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Purpose: Determine peri-operative risk factors predictive for prematurely stopping surgery prior to completion of deformity correction due to intra-operative neuromonitoring changes., Methods: A single institution retrospective review of adolescent idiopathic scoliosis (AIS) patients that underwent spinal fusion for curves greater than 70°. Cases aborted due to persistent loss of IONM were compared to completed cases. Demographic, radiographic, neurologic, and surgical information was reviewed., Results: There were 453 total cases. Nine (9/453: (2%)) cases were aborted due to persistent loss of IONM, and 4 (4/453; (0.88%)) awoke with a neurologic deficit. Comparing to the 444 completed cases, pre-operative risk factors associated with case abortion were older age (15.3 vs. 13.8 years; p = 0.02), sex (male) (66.7% vs. 20.3%, p = 0.004), and larger cobb angles (87.6° vs. 79.2°; p = 0.01). Being male increased the risk of case abortion: 7.9X. Intraoperative risk factors associated with case abortion were combined anterior/posterior approach (ASF/PSF) (44.4% vs. 7.2%; p = 0.003) and increased index procedure EBL (1127 vs. 769 mL; p = 0.043). ASF/PSF increased the risk: 10.3X. Four (4/9;44%) of the aborted cases awoke with neurologic deficit. Motor strength returned at 2.3 days (0-18). Aborted cases returned to the OR after 12.6 ± 7.0 days (1-23) which was related to time to regain motor strength., Conclusion: Pre-operative risk factors for AIS case abortion due to persistent loss of IOMN are older age, males, with larger Cobb angles. Intraoperative risk factors are combined ASF/PSF and increased index procedure EBL. Independent risk factors were sex (male) and ASF/PSF which increased the risk 7.9X and 10.3X, respectively., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: It is unclear if intra-wound vancomycin powder significantly reduces the infection rate for uninstrumented spine surgery. The purpose of this study is to compare the rate of surgical site infection (SSI) in uninstrumented spine surgery that used vancomycin powder against controls., Methods: A search was performed on PUBMED/MEDLINE, Cochrane Database and Embase on 14 October 2022. Search keywords were "vancomycin, spine surgery, uninstrumented and spinal surgery." Instrumented cases were excluded. Type of surgery, type of treatment and incidence of infection among experimental or control were recorded., Results: 288 articles were obtained from a literature search. 16 studies met inclusion criteria. 6/16 studies that reported on the infection rate using vancomycin were obtained. There were 1376 control cases with 20 cases of post-operative infection (1.45% overall). There were 795 cases that received prophylactic intra-wound vancomycin powder with 10 cases of infection reported (1.26%). There was no significant difference in infections between cases that received vancomycin compared to control. On subgroup analysis, studies that had a high rate of infection (Strom and Cannon) had a significant difference on the rate of infection with the use of vancomycin compared to control., Discussion and Conclusion: The current study was unable to conclude that vancomycin decreased the rate of surgical site infections. Vancomycin use may be useful in populations that have a high rate of infection. Limitations in this study include the small number of studies that report on the use of vancomycin on uninstrumented spine surgery., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Children with autism/Asperger are grouped into the diagnosis of autism spectrum disorder (ASD). It remains uncertain whether children with ASD and scoliosis have radiographic and clinical outcomes similar to idiopathic scoliosis (IS) patients., Methods: A single-center, retrospective review of a prospective scoliosis registry evaluated patients who had a posterior spinal fusion±Anterior Spinal Fusion and an underlying diagnosis of ASD between 1990 and 2021. A 2:1 match with AIS patients by age and sex was compared using demographic, radiographic, intraoperative, and SRS-22/30 variables., Results: Thirty patients with ASD (63% male, mean age at surgery 14.6±2.5 y) met inclusion criteria, with a follow-up of 2.46±1.00 years. Despite no differences in curve magnitude preoperatively, patients with ASD had a higher percent correction at 2-year follow-up (66% vs. 57%, P =0.01) and improved mean curve magnitude (20±10 degrees) at 2-year follow-up compared with IS patients (27±11 degrees, P <0.01). ASD patients had less lumbar lordosis preoperatively (40±12 vs. 53±14, P <0.01), but there were no significant differences in sagittal parameters at 2-year follow-up. There were no significant differences in the rate of complications at 2-year follow-up between ASD and AIS cohorts., Conclusions: Although patients with ASD exhibited decreased lordosis compared with IS patients preoperatively, their radiographic outcomes at 2-year follow-up were the same. In addition, ASD patients maintained greater curve correction than IS patients at 2 years follow-up., Level of Evidence: Prognostic retrospective study., Competing Interests: J.T.B. is a consultant to OrthoPediatrics, Medtronic, and Johnson & Johnson. Dr K.R. has received royalties from Elsevier and has stocks/stock options in Mati Therapeutics. Dr D.J.S. has received royalties from Globus Medical. Dr A.M. reports being a paid speaker for NuVasive. Dr B.R. reports receiving royalties from Elsevier. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Malpositioning of the femoral button is a known technical complication after anterior cruciate ligament (ACL) reconstruction with cortical suspensory fixation. The incidence of malpositioning, as well as the efficacy of methods to prevent malpositioning of cortical suspensory fixation devices, has not been reported., Purpose: To determine the rate of malpositioned cortical suspensory fixation devices after ACL reconstruction, investigate which intraoperative technique yields the lowest rate of malpositioning, and determine the return-to-duty rate for active-duty service members with malpositioned buttons and the revision rate for malpositioned buttons., Study Design: Case series; Level of evidence, 4., Methods: The records of patients who underwent primary ACL reconstruction with a cortical suspensory fixation device between 2008 and 2018 were reviewed at our institution. Postoperative radiographs were reviewed for evidence of malpositioned femoral buttons. Malpositioned buttons were classified as (1) fully positioned in the bone tunnel, (2) partially positioned in the bone tunnel, (3) >2 mm from cortical bone, or (4) deployed over the iliotibial band. Operative reports were reviewed to determine the intraoperative methods undertaken to verify the button position. The rate of malpositioned cases with subjective instability and revision surgery performed were determined. The ability of patients to return to full military duty was reviewed for active-duty personnel., Results: A total of 1214 patients met the inclusion criteria. A 3.5% rate (42 cases) of malpositioned cortical suspensory fixation devices (femoral buttons) was identified. For patients with malpositioned buttons, 7 (16.7%) patients underwent revision surgery in the immediate postoperative period. Techniques used to avoid malpositioning included direct arthroscopic visualization, direct open visualization, intraoperative fluoroscopy, and first passing the button through the skin before positioning on the femoral cortex. There was a 4.6% malposition rate using direct arthroscopic visualization and a 5.1% malposition rate using passage of the button through the skin, while no malpositioning occurred with intraoperative fluoroscopy or direct open visualization ( P < .05). Overall, 12 (28.6%) patients with malpositioned buttons ultimately underwent revision surgery. Despite having been diagnosed with malpositioned buttons, 21 (63.6%) active-duty members were able to return to full duty., Conclusion: Malpositioning of femoral buttons during ACL reconstruction occurred in 3.5% of patients in this series. The techniques of intraoperative fluoroscopy and direct open visualization are encouraged to prevent malpositioning., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.A. has received education payments from ImpactOrtho. L.Z. has received grant support from Arthrex and hospitality payments from Stryker. C.R.B. has received education payments from Arthrex, nonconsulting fees from Arthrex, and honoraria from MTF Biologics. S.M.G. has received education payments from Supreme Orthopedic Systems and Sea Pearl and grant support from Arthrex. The views expressed in this article are those of the author(s) and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the United States government. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Case: A 4-year-old girl sustained a traumatic atlantoaxial rotatory subluxation. She presented at the treating facility 8 months after injury with cervical deformity, neck pain, gait instability, and decreased cervical motion. Her delay in presentation was partially because of international Corona Virus of 2019 (COVID-19) travel restrictions. The case was successfully treated with halo traction, followed by halo vest immobilization., Conclusion: Chronic atlantoaxial rotatory fixation can be treated nonsurgically with closed reduction and halo traction, but is associated with operative risks. Optimal pin placement is challenging in the pediatric skull and may be improved with a preoperative or intraoperative computed tomography (CT) scan., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C106)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

A project with the goal of implementing electronic health record (EHR)-based patient-reported outcome measures (PROMs) into a large inpatient spinal cord injury (SCI) rehabilitation program took twice as long as expected. This report details the lessons learned from the barriers, successes, and unexpected issues that arose during this prolonged, but now successful, project. The goals of this implementation project were to (1) identify barriers and supports to the use of PROMs; (2) develop an implementation strategy to incorporate the use of PROMs into inpatient rehabilitation; and (3) implement the strategy and evaluate its effects on team communication. In brief, we conducted an initial pilot phase outside of the EHR and used our findings to guide procedural and EHR incorporation during a demonstration phase. We encountered multiple barriers. Procedural issues were significant; although grant funding covered the cost of writing the code for integration of the PROMs into the EHR, our institution's competing priorities slowed progress. Institutional inertia was reflected in the reluctance of some clinical staff members to assume new duties that would take away from direct patient care responsibilities. Therefore, we needed to obtain additional staffing. Detailed planning upfront, guided by changes when necessary; cooperation and interaction with our institution's Information Systems department; and identification of key players and Implementation Champions proved essential to our success. We now have an up-and-running system and are sharing our experience, observations, and recommendations to assist other health care organizations incorporate PROMs into their EHRs., (Copyright © 2021 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: There is a lack of information on anterior cruciate ligament (ACL) reconstruction outcomes and complications for patients with congenital hypocoagulable conditions. The specific aim of this retrospective study was to report operative outcomes and complications for patients with congenital hypocoagulable disorders who underwent ACL reconstruction., Methods: We performed a retrospective review of all patients who underwent an ACL reconstruction within Truven MarketScan Commercial Claims and Encounter Database from 2010 to 2014. Hemophilia A, hemophilia B and patients were identified. Patient demographics, cost of surgery, blood product use, concomitant injuries, repeat ACL injury, complications and various operative variables were collected. Statistical tests were conducted on SAS 9.4 2013., Results: Thirty-three hemophilia A, three hemophilia B, 63 von Willebrand factor patients, and 103,478 controls underwent ACL reconstruction. There is a statistically significant difference for hemarthrosis 1 year leading up to injury for hemophilia A compared with control (P = 0.0083). Total healthcare utilization 90 days after surgery was statistically significant for hemophilia A ($30,310 ± 52,745, P < 0.001) and von Willebrand factor ($20,355 ± 23,570, P < 0.001) compared with control ($14,564 ± 9512). Length of hospital stay, postoperative hemorrhage, concomitant injuries to the knee, additional ACL injury, infection rate, deep-vein thrombosis, and pulmonary embolism were not statistically significant. None of the hemophilia A or von Willebrand factor patients received blood products intraoperatively or postoperatively., Conclusion: Hemophilia A and von Willebrand factor patients had rates of postoperative complications and ACL re-injuries that were not statistically significant. Cost of healthcare utilization was identified as dramatically greater for hemophilia A and von Willebrand factor patients., Competing Interests: Declaration of Competing Interest The authors have no potential conflicts of interest to disclose., (Published by Elsevier B.V.)