Graduates of Orthopaedic Residency Training Are Increasingly Subspecialized: A Review of the American Board of Orthopaedic Surgery Part II Database.

BACKGROUND: Orthopaedic fellowships first gained popularity in the U.S. in the 1970s, and since that time, the percentage of orthopaedic residency graduates pursuing subspecialty fellowship training has increased. Prior reports have shown an increase in subspecialization from 1988 through 2002; however, the current number and proportion of graduates pursuing fellowship training since 2002 are unknown. The purpose of this study was to determine the percentage of recent graduates who pursue fellowship training and the proportion of procedures that these graduates perform within their area of fellowship training. METHODS: Data from the American Board of Orthopaedic Surgery Part II examination for board certification were used to determine the number and percentage of fellowship-trained and non-fellowship-trained applicants from 2003 to 2013. The percentage of cases performed by fellowship-trained applicants within their area of fellowship training was calculated and was analyzed as a function of time and a function of fellowship training category. Linear regression was used to determine trend as a function of time. RESULTS: The percentage of fellowship-trained applicants increased from 76% in 2003 to 90% in 2013. Of the 1,257,161 procedures performed by fellowship-trained applicants, 981,077 (78%) were performed within the surgeon's area of fellowship training. Spine and hand-trained applicants performed more than 85% of their procedures within their area of fellowship training. CONCLUSIONS: From 2003 to 2013, the percentage of fellowship-trained applicants taking the American Board of Orthopaedic Surgery Part II examination gradually increased to 90%. In the same time period, fellowship-trained surgeons performed an increasing proportion of procedures within their area of subspecialty training. Orthopaedic graduates have become increasingly subspecialized over the past decade.

Disease severity and treatment in adolescent idiopathic scoliosis: the impact of race and economic status.

BACKGROUND CONTEXT: Ethnic disparities have been documented in the incidence and treatment of many diseases. Additionally, race and socioeconomic status (SES) have been shown to affect disease severity and access to care in the recent orthopedic literature. PURPOSE: To assess the role, if any, that race, SES, and health insurance type play in disease severity and treatment decisions in patients with adolescent idiopathic scoliosis. STUDY DESIGN: Retrospective chart review. PATIENT SAMPLE: Pediatric patients seen in a single surgeon's practice over 6 years (2004-2009). OUTCOME MEASURES: Treatment modality (observation, bracing, or surgery). METHODS: Data were obtained from 403 patients seen over 6 years (2004-2009). A patient-reported questionnaire was used to collect race, age, family income, and parent marital status data. Race was self-reported as "Asian," "black or African American," "Hispanic or Latino," "white or Caucasian," or "Other." Socioeconomic status was determined using family income and type of health insurance as indicators. Major curve magnitude and prescribed initial treatment (observation, brace, or surgery) were assessed from physician records. An independent sample t test was used to detect differences in curve magnitude of the different racial groups. A Pearson chi-square analysis was used to detect group differences for curves in surgical patients, defined as curves greater than 40°, and their initial treatment. RESULTS: Patients self-identified with one of the following racial groups: white (N=219), black (N=86), Hispanic (N=44), Asian (N=37), or Other (N=17). Mean curve magnitude was greater in black than in white patients (33° vs. 28°, p<.05). Black patients were more likely to present with curves in the surgical range (34% vs. 24%, p<.05) and were more likely to have surgery as their initial treatment than white patients (34% vs. 19%, p<.05). Black patients had more limited health care plans and lower incomes compared with whites (p<.001). Patients with higher access insurance plans presented at a younger age than patients with more limited access plans, irrespective of race (13.6 vs. 14.1, p<.05). There was no difference in Cobb angle at presentation by income or type of insurance. CONCLUSIONS: Curve magnitude and percentage of patients with curves in the surgical range were greater in black than in white patients. There was no difference in age on presentation or treatment offered across all racial groups. Black patients were more likely to have surgery as their initial treatment than white patients. While race did have an impact on disease severity in this single surgeon's practice, SES did not.

Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version.

BACKGROUND: Appearance concerns in individuals with adolescent idiopathic scoliosis can result in impairment in daily functioning, or body image disturbance. The Body Image Disturbance Questionnaire (BIDQ) is a self-reported, seven-question instrument that measures body image disturbance in general populations; no studies have specifically examined body image disturbance in those with adolescent idiopathic scoliosis. This study aimed to validate a modified version of the BIDQ in a population with adolescent idiopathic scoliosis and to establish discriminant validity by comparing responses of operatively and nonoperatively treated patients with those of normal controls. METHODS: In the first phase, a multicenter study of forty-nine patients (mean age, fourteen years; thirty-seven female) with adolescent idiopathic scoliosis was performed to validate the BIDQ-Scoliosis version (BIDQ-S). Participants completed the BIDQ-S, Scoliosis Research Society (SRS)-22, Children's Depression Index (CDI), and Body Esteem Scale for Adolescents and Adults (BESAA) questionnaires. Descriptive statistics and Pearson correlation coefficients were calculated. In the second phase, ninety-eight patients with adolescent idiopathic scoliosis (mean age, 15.7 years; seventy-five female) matched by age and sex with ninety-eight healthy adolescents were enrolled into a single-center study to evaluate the discriminant validity of the BIDQ-S. Subjects completed the BIDQ-S and a demographic form before treatment. Independent-sample t tests and Pearson correlation coefficients were calculated. RESULTS: The BIDQ-S was internally consistent (Cronbach alpha = 0.82), and corrected item total correlations ranged from 0.47 to 0.67. The BIDQ-S was significantly correlated with each domain of the SRS-22 and the total score (r = -0.50 to -0.72, p ≤ 0.001), with the CDI (r = 0.31, p = 0.03), and with the BESAA (r = 0.60, p < 0.001). BIDQ-S scores differed significantly between patients (1.50) and controls (1.06, p < 0.005), establishing discriminant validity. CONCLUSIONS: The BIDQ-S is an internally consistent outcomes instrument that correlated with the SRS-22, CDI, and BESAA outcomes instruments in a scoliosis population. The scores of the patients with scoliosis indicated greater back-related body image disturbance compared with healthy controls. To our knowledge, this user-friendly instrument is the first to examine body image disturbance in adolescent idiopathic scoliosis, and it provides a comprehensive evaluation of how scoliosis-related appearance concerns impact psychosocial and daily functioning.

Is radiation-free diagnostic monitoring of adolescent idiopathic scoliosis feasible using upright positional magnetic resonance imaging?

STUDY DESIGN: Prospective clinical trial. OBJECTIVE: The purpose of this study was to determine if an upright positional magnetic resonance imaging (MRI) protocol could produce reliable spinal curvature images and measurements compared with traditional radiograph. SUMMARY OF BACKGROUND DATA: Concerns about the oncological potential from cumulative doses of ionizing radiation in children and adolescents being monitored for adolescent idiopathic scoliosis (AIS) initiated a search for radiation-free diagnostic imaging modalities, including MRI. We submit that upright, positional MRI (uMRI) produces reliable spinal curvature images compared with traditional radiograph. METHODS: Twenty-five consecutive patients (16 female; 9 male; average age, 14.6 yr; range, 12-18 yr) with a diagnosis of AIS were enrolled. Average major curve magnitude was 30° (range, 6°-70°). Subjects received anterior-posterior and lateral plain radiographical scoliosis imaging followed within 1 week by uMRI. MRI data acquisition was performed in less than 7 minutes. Two independent observers performed all Cobb angle, T5-T12 kyphosis, and vertebral rotation measurements for comparison. The Pearson correlation method was performed to compare radiograph to uMRI measurements, while inter-rater and intrarater correlations were performed to assess reliability. RESULTS: We found outstanding correlation between all plain film radiography and uMRI measurements (P = 0.01); major Cobb angles (R = 0.901), minor Cobb angles (R = 0.838), and kyphosis (R = 0.943). Inter-rater reliability for both radiographical and MRI measurements of major Cobb angles (R = 0.959, 0.896, respectively), minor Cobb angles (R = 0.951, 0.857, respectively), and vertebral rotation (R = 0.945) were outstanding. Intrarater reliability for both radiographical and MRI measurements of major Cobb angles (R = 0.966, 0.966, respectively) and minor Cobb angles (R = 0.945, 0.943, respectively) were also outstanding. CONCLUSION: Our results show that uMRI is capable of producing coronal and sagittal plane measurements that highly correlate with traditional plain film radiographical measurements. This, in addition to reliable vertebral rotation measurements, makes uMRI a valuable, radiation-free alternative/substitute for diagnostic evaluation in AIS.

Low-density versus high-density thoracic pedicle screw constructs in adolescent idiopathic scoliosis: do more screws lead to a better outcome?

BACKGROUND CONTEXT: Thoracic pedicle screw (TPS) constructs have improved curve correction measurements compared with hook and hybrid constructs in the treatment of adolescent idiopathic scoliosis (AIS), but the optimal implant density, or the number of screws per level, remains unknown in the treatment of flexible thoracic curves. PURPOSE: To determine how implant density affects clinical outcome, radiographic outcome, and cost in the treatment of Lenke Curve Type I AIS. STUDY DESIGN: A retrospective clinical study. PATIENT SAMPLE: Ninety-one consecutive AIS patients with Lenke Type I curves who underwent surgical correction with a minimum follow-up of 24 months. OUTCOME MEASURES: Radiographic outcomes included assessment of preoperative and 2-year postoperative thoracic Cobb angle, T5-T12 kyphosis, and curve flexibility. We also assessed SRS-22 outcome measures and thoracic angle of trunk rotation (ATR) before surgery and at the 2-year postoperative time point. The cost of each construct was also evaluated. METHODS: Bivariate analysis was conducted between implant density and the following factors: percent correction of the major curve, ATR, and change in kyphosis. The correlation between curve flexibility and percent correction of the major curve was determined. Patients were then divided into two groups: the low-density (LD) TPS group defined by implant density below the mean number of screws per level for the entire cohort (less than 1.3 screws per level) and the high-density (HD) TPS group defined by implant density above the mean number of screws per level (more than 1.3 screws per level). Independent sample t tests were used to compare demographic data as well as radiographic and clinical outcomes at baseline and at follow-up between the two groups. RESULTS: Sixty-one female and 30 male patients met inclusion criteria. No significant correlations were found between implant density and the following parameters: percent correction of the major curve (p=.25), ATR (p=.75), and change in T5-T12 kyphosis (p=.40). No correlation was found between curve flexibility and percent correction of the major curve (p=.54). The LD group consisted of 57 patients, whereas the HD group had 34 patients. There were no differences between the HD group and the LD group in regard to major curve correction, change in T5-T12 kyphosis, or change in ATR. Total implant costs were significantly higher in the HD group ($13,272 vs. $10,819; p<.01). The SRS-22 image domain and overall score improved at 2 years within both groups, but there were no group differences in any of the SRS-22 domains or the overall score. CONCLUSIONS: We identified no clinical, radiographic, perioperative, or complication-related advantage of constructs with higher TPS implant density in this patient cohort with flexible idiopathic scoliosis. Cost was significantly higher with HD constructs in comparison with LD constructs. Optimal implant density chosen by the surgeon should rely on a number of factors including curve magnitude and rigidity, bone density, and desired correction.

Discriminative validity of the Scoliosis Research Society 22 questionnaire among five curve-severity subgroups of adolescents with idiopathic scoliosis.

BACKGROUND CONTEXT: Previous studies of the Scoliosis Research Society (SRS) 22 discriminative validity have lacked sufficiently matched study groups and were limited to a comparison with three or fewer subgroups of disease severity. PURPOSE: To evaluate the discriminative validity of SRS-22 by assessing the questionnaire's ability to discriminate among five groups of pretreatment adolescent idiopathic scoliosis (AIS) patients with increasing curve severity. STUDY DESIGN: Retrospective review of prospectively administered surveys. METHODS: Two hundred eighty-six SRS-22 questionnaires were issued to two AIS pretreatment patient populations: 67 nonoperative and 219 preoperative. Study subjects were separated into five subgroups depending on the major Cobb angle (nonoperative 0°-19° and 20°-40° and preoperative 41°-50°, 51°-60°, and >60°). Each group (n=31) was matched for age (within 1 year) and sex (23 females and 8 males), resulting in a total of 155 study subjects. Analysis of variance was used to determine statistically significant differences (p<.05) between the five subgroups' domains and total scores. RESULTS: Significant differences between study groups were found within two of the four domains (pain and image) and the total score. Both nonoperative groups (0°-19° and 20°-40°) demonstrated significantly less pain than the preoperative group (41°-50°) and significantly better self-image than all three preoperative groups. Both nonoperative groups' total scores were significantly higher than all three preoperative groups' scores, with the exception of the 20° to 40° subgroup versus the >60° subgroup. No significant differences were found between groups within the same planned treatment category. CONCLUSIONS: The SRS-22 questionnaire demonstrated good discriminative validity between small nonoperative curves and larger surgical curves within the pain, image, and total domains. However, SRS-22 lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limitation to the questionnaire's discriminative capacity. The discriminative validity of the Scoliosis Research Society (SRS) 22 has not been clearly defined. Our analysis of 155 adolescent idiopathic scoliosis patients evaluates the instrument's discriminative validity among five age- and sex-matched curve-severity subgroups. The SRS-22 questionnaire lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limit to the questionnaire's discriminative capacity.

Multicenter validation of a formula predicting postoperative spinopelvic alignment.

OBJECT: Sagittal spinopelvic imbalance is a major contributor to pain and disability for patients with adult spinal deformity (ASD). Preoperative planning is essential for pedicle subtraction osteotomy (PSO) candidates; however, current methods are often inaccurate because no formula to date predicts both postoperative sagittal balance and pelvic alignment. The authors of this study aimed to evaluate the accuracy of 2 novel formulas in predicting postoperative spinopelvic alignment after PSO. METHODS: This study is a multicenter retrospective consecutive PSO case series. Adults with spinal deformity (> 21 years old) who were treated with a single-level lumbar PSO for sagittal imbalance were evaluated. All patients underwent preoperative and a minimum of 6-month postoperative radiography. Two novel formulas were used to predict the postoperative spinopelvic alignment. The results predicted by the formulas were then compared with the actual postoperative radiographic values, and the formulas' ability to identify successful (sagittal vertical axis [SVA] ≤ 50 mm and pelvic tilt [PT] ≤ 25°) and unsuccessful (SVA > 50 mm or PT > 25°) outcomes was evaluated. RESULTS: Ninety-nine patients met inclusion criteria. The median absolute error between the predicted and actual PT was 4.1° (interquartile range 2.0°-6.4°). The median absolute error between the predicted and actual SVA was 27 mm (interquartile range 11-47 mm). Forty-one of 54 patients with a formula that predicted a successful outcome had a successful outcome as shown by radiography (positive predictive value = 0.76). Forty-four of 45 patients with a formula that predicted an unsuccessful outcome had an unsuccessful outcome as shown by radiography (negative predictive value = 0.98). CONCLUSIONS: The spinopelvic alignment formulas were accurate when predicting unsuccessful outcomes but less reliable when predicting successful outcomes. The preoperative surgical plan should be altered if an unsuccessful result is predicted. However, even after obtaining a predicted successful outcome, surgeons should ensure that the predicted values are not too close to unsuccessful values and should identify other variables that may affect alignment. In the near future, it is anticipated that the use of these formulas will lead to better surgical planning and improved outcomes for patients with complex ASD.

An aggressive group a streptococcal cellulitis of the hand and forearm requiring surgical debridement.

Group A streptococcus is responsible for a diverse range of soft tissue infections. Manifestations range from minor oropharyngeal and cellulitic skin infections to more severe conditions such as necrotizing fasciitis and septic shock. Troubling increases in the incidence and the severity of streptococcal infections have been reported over the past 25 years. Cases of streptococcal necrotizing fasciitis have received significant attention in the literature, with prompt surgical debridement being the mainstay of treatment. However, cases of rapidly progressing upper extremity streptococcal cellulitis leading to shock and a subsequent surgical intervention have not been well described. This article presents a case of an 85-year-old woman with a rapidly progressing, erythematous, painful, swollen hand associated with fever, hypotension, and mental status change. Due to a high clinical suspicion for necrotizing fasciitis, the patient was rapidly resuscitated and underwent immediate surgical irrigation and debridement. All intraoperative fascial pathology specimens were negative for necrotizing fasciitis, leading to a final diagnosis of Group A streptococcal cellulitis. Although surgical intervention is not commonly considered in patients with cellulitis, our patient benefited from irrigation and debridement with soft tissue decompression. In cases of necrotizing fasciitis as well as rapidly progressive cellulitis, prompt diagnosis and aggressive treatment may help patients avoid the catastrophic consequences of rapidly progressive group A streptococcal infections.