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Study design This is a retrospective case review. Objective The objective of this study was to present an anatomic approach to transpsoas interbody fusion without psoas stimulated electromyography (sEMG) and to evaluate the rate of neurological and approach-related complications. Background The transpsoas approaches have become commonly utilized for lumbar interbody fusion and may have certain advantages compared with other methods of interbody stabilization. Traditionally, transpsoas approaches have been performed utilizing sEMG as it has been purported to reduce the risk of injury to the lumbar plexus; however, an anatomic approach to transpsoas surgery is also possible as cadaveric studies have demonstrated the anatomy of the psoas muscle and lumbar plexus. Methods Patients who underwent transpsoas interbody fusion using an anatomic approach without psoas sEMG between 2005 and 2018 were enrolled in this study. The preoperative and postoperative medical records for this cohort were carefully reviewed to identify any new or persistent radicular symptoms, neurological deficits or approach-related complications. Results A total of 133 patients (48 males, 85 females) underwent transpsoas interbody fusion at 222 levels in this cohort-which had a mean age of 63 (61, 65) years and body mass index of 28.8 (27.8, 29.9). New neurological complications were seen in 5 patients (3.8%) and 5 patients (3.8%) were found to have new postoperative radicular pain, up to 3 months postoperatively. The total number of perioperative, approach-related complications was 7 (5.3%) for the entire cohort. Conclusion An anatomic transpsoas approach to the interbody space without psoas sEMG demonstrated a rate of neurological and approach-related complications that was comparable or superior to the rate of complications reported using the traditional transpsoas approach with sEMG.

Introduction The COVID-19 pandemic resulted in a transition to a virtual format for all medical residency and fellowship application processes. Previous studies have discussed the successful implementation of virtual interviews, but a deep analysis of how the application process has changed for orthopedic surgery fellowship programs during the pandemic is lacking. The purpose of this study was to assess how COVID-19 impacted the orthopedic spine fellowship application and selection process. Methods A web-based survey was administered to the program directors of all 75 U.S. orthopedic surgery spine fellowship programs, which often can accept both orthopedic surgery and neurosurgery trained graduates. Questions focused on the changes from the 2019-2020 application cycle to the 2020-2021 cycle. We collected data on connecting with potential applicants, the general application process, and interviews offered by programs. Univariate analyses were used to compare data from the 2020-2021 cycle with the prior 2019-2020 cycle. Results Twenty-five of the 75 contacted program directors responded to our survey (33% response rate). The percentage of programs that offered virtual open houses/meet-and-greets increased from 20% in 2019-2020 to 52% in 2020-2021 (p=0.018). Social media use was unchanged (0.0% vs. 4.0%, p0.05). Compared to the prior year, the number of interviews offered by programs increased by 1.5 (32.7 vs. 21.9 interviews, p=0.024). There were no significant differences in the numbers of applications received by programs, interview dates available, or separate interviews each candidate completed during an interview day (p0.05 for all). The in-person interview was the most important factor in 2019-2020 for selecting applicants, whereas the virtual interview, letters of recommendation (LOR), and research were equally ranked as the most important factors in 2020-2021. Regarding interviews, 50% of respondents would "likely" consider virtual interviews as an option in addition to in-person interviews in the future, but most (55%) answered that it was "unlikely" that virtual interviews would entirely replace in-person interviews. Conclusion Spine fellowship programs were more likely to use virtual social events to recruit potential applicants, send out more interview invitations, and equally consider LOR and research with interview performance during an entirely virtual application cycle. Half of the program directors would consider offering virtual interviews as an option for future application cycles, which may help reduce costs associated with the process.

A 75-year-old woman with remote history of T10-S1 spinal fusion with pelvic fixation presented with radicular back pain and numbness in the right lower extremity. Imaging showed bilateral rod fractures at L4-5 and a dorsal spinal epidural hematoma (SEH) with associated severe canal narrowing and cauda equina compression. The patient underwent bilateral L4-5 laminectomies, hematoma evacuation, reinforcement of multilevel nonunion, and implant replacement. Her symptoms resolved after the procedure.SEH is a rare complication that may occur secondary to failed spinal fusion and must be considered in the differential diagnosis of new or progressive neurological symptoms.

CASE A 66-year-old woman with polymyositis and recurrent urinary tract infections presented with lumbar pain and progressive lower extremity neuropathy. Imaging showed lytic destruction of the vertebral bone from L2 to L4 with extension into adjacent musculature. Histological examination demonstrated Michaelis-Gutmann bodies consistent with malakoplakia. The patient underwent revision T12-sacrum posterior fusion, L2-5 laminectomy, and anterior L3-4 corpectomy, followed by L2-4 anterior stabilization and a 6-week course of ceftriaxone. At 3 months postoperatively, she was asymptomatic without recurrence. CONCLUSION Malakoplakia of bone should be considered in the differential diagnosis of lytic bone lesions and can be effectively treated with surgical debulking with penetrative antibiotics.

Previous studies have demonstrated varying rates of heterotopic ossification (HO) after total hip arthroplasty (THA) depending on which anatomical approach is utilized. The direct anterior approach (DAA) is considered to be a muscle-sparing approach to the hip, which may lead to decreased rates of HO formation. This study evaluated the incidence of HO formation after DAA THA. The current work is a retrospective review of patients who underwent DAA THA. Six-month postoperative radiographs were evaluated and HO grade was classified using the Brooker classification system. Baseline characteristic differences between the Brooker classification groups were analyzed, specifically looking at: age, sex, type of deep venous thrombosis prophylaxis utilized, and preoperative Bombelli arthritis type. The overall incidence of HO in this DAA group was 179/485 patients (36.9%). There were 14 patients (2.9%) with Brooker Type 3 HO and 1 patient (0.21%) with Brooker Type 4 HO. No surgical excision of HO was performed. Patients were significantly more likely to develop HO if they had Bombelli hypertrophic arthritis (p

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.

Comminuted olecranon fractures are commonly fixed with posterior locking plates (PLPs). Though biomechanically validated, this method comes with risks of symptomatic implant prominence and wound breakdown. Dual locking plates (DLPs) placed on the medial and lateral surfaces of the olecranon theoretically avoid these risks and allow for fixation of proximal fracture fragments in multiple planes. A biomechanical comparison of DLP and PLP fixation would help to validate the use of DLPs in comminuted olecranon fractures.Seven matched pairs of cadaveric upper extremities were evaluated with quantitative computed tomography scans to evaluate bone mineral density (BMD). Osteotomies simulating comminuted olecranon fractures (Mayo Type IIB) were created and the specimens were fixed either with variable angle PLPs or variable angle DLPs. The specimens were then cyclically loaded and loaded to failure. The ultimate strength, fracture displacement, and mechanism of failure were recorded and compared across groups. The correlation between BMD and ultimate strength was analyzed.The mean total BMD was 0.79 g/cmDual locking plates display biomechanical properties that suggest that they can be used in the fixation of comminuted olecranon fractures. Catastrophic failure of the fixation constructs occurs around stress risers at the proximal screws rather than due to displacement at the fracture itself.Dual locking plate constructs can be considered for use in the fixation of comminuted olecranon fractures.

» The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. » Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. » Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. » Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. » Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Case We present a case of a 41-year-old male bodybuilder with a partial delaminated quadriceps tendon rupture after a traumatic injury. Partial quadriceps tendon tears are rare overall and usually are treated nonoperatively with conservative management depending on the patient's limitations. He was found to have an intact superficial quadriceps tendon with a partial thickness tear of the vastus intermedius and delamination of the undersurface quadriceps tendon precluding active knee extension. Conclusion To our knowledge, there has never been a reported partial quadriceps tendon tear with delamination of the undersurface, causing a complete extensor mechanism failure necessitating operative repair.

Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt “very prepared” to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy ( P P =.0002), and cervical myelopathy ( P P =.0007) and neurology ( P P P Orthopedics . 2020;43(4):e244–e250.]

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.

To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease.A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA2 years previously, and 3) patients with a history of LSF after having recent THA2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use.Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P0.0001; hazard ratio, 1.69; P0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120).Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (2 years).

Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

Background: Sarcopenia is a condition of clinically relevant loss of muscle mass and function. Acetabular fractures in elderly patients are common and difficult to treat. This study aimed to determine if sarcopenia is common in elderly patients with acetabular fractures and correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than patients with normal muscle mass. Methods: The Rhode Island Hospital Trauma Database was queried for patients who were ≥60 years of age from 2005 to 2014 using the International Classification of Diseases, Ninth Revision, code for closed acetabular fracture, 808.0. Charts were retrospectively reviewed for demographic data, operative intervention, mechanism of injury, mortality, comorbidities, and other factors. Computed tomography (CT) was used to determine the muscle cross-sectional area and to calculate the skeletal muscle index. Results: The database revealed 192 patients coded for acetabular fracture; of these, 181 were correctly diagnosed. Ninety-nine patients had recorded body mass index (BMI) and adequate CT scans to measure the skeletal muscle index. Forty-two patients (42.4%) had sarcopenia, and 57 patients (57.6%) did not have sarcopenia. There were no significant differences in demographic characteristics between the groups with the exception of BMI and sex. BMI was higher in patients who did not have sarcopenia (31.7 kg/m2) than it was in patients with sarcopenia (23.6 kg/m2) (p < 0.001). Male sex was significantly greater (p = 0.0104) in patients with sarcopenia at 76.2% (32 of 42 patients) than in patients without sarcopenia at 50.9% (29 of 57 patients). Fractures in patients without sarcopenia were associated with a higher-energy mechanism of injury in 78.9% of cases compared with 52.4% of cases of patients with sarcopenia (p = 0.005). Sarcopenia was significantly associated (p = 0.0419) with increased 1-year mortality (28.6%) compared with the absence of sarcopenia (12.3%). This association was even stronger if in-hospital mortality was excluded (p = 0.00074). Finally, anterior column fractures were more likely (p = 0.017) to be sustained by patients with sarcopenia at 47.6% (20 patients) than by patients who did not have sarcopenia at 24.6% (14 patients). Conclusions: Sarcopenia is common in elderly patients with acetabular fractures and is associated with lower-energy mechanisms, anterior column fractures, and higher risk of 1-year mortality. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.

Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain, with an incidence of 1.8 per 1000 patients, most commonly occurring between the fourth and sixth decades of life. When GTPS fails to improve with conservative management, hip abductor insufficiency should be suspected. The diagnosis of hip abductor insufficiency is made by a combination of physical exam findings and imaging studies, with Magnetic Resonance Imaging (MRI) being the diagnostic study of choice. Initial conservative management consists of activity modification, physical therapy, non-steroidal anti-inflam- matories and corticosteroid injections. If conservative management fails, this may be suggestive of a hip abductor tear. Surgical intervention has been shown to provide excellent outcomes, and may be necessary if a tear is present. The purpose of this paper is to review and raise awareness of hip abductor insufficiency as an under- diagnosed and under-treated condition that can limit patient mobility and quality of life.

Sarcopenia, an age-related loss of muscle mass and function, has been previously linked to an increased risk of morbidity, mortality, and infection after a variety of surgical procedures. This study is the first to evaluate the impact of the psoas-lumbar vertebral index (PLVI), a validated marker for central sarcopenia, on determining post-arthroplasty infection status.This is a case-control, retrospective review of 30 patients with prosthetic joint infection (PJI) diagnosed by the Musculoskeletal Infection Society criteria compared to 69 control patients who underwent a total hip or knee arthroplasty. All patients had a recent computed tomography scan of the abdomen/pelvis to calculate the PLVI. PLVI was evaluated alongside age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, and smoking status to determine the predictive value for infection.Notably, the infected group had a large, significant difference in their average PLVI (0.736 vs 0.963, P.001). The patient's PLVI was a predictor of infection status, with a higher PLVI being protective against infection (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.109-0.715, P = .008). Additional predictors of infection status were higher American Society of Anesthesiologists score (OR 10.634, 95% CI 3.112-36.345, P.001) and Charlson Comorbidity Index (OR 1.438, 95% CI 1.155-1.791, P = .001). Multivariate, binary logistic regression analysis confirmed that PLVI was a significant independent predictor of infection status (B = -0.685, P = .039).PLVI, a marker for central sarcopenia, was demonstrated to be a risk factor for PJI. Further research and consideration of sarcopenia as a screening and optimizable risk factor for total joint arthroplasty must be explored.

Orthopedic trauma surgeons play a pivotal role in the management of trauma patients. It is important to keep in mind the ABC’s of the trauma primary survey: Airway, Breathing and Circulation during evaluation. The secondary survey includes a comprehensive and focused physical exam, often identifying extremity injuries. Life-saving measures should be initiated prior to limb-saving interventions. Often in the polytrauma patient, damage control orthopedics may be necessary. Damage control orthopedics consists of the stabilization of non-life-threatening orthopedic injuries until the patient is adequately resuscitated and optimized for definitive fixation. Traumatic injuries place a burden on society in terms of disability, lost income potential, and healthcare expenditures. Orthopedic trauma can be a versatile entity, consisting of high energy injuries, fragility fractures in elderly patients, and infections.

Cervical spine fractures can result in devastating outcomes for patients and their families. The acute management of a patient with a cervical spine fracture/dislocation can be potentially life-saving or leave lasting neurologic consequences. Appropriate immobilization and assurance of maintenance of cervical spine precautions are key until radiographic evaluation and specialized treatment can be provided. The goal of treatment for a cervical spine fracture/dislocation is to remove or minimize the insult on the spinal cord while ensuring that stability is provided via cervical orthosis, traction, or open reduction and internal fixation. An understanding of the management of cervical spine pathology can prevent potential disastrous outcomes for injured patients.

Traumatic spinal cord injury (SCI) can produce devastating consequences from complete paralysis to less severe, permanent deficits. Like most other traumatic injuries, it occurs in a bimodal distribution: afflicting younger patients in high energy accidents and elderly patients with degenerative changes more susceptible to cord injury from low energy events. Traumatic SCI is incredibly costly to society, rendering more severely injured patients unemployable and necessitating hospital care throughout their lifetimes. SCI is often thought to be the cumulative result of two separate processes. The initial time and mechanism of injury produces the majority of the potential deficits, while the second hit is the result of inflammatory cells causing damage and edema around the cord. The intervention of the healthcare provider can help minimize the effect of the second hit by ensuring appropriate precautions, spinal immobilization and stabilization, and spinal cord perfusion during the period after initial injury.

Case: A forty-seven-year-old woman presented with recurrent urinary tract infections eleven years after open fixation of a pelvic ring injury. Cystoscopy revealed that the pelvic reconstruction plate had eroded into the bladder, likely the source of the recurrent infections. Following removal of the involved pelvic hardware and repair of the bladder, the patient had no further urinary tract infections. Conclusion: Operative fixation of osseous pelvic injuries places metal implants in proximity to the bladder. Late erosion of hardware into the bladder can occur. A low threshold for urological work-up should be maintained for recurrent genitourinary symptoms in these patients.

Objectives: This study seeks to identify the ability of shorter Osteochondral Allografts (OCAs) to resist displacement/failure. Additionally, this study seeks to evaluate the effect of pulsatile lavage on the biomechanical stability of the OCA graft. Methods: Fifteen millimeter diameter, human cadaveric, osteochondral allografts of 4 mm, 7 mm, and 10 mm in depth were harvested for comparison of resistance to compressive and tensile loads. For each group 7 specimens were subjected to tensile loads and 3 specimens subjected to compressive loads until failure (pull-out or subsidence). An additional study group of 10 pulsatile lavaged (PL) osteochondral allografts of 15 mm in diameter and 7 mm in depth were introduced for comparison to the original 7 mm depth OCA group. Results: The average tensile forces for failure for the 4 mm, 7 mm, and 10 mm plugs were 23.74 N, 199.57 N and 197.69 N respectively (p=1.5x10-5). After post-hoc analysis of the tensile groups, significant differences in the mean tensile force to failure were appreciated between the 4 mm and 7 mm groups (p=4.12 x10-5) and the 4 mm and 10 mm groups (p=1.78x10-5), but not between the 7 mm and 10 mm groups (p=.9601). There were no significant differences between the average tensile forces resulting in failure for the 7 mm and 7mm-PL groups (199.57 N and 205.2 N, p=.90) or compressive forces to failure respectively (733.6 N and 656 N, p=.7062). Conclusion: For OCAs of 15 mm in diameter, a commonly used size in practice, we recommend that plugs of 7 mm in depth be utilized. Pulsatile lavage of allografts prior to insertion does not appear to take away from the structural integrity and stability of the plug, however an adequately powered study should confirm this. With many described theoretical benefits of decreased immunogenicity and better long term graft incorporation after lavage, we recommend that this practice continue. [Table: see text]

BACKGROUND CONTEXT Spinal pathology, particularly spinal emergencies, require prompt identification, management, and surgical referral (if needed) from first-line providers. As such, diagnostic delays from the failure to recognize emergency conditions lead to adverse patient outcomes. In addition, even with nonemergent pathologies, the failure to provide adequate care can result in suboptimal patient outcomes and unnecessary resource utilization. PURPOSE We sought to understand the proficiency with which different types of first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This may aid in tailoring education resources for first-line providers. STUDY DESIGN/SETTING Cross-sectional analysis of collected single-site data. PATIENT SAMPLE A total of 143 internal medicine, family medicine, emergency care, and neurology providers. OUTCOME MEASURES Inter-departmental differences in management of spinal pathology, familiarity, and preparedness for the diagnosis of spinal emergencies. METHODS A pilot survey was distributed to physicians, physician assistants, and nurse practitioners via the REDCap data collection tool. Chi square, Fisher's Exact, and Kruskal–Wallis tests were utilized, as appropriate. RESULTS Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Bivariate analyses revealed inter-departmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (p CONCLUSIONS Disparities exist between the first-line provider specialties with regard to clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. As appropriate recognition and management of emergent spinal pathologies is essential to patient outcomes and optimal resource utilization, it is necessary that measures be taken educationally to ensure first-line providers are familiar and proficient with the established standard of care for the spinal conditions they will be treating.