explored for a diagnosis of osteoporosis via ICD-10 code and, if present, whether pharmacological treatment was prescribed. T-tests and chi-squared analyses were used to determine statistical significance. Results Three hundred ninety-nine patients matched the study's inclusion criteria. Among this group, 131 patients (32.8%) had been diagnosed with osteoporosis prior to surgery. With a mean age of 66.4 years, osteoporotic patients were on average three years older than non-osteoporotic (P=0.002) and more likely to be female (74.8% vs. 61.9%; P=0.01). At the time of surgery, 34.4% of osteoporotic patients were receiving pharmacological treatment. Although not statistically significant, women were more likely to receive medical treatment than men (P=0.07). Conclusions The prevalence of osteoporosis in ASD patients undergoing a long spinal fusion is substantially higher than that of the general population. Surgeons should have a low threshold for bone density testing in ASD patients. With only about one-third of osteoporotic patients treated, there is a classic "missed opportunity" in this population.

BACKGROUND CONTEXT Incidental durotomy during elective spine surgery is relatively common. While usually benign and self-limited, it can be associated with morbidity, increased cost, and medicolegal ramifications. Dural repair typically involves performing a primary closure using a suture or dural staple; repairs are then frequently augmented with a sealant, patch, or fat/fascial graft. Although primary repair of an incidental durotomy is standard practice, the ideal secondary sealant or augment choice remains unclear. A wide variety of commercially available dural sealant options exist, and while none have demonstrated consistent superiority, all are associated with single-use costs in the hundreds to thousands of dollars and have concerns regarding swelling, local inflammation, or short-lived dural adherence. PURPOSE The goal of this study is to compare the results of dural repair augmentation using an open intraoperative epidural blood patch to a hydrogel technique. STUDY DESIGN/SETTING Retrospective comparative cohort study at an academic referral center PATIENT SAMPLE Adult patients undergoing lumbar spine surgery from March 2017 to January 2021 who sustained an incidental durotomy. Patients undergoing surgery for infection were excluded. OUTCOME MEASURES The primary outcome was failure of the repair as determined by a return to the operating room for re-exploration of a persistent cerebrospinal fluid (CSF) leak within 30 days of the index procedure. A secondary outcome was the incidence of a postoperative positional headache, and if present, the method used to obtain resolution. The primary predictor was use of a suture and hydrogel technique (“hydrogel” group), or the use of an epidural blood patch (“EBP” group). METHODS The method for applying an open epidural blood patch is presented in detail and involves primarily repairing the durotomy followed by allowing whole blood to pool and clot in the operative field until the durotomy is completely covered. This was compared with a group of patients undergoing secondary augmentation with commercially available hydrogel. In both groups, mechanical resistance to CSF leakage was confirmed with direct visualization and a Valsalva maneuver, respectively. Patients were instructed to remain flat until the morning after surgery. Chart review was used for data abstraction on preoperative, demographic, perioperative, and postoperative clinical factors. To compare between the hydrogel and EBP group, Wilcoxon rank-sum testing was used to test for non-parametric comparisons of means, and chi-square testing between binomial data. RESULTS Of 732 patients during the study period, forty-eight patients met study criteria. Twenty-five patients were in the hydrogel group and 23 in the EBP group. Mean age was 69.3 years (standard error 1.3 years). Patients were predominantly female (n = 31, 64.6%) with a mean BMI of 29.5 (SE 0.8), with no significant baseline differences between the hydrogel and EBP groups. Two patients in the hydrogel group (8.0%) and two in the EBP group (8.7%) had mild positional headaches postoperatively that resolved without intervention within 24 hours. One (4.3%) patient in the EBP group had positional headaches following an initial headache-free period; this patient was returned to the operating room and no evidence of a persistent CSF leak was found despite meticulous exploration. CONCLUSIONS An open, intraoperatively placed epidural blood patch may be an efficacious and cost-effective way to manage an incidental durotomy. This method merits further study as an allergy-free, no swell, cost-neutral method of dural repair augmentation.

Retrospective radiographic study.To evaluate cervical sagittal alignment measurement reliability and correlation between upright radiographs and magnetic resonance imaging (MRI).Cervical sagittal alignment (CSA) helps determine the surgical technique employed to treat cervical spondylotic myelopathy. Traditionally, upright lateral radiographs are used to measure CSA, but obtaining adequate imaging can be challenging. Utilizing MRI to evaluate sagittal parameters has been explored; however, the impact of positional change on these parameters has not been determined.One hundred seventeen adult patients were identified who underwent laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy from 2017 to 2019. Two clinicians independently measured the C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and the T1 tilt. Interobserver and intraobserver reliability were assessed by intraclass correlation coefficient.Intraobserver and interobserver reliabilities were highly correlated, with correlations greater than 0.85 across all permutations; intraclass correlation coefficients were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between x-ray and MRI at 0.76 with no significant difference (P=0.46). There was a weaker correlation with regard to C2-C7 SVA (0.48) and T1 tilt (0.62) with significant differences observed in the mean values between the 2 modalities (P0.01).The C2-C7 sagittal angle is highly correlated and not significantly different between upright x-ray and supine MRIs. However, cervical SVA and T1 tilt change with patient position. Since MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning a posterior-based cervical procedure.

BACKGROUND CONTEXT Cervical sagittal alignment (CSA) parameters are helpful in determining the surgical technique used to treat cervical spondylotic myelopathy. Upright lateral radiographs are routinely used to measure CSA parameters, but obtaining adequate imaging is difficult. Utilizing magnetic resonance imaging (MRI) to evaluate sagittal parameters has been explored; however, the impact of positional changes on these parameters has not been elucidated. PURPOSE To evaluate CSA parameter measurement reliability and correlation between XR and MRI modalities in patients undergoing posterior decompressive procedures for cervical spondylotic myelopathy. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE We evaluated adult patients who had undergone laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy between 2017 and 2019 and who had cervical spine XR and MRI within a 6-month timespan of one another. OUTCOME MEASURES Outcomes of interest included intra- and interobserver reliability assessment of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements as well as correlations in these parameters between imaging modalities. METHODS Two clinicians completed two independent rounds of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements; intra- and interobserver reliability were assessed by intraclass correlation coefficient (ICC). Correlations between imaging modalities were analyzed using parametric and nonparametric statistical tests. RESULTS Intra- and interobserver reliabilities were highly correlated with correlations greater than 0.85 across all permutations; ICCs were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between XR and MRI at 0.76 with no significant difference (p = 0.46). Weaker correlations existed for C2-C7 SVA (0.48) and T1 tilt (0.62) measurements with significant differences observed in the mean values between the two imaging modalities (p CONCLUSIONS The C2-C7 sagittal angle is highly correlated and not significantly different between upright XR and supine MR images. However, cervical SVA and T1 tilt change with patient position. As MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning posterior based cervical fusions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument. PURPOSE The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery. PATIENT SAMPLE This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019. OUTCOME MEASURES The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity). METHODS Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application. RESULTS Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression.

Background Context Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered. Purpose We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM. Study Design Retrospective comparative study. Patient Sample Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded. Outcome Measures The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs. Methods Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material – both implant and non-implant – cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables. Results Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF. Conclusions This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.

STUDY DESIGN Retrospective study. OBJECTIVE The goal of this study is to identify and validate the reliability and accuracy of 2 methods used to assess lumbar disk herniations (LDHs): anteroposterior length and cross-sectional area. BACKGROUND Many clinicians characterize LDHs through the measurement of the anteroposterior length in the axial plane. Radiologists, on the other hand, have utilized software to measure the disk and canal areas to define the injury. In this study, the authors consider the reliability and accuracy of anteroposterior length in comparison with the area. METHODS Using International Classification of Diseases, 10th Revision (ICD-10) code M51.26, patients at a single academic medical center who received a diagnosis of primary lumbar radicular pain with subsequent magnetic resonance imaging documentation of a single-level disk herniation in 2015 and 2016 were identified. AGFA-IMPACS software was utilized to make the following measurements: anterior-posterior canal length; anterior-posterior disk length; mid-canal width; mid-disk width; total canal area; total disk area. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach alpha as a measure of reliability was obtained. RESULTS A total of 408 patients met the inclusion and exclusion criteria for this study. Sixteen (3.9%) had L3-L4 herniation, 208 had L4-L5 herniation (51.0%), and 184 had L5-S1 herniation (47.5%). The least reliable interobserver metrics, with respective Cronbach alpha values of 0.381 and 0.659, were the linear measurements of mid-disk width and anterior-posterior canal length. Area measurements of the disk and canal areas generated Cronbach alpha values of 0.707 and 0.863. Intraobserver Cronbach alpha values for all measurements, including all areas and lengths, met or exceeded 0.982. CONCLUSIONS The cross-sectional area provides a more reliable measurement modality for diskLDHs in comparison to linear measurements. Unlike anteroposterior length, cross-sectional area incorporates the shape of a herniation or canal in its measurement. Thus, it is superior in its characterization LDH particularly in light of its stronger reproducibility. LEVEL OF EVIDENCE Level III-retrospective study.

Osteoporosis is the most common metabolic bone disorder; through its prevalence and utilization of healthcare resources, the disease creates an enormous medical and economic burden that is set to worsen based on current population predictions. The transition of US healthcare from a volume-based to value-based reimbursement system presents an opportunity to address large population health problems such as osteoporosis. By reorganizing treatment plans and outcomes around the needs of the patient, the burden of osteoporosis can be managed in a more cost-effective way.

STUDY DESIGN Review of TRICARE claims (2006-2014) data to assess Emergency Department (ED) utilization following spine surgery. OBJECTIVE The aim of this study was to determine utilization rates and predictors of ED utilization following spine surgical interventions. SUMMARY OF BACKGROUND DATA Visits to the ED following surgical intervention represent an additional stress to the healthcare system. While factors associated with readmission following spine surgery have been studied, drivers of postsurgical ED visits, including appropriate and inappropriate use, remain underinvestigated. METHODS TRICARE claims were queried to identify patients who had undergone one of three common spine procedures (lumbar arthrodesis, discectomy, decompression). ED utilization at 30- and 90 days was assessed as the primary outcome. Outpatient spine surgical clinic utilization was considered the primary predictor variable. Multivariable logistic regression was used to adjust for confounders. RESULTS Between 2006 and 2014, 48,868 patients met inclusion criteria. Fifteen percent (n = 7183) presented to the ED within 30 days postdischarge. By 90 days, 29% of patients (n = 14,388) presented to an ED. The 30- and 90-day complication rates were 6% (n = 2802) and 8% (n = 4034), respectively, and readmission rates were 5% (n = 2344) and 8% (n = 3842), respectively. Use of outpatient spine clinic services significantly reduced the likelihood of ED utilization at 30 [odds ratio (OR) 0.48; 95% confidence interval (95% CI) 0.46-0.53] and 90 days (OR 0.55; 95% CI 0.52-0.57). CONCLUSION Within 90 days following spine surgery, 29% of patients sought care in the ED. However, only one-third of these patients had a complication recorded, and even fewer were readmitted. This suggests a high rate of unnecessary ED utilization. Outpatient utilization of spine clinics was the only factor independently associated with a reduced likelihood of ED utilization. LEVEL OF EVIDENCE 3.

BACKGROUND CONTEXT Spinal injuries are relatively common injuries that have a lasting impact on patients and are a significant cause of disability. Gunshot induced spinal injuries (GSIs) are the third most common cause of spinal injury and are increasing in proportion. Despite the severity and frequency of these injuries, there remains a lack of conclusive evidence regarding the optimal management of patients with GSIs. PURPOSE We aimed to better understand the impact of surgical intervention in patients who sustained gunshot induced spinal injuries. STUDY DESIGN/SETTING Retrospective comparative study. PATIENT SAMPLE Patients in the National Spinal Cord Injury Statistical Center (NSCISC) database with GSIs and complete one-year follow-up information. (n = 961) OUTCOME MEASURES The primary outcome measure was defined as improvement in ASIA Impairment Scale from the time of presentation. METHODS Patient demographics, clinical information, and outcome data were extracted from the NSCISC database. Surgical intervention was defined as any procedure involving a laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine. Functional assessments included the American Spinal Injury Association (ASIA) Impairment scale. Bivariate analysis as well as multivariate analysis was performed. RESULTS A total of 961 patients with GSI and one-year follow-up were identified from 1975-2016. The majority of patients were Black/African American (55.6%), male (89.7%), and aged 15-29 (73.8%). Of those who underwent surgical intervention, 34.2% had an improvement in their ASIA Impairment Scale at one year as compared to 20.6% of those treated non-operatively. Overall, surgery was associated with 2.0 [95% CI 1.4 - 2.8] times greater likelihood of ASIA Impairment Scale improvement at one year. Specifically, benefit was seen in thoracic (OR 2.5 [95% CI 1.4-4.6]) and lumbar injuries (OR 1.7 [95% CI 1.1-3.1]), but not cervical injuries. At 5-year follow-up, surgery was associated with 6.2 [95% CI 1.4-16.0] times greater likelihood of improvement in the ASIA Impairment Scale. CONCLUSIONS While the decision to undergo surgery should be individualized, in our large review of GSIs, surgical intervention was associated with a greater likelihood of neurologic recovery. Specifically, patients with thoracic and lumbar GSI have a 2.5- and 1.7-times, respectively, greater likelihood of improvement in their ASIA Impairment Scale one year after injury if they underwent surgical intervention. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Is advanced imaging necessary in the evaluation of pelvic fractures caused by low-energy trauma in elderly patients?Retrospective review.Single institution, Level 1 Trauma Center.Age ≥60 years old treated for low-energy traumatic pelvic ring injuries.None.Posterior pelvic ring injuries diagnosed on advanced imaging, radiographic displacement, admission status, hospital length of stay, change in weight-bearing status recommendations, and whether operative treatment was pursued.Eighty-seven patients met the inclusion criteria, of which 42 had advanced imaging to evaluate the posterior pelvic ring (10 magnetic resonance imaging, 32 computed tomography). More posterior pelvic ring injuries were identified with advanced imaging compared with radiographs alone (P0.001). There was no statistically significant difference in rate of admission (P = 0.5) or hospital length of stay (P = 0.31) between patients with radiographs alone compared with patients evaluated with radiographs plus advanced imaging. The rate of displacement1 cm at presentation and 6-week follow-up was unaffected by the presence of a posterior injury diagnosed on advanced imaging. Treatment for all 87 patients remained weight-bearing as tolerated with assist device irrespective of advanced imaging findings, and no patient underwent surgical intervention by 12-week follow-up.Despite frequent identification of posterior pelvic ring injuries in patients evaluated with advanced imaging, admission status, length of hospital stay, radiographic displacement, and treatment recommendations were unaffected by these findings. The use of advanced imaging in elderly patients with low-energy traumatic pelvic ring fractures may not be necessary.Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND CONTEXT Intraoperative vascular injury may be an unavoidable complication of anterior lumbar spine surgery. However, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated surveillance of intraoperative vascular injury from free-text notes in anterior lumbar spine surgery. STUDY DESIGN/SETTING Retrospective review of electronic health records at two academic and three community medical centers. PATIENT SAMPLE Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery OUTCOME MEASURES The primary outcome was unintended vascular injury during anterior lumbar spine surgery. METHODS The training set (n=786) consisted of patients who underwent surgery prior to December 31, 2013. The independent testing set (n=249) consisted of patients who underwent surgery after January 1, 2014. An extreme-gradient boosting supervised machine learning NLP algorithm was trained for detection of intraoperative vascular injury. Performance of this algorithm was compared to current procedural terminology (CPT) and international classification of diseases (ICD) codes. RESULTS In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative vascular injury was 7.2% (n=75). On temporal validation in the independent testing set, the NLP algorithm achieved c-statistic of 0.92 in comparison to 0.64 for the CPT and ICD codes. At a threshold equal to the Youden index, the NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a vascular injury whereas the CPT and ICD codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64. CONCLUSIONS Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative vascular injury in anterior lumbar spine surgery. External and prospective validation of this NLP algorithm may improve quality and safety reporting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND Incidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery. PATIENT SAMPLE Adult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers. OUTCOME MEASURES The primary outcome was defined as intraoperative durotomy recorded in free-text operative notes. METHODS An 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy. RESULTS Overall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99. CONCLUSIONS Internal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies.

Introduction: Adult spinal deformity (ASD) surgery patients are at higher risk for surgical site infections (SSIs) due to large incisions, high blood loss, long surgical duration, and extensive instrumentation. The use of vancomycin powder has demonstrated inconsistent results in ASD surgery. Antibiotic-impregnated calcium sulfate beads have been used in arthroplasty and foot and ankle surgery with promising results. The purpose of this study was to provide preliminary data on the use of vancomycin-impregnated calcium sulfate beads in the prevention of SSI following ASD surgery and provide comparisons to the use of vancomycin powder. Methods: A retrospective chart review was performed for 95 consecutive surgical ASD patients at a tertiary care center from January 2017 until March 2020. Patients received either vancomycin powder (powder group) or vancomycin-impregnated calcium sulfate beads (bead group) intrawound prior to closure. Patient demographics, operative course, and incidence of postoperative infections were recorded. A two-tailed chi-squared test was performed to compare infection rates. Results: Ninety-five patients were included for review. Forty-two patients were in the powder group and 53 patients were in the bead group. The bead group was older (59.8 vs 67.8 years, p < 0.01) with similar BMI and rates of diabetes, smoking, and length of surgery. There were four postoperative SSI in the powder group requiring operative irrigation and debridement and one SSI in the bead group (9.5% vs 1.9%, p = 0.09). All infections occurred in the first 90 days of the postoperative period. Conclusion: Preliminary examination of the use of vancomycin-impregnated calcium sulfate beads demonstrated a 1.9% surgical site infection rate in adult spinal deformity surgical patients, which was not significantly different compared with the 9.5% infection rate in patients who received vancomycin powder. Prospective study is needed to determine if the differences found are significant in a larger number of patients.

The residency match is increasingly competitive. The interview is an essential component, yet little has been documented about the costs applicants incur during the interview process and it is unclear how they manage these expenses.The purpose of this study was to define the economic burden of residency interviews for United States (U.S.) allopathic students participating in the 2016 Main Residency Match. We hypothesized that the financial burden of residency interviews varies based on specialty and plays a role in the applicant's ability to participate in all desired interviews.A 26 question electronic survey was developed following pilot study of applicants to a single residency program. Following validation, the survey was distributed to administrative officials at all U.S. allopathic medical schools for circulation to senior students. Results were pooled for statistical analysis.We received responses from 759 U.S. allopathic seniors. A single interview most commonly costs $250 - $499. Most applicants incurred substantial interview related costs. Sixtyfour percent of respondents spent at least $2,500, while 13% spent $7,500 or more. Specialty competitiveness was predictive of higher interview costs. Seventy-one percent of respondents borrowed money to fund interview costs, and 41% declined interviews for financial reasons.Senior medical students incur substantial costs to participate in residency interviews, often adding to already burdensome educational debt. We encourage residency programs, especially those in competitive specialty fields, to pursue cost reduction strategies. Additionally, medical schools should provide financial counseling to allow students to anticipate interview costs.

The intense competition for orthopedic surgery residency positions influences the interview process. The financial impact on residency applicants is less well understood. The purpose of the present study was to define the economic burden of the orthopedic surgery residency interview process while additionally describing how applicants finance the expense.We distributed surveys to 48 nonrotating applicants at our institution's residency interview days for the 2015 match year. The survey consisted of eleven questions specific to the costs of interviewing for orthopedic surgery residency positions.The survey response rate was 90% (43/48). Applicants applied to a median of 65 orthopedic surgery residency programs (range 21-88) and targeted a median of 15 interviews (range 12-25). The mean cost estimate for a single interview was $450 (range $200-800) and the cost estimate for all interviews was $7,119 (range $2,500-15,000). Applicants spent a mean of $344 (range $0-750) traveling to our interview. Seventy-two percent borrowed money to finance their interview costs and 28% canceled interviews for financial reasons.The financial cost of interviewing for orthopedic surgery is substantial and a majority of applicants add to their educational debt by taking out loans to finance interviews. Future considerations should be made to minimize these costs for an already financially burdened population.

Background : From 2002 to 2014, the orthopedic surgery residency applicant pool increased by 25% while the number of applications submitted per applicant rose by 69%, resulting in an increase of 109% in the number of applications received per program. Objective : This study aimed to identify applicant factors associated with an increased number of applications to orthopedic surgery residency programs. Design : An anonymous survey was sent to all applicants applying to the orthopedic surgery residency program at Loyola University. Questions were designed to define the number of applications submitted per respondent as well as the strength of their application. Of 733 surveys sent, 140 (19.1%) responses were received. Setting : An academic institution in Maywood, IL. Participants : Fourth-year medical students applying to the orthopedic surgery residency program at Loyola University. Results : An applicant’s perception of how competitive he or she was (applicants who rated themselves as ‘average’ submitted more applications than those who rated themselves as either ‘good’ or ‘outstanding’, p =0.001) and the number of away rotations (those who completed >2 away rotations submitted more applications, p =0.03) were significantly associated with an increased number of applications submitted. No other responses were found to be associated with an increased number of applications submitted. Conclusion : Less qualified candidates are not applying to significantly more programs than their more qualified counterparts. The increasing number of applications represents a financial strain on the applicant, given the costs required to apply to more programs, and a time burden on individual programs to screen increasing numbers of applicants. In order to stabilize or reverse this alarming trend, orthopedic surgery residency programs should openly disclose admission criteria to prospective candidates, and medical schools should provide additional guidance for candidates in this process. Keywords: orthopedic surgery; residency application; National Residency Matching Program; United States Medical Licensing Exam (Published: 21 July 2016) Citation: Med Educ Online 2016, 21 : 31865 - http://dx.doi.org/10.3402/meo.v21.31865

BackgroundIn sum, 1-, 2-, and 4-stranded allografts are used for soft tissue anterior cruciate ligament reconstruction; however, the fixation properties of fixation devices are not well assessed.HypothesisThere are no differences in the biomechanical characteristics of 1 (Achilles)-, 2 (posterior tibialis)-, and 4 (semitendinosus)-stranded allograft tibial fixation.Study DesignControlled laboratory study.MethodsSixty-three fresh-frozen porcine tibiae were used to evaluate the fixation of 1-, 2-, and 4-stranded human tendon allografts (Achilles, posterior tibialis, and semitendinosus) with 3 fixation devices (Delta, Intrafix, and Calaxo screws). With use of a materials testing system, each graft was subjected to 500 cycles of loading (50-250 N, 0.75 mm/sec) to determine displacement and cyclic stiffness, followed by a monotonic failure test (20 mm/min) to determine maximum load and pullout stiffness.ResultsFor each graft type, there were no significant biomechanical differences between fixation devices. However, the 1-stranded graft (Achilles) construct demonstrated significantly higher mean displacement (3.17 ± 1.62 mm), lower cyclical stiffness (156 ± 25 N/mm), lower load to failure (479 ± 87 N), and lower pullout stiffness (140 ± 28 N/mm). In comparison with the 2-stranded graft (posterior tibialis), the 4-stranded graft (semitendinosus) exhibited lower displacement (0.86 ± 0.44 to 1.12 ± 0.51 mm) and higher ultimate failure load (832 ± 255 to 656 ± 168 N). Numerous differences in fixation properties were noted when comparing a device to each of the 3 grafts.ConclusionThe 1-stranded allograft demonstrated inferior biomechanical tibial fixation properties when compared with 2 (posterior tibialis)- and 4 (semitendinosus)-stranded allograft constructs for all fixation devices tested.Clinical RelevanceThis study demonstrated that not all tibial fixation devices are designed to adequately accommodate different types of anterior cruciate ligament allografts. Biomechanical evidence suggests that caution is warranted when using an Achilles allograft fixated solely with an interference device.