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Matthew W Konigsberg, John D Mueller, Jordan A Lebovic, R Kumar Kadiyala Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USACorrespondence: Matthew W KonigsbergDepartment of Orthopedic Surgery, Columbia University Medical Center, 622 W. 168th St. 11th Floor, New York, NY 10032, USATel +1-212-305-5976Fax +1-212-305-6193Email Mk3294@cumc.columbia.eduIntroduction: The purpose of this study was to describe four cases of patients who developed concomitant upper extremity and gluteal compartment syndrome in the context of substance abuse. In somnolent patients unable to provide a reliable physical exam, the healthcare provider must be aware of patients presenting with concomitant upper extremity and gluteal compartment syndrome.Methods: Retrospective chart review identified cases of the combined upper extremity and gluteal compartment syndrome following illicit drug abuse at a single academic center during the years 2009– 2019.Results: During the 11-year period examined, a total of eight patients were diagnosed with compartment syndrome secondary to illicit drug use and prolonged immobilization. Four (50%) patients presented with combined upper extremity and gluteal compartment syndrome. All of these patients underwent prompt surgical release of the affected compartments. All eventually returned to normal activities of daily living.Discussion: Compartment syndrome is primarily a clinical diagnosis, with physical exam being extremely important. In patients presenting with somnolence secondary to illicit drug use, physical exam may not be reliable. It is critical to have a high clinical suspicion in this patient population, understanding that these patients may present with concomitant upper extremity and gluteal compartment syndrome.Level of Evidence: Level IV, case series.Keywords: compartment syndrome, fasciotomy, trauma, upper extremity, gluteal

Objective: Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD., Methods: ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions [interbody fusion, thoracolumbar posterior column osteotomies, and 3CO]). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups., Results: A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043)., Conclusions: MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.

Study Design/setting: Retrospective single-center study., Background: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD)., Purpose: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD., Methods: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years., Results: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF., Conclusion: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement., Competing Interests: P.G.P.: Allosource: other financial or material support; Cervical Scoliosis Research Society: research support; Globus Medical: paid presenter or speaker; Medicrea: paid consultant; Royal Biologics: paid consultant; SpineWave: paid consultant; Terumo: paid consultant; Zimmer: paid presenter or speaker. R.L.: Nemaris: stock or stock options. V.L.: DePuy, A Johnson & Johnson Company: paid presenter or speaker; European Spine Journal : editorial or governing board; Globus Medical: paid consultant; International Spine Study Group: board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: paid presenter or speaker. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

It has been postulated that injury to the medial collateral ligament (MCL) of the elbow is rare in cases of elbow fracture-dislocation, and if the MCL is torn, it does not require surgical repair. Elbow fracture-dislocations with MCL insufficiency are associated with recurrent instability, secondary surgery, and the development of posttraumatic arthritis. With the current study, our aim was to investigate whether evidence of an MCL attachment-site fracture on a radiograph or computed tomography (CT) scan is predictive of MCL insufficiency, the need for MCL repair, and postoperative instability., Methods: This retrospective study included 219 patients (median age of 50 years; 53% female) with elbow fracture-dislocations treated at 2 Level-I trauma centers during the period of 2005 to 2016. Patients were followed for a median of 6.3 years to determine postoperative stability. Operative notes and radiology reports were reviewed to confirm MCL insufficiency and periarticular fractures. Radiographs and CT scans were analyzed by a musculoskeletal fellowship-trained emergency radiologist and a board-certified upper-extremity orthopaedic surgeon., Results: Of the 33 patients with confirmed fractures at an MCL attachment site, 26 (79%) had MCL insufficiency, whereas of the 186 patients without fracture at an MCL attachment site, only 17 (9%) had MCL insufficiency. Of the 6 patients with an attachment-site fracture and MCL insufficiency who did not undergo initial MCL repair, 5 required reoperation. Of the 7 patients without an attachment-site fracture and with MCL insufficiency who did not undergo initial MCL repair, only 1 required reoperation., Conclusions: Fractures involving an MCL attachment site, regardless of their size, help to predict MCL insufficiency. These fractures can be visualized using initial radiographs and CT scans that are routinely obtained. Additional research is required to assess these findings. Our findings further suggest that repairing an MCL-complex injury in cases of fracture-dislocation in which the fracture has occurred at an MCL attachment site may improve elbow stability and decrease the likelihood of requiring reoperation., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2019 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)