Insulin dependence negatively impacts outcomes in anterior cervical discectomy with fusions: a ten-year retrospective analysis.

BACKGROUND CONTEXT: Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing diabetic patient population, there is a paucity of literature focusing on insulin-dependence as a risk-factor for post-operative ACDF complications. PURPOSE: To evaluate the differential impact of insulin dependence on perioperative outcomes including total length of stay, surgical, and medical complications within thirty days following ACDF. STUDY DESIGN/SETTING: A retrospective cohort, large multicenter database study. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program database was queried to retrospectively identify patients who had undergone ACDF between 2011 and 2021 using the Current Procedural Terminology code 22551. OUTCOME MEASURES: Perioperative surgical and medical complications. METHODS: The study population was divided into 3 groups 1) insulin-dependent diabetes mellitus (IDDM), 2) non-insulin-dependent diabetes mellitus (NIDDM), and 3) no diabetes mellitus (non-DM). One-way analysis of variance for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the 3 groups. Multivariable logistic regression analysis assessed the effect of diabetes mellitus status on post-operative medical and surgical outcomes. RESULTS: A total of 85,758 ACDF procedures were identified between 2011 and 2021, of which 5,178 were IDDM, 9,652 were NIDDM, and 70,982 were non-DM. The rates of surgical and medical complication varied between the 3 groups. IDDM patients had the highest rates of at least one medical complication (6.1%). Only IDDM increased the risk for medical complications (OR: 1.320, 95% CI [1.144-1.518]) and extended hospital length of stay (LOS) (OR: 1.244, 95% CI [1.071-1.441]) following a multivariate logistic regression analysis. CONCLUSION: Patients with IDDM were at an increased risk for postoperative medical complications and extended hospital LOS. Personalized postoperative management, guided by risk assessment is indicated for this population. These findings can be used to improve risk stratification and informed consent for DM patients who are insulin dependent.

Feasibility of Machine Learning in the Prediction of Short-Term Outcomes Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Increased emphasis is being placed on efficiency and resource utilization when performing anterior cervical discectomy and fusion (ACDF), and accurate prediction of complications is increasingly important to optimize care. This study aimed to compare predictive models for postoperative complications following ACDF using machine learning (ML) models based on traditional comorbidity indices. METHODS: In this retrospective case series, the American College of Surgeons National Surgical Quality Improvement Program database was queried between 2011 and 2017 for all elective, primary ACDF cases. Levels of surgery, use of interbody implants, and graft selection were calculated by procedural codes. Six ML algorithms were constructed using available preoperative and intraoperative features. The overall dataset was randomly split into training (80%) and validation (20%) subsets wherein the training subset optimized the model, and the validation subset was evaluated for accuracy. ML models were compared with models constructed from American Society of Anesthesiologists classification and frailty index alone. RESULTS: There were 42,194 ACDF cases eligible for inclusion. Mean age was 47.7 ± 11.6 years, body mass index was 30.4 ± 6.7, and levels of operation were 1.6 ± 0.7. ML algorithms uniformly outperformed comorbidity indices in predicting complications. Logistic regression ML algorithm was the best performing for predicting any adverse event (area under the curve [AUC] 0.73), transfusion (AUC 0.90), surgical site infection (AUC 0.63), and pneumonia (AUC 0.80). Gradient boosting trees ML algorithm was the best performing for predicting extended length of stay (AUC 0.73). CONCLUSIONS: ML algorithms modeled the development of postoperative adverse events with superior accuracy to that of comorbidity indices and may guide preoperative clinical decision making before ACDF.

A Novel Local Cancellous Autograft Source for Anterior Cervical Discectomy With Fusion.

STUDY DESIGN: Case series. OBJECTIVES: Successful clinical outcome scores following anterior cervical discectomy and fusion (ACDF) have been correlated with high fusion rate. Published fusion rates using iliac crest bone graft (ICBG) have been shown to be as high as 100% for single-level fusions in some studies; however, there is potential associated morbidity with ICBG harvest. This technical description and preliminary case series assessed the clinical efficacy and results of a novel grafting technique for ACDF. METHODS: Twelve patients underwent novel grafting technique for ACDF in which autograft was procured from the cervical vertebra adjacent to the operative disk. Patients were followed for 2 years using visual analogue pain scale (VAS) and radiological assessment of fusion. RESULTS: Patients experienced clinically meaningful reduction of radicular symptoms in the affected arm(s) with an average preoperative VAS score of 5.0 ± 0.8 and an average 2-year postoperative score of 1.108 ± 0.475 (P = .0013). Patients also experienced significant resolution of neck pain with an average preoperative VAS score of 7.1 ± 0.5 and average 2-year postoperative score of 2.708 ± 0.861 (P = .0018). All patients achieved solid fusion by 1 year. There were no major or minor complications noted during follow-up. CONCLUSIONS: This procedure allows for both autograft harvest and cervical decompression to be performed through a single incision. In this series, this technique eliminated the morbidity associated with autograft harvest from the iliac crest while achieving high fusion rates and without additional technique-related complications.

Distinguishing Pseudosubluxation From True Injury: A Case of C2-3 and C3-4 Subluxation in a Pediatric Patient.

A 6-year-old girl presented with a one-week history of neck pain after a trampoline accident. Cervical radiographs interpreted as pseudosubluxation of C2 on C3. CT demonstrated the reversal of lordosis with anterolisthesis of C2-C3 and C3-C4. Ten weeks after two months of halo traction, radiographs demonstrated anatomic alignment and maintained disk heights. This case highlights the similarities of pseudosubluxation and true injury, emphasizing the need for high index of suspicion in this population and a successful treatment of subluxation using a halo construct.

Bilateral Pedicle Fractures at Contiguous Segments in a Low Trauma Setting: A Case Report.

CASE: A 74-year-old patient with a history of osteoporosis presented with a 2-month history of lower back pain after low-energy trauma. Imaging revealed bilateral subacute L4 and L5 pedicle fractures-the first reported case of this low-energy mechanism of bilateral contiguous-segment pedicle fractures. CONCLUSION: Bilateral pedicle fractures have infrequently been reported in the literature. There have been a few reports of bilateral pedicle fractures because of isolated osteoporosis, and these have all been single level. The current report presents an unusual fragility fracture pattern that can be conservatively managed.

Cervical Spine CT Can Miss Fractures in American Football Players When Protective Equipment is in Place: A Cadaver Study.

BACKGROUND: Iatrogenic worsening of spinal injury can result in significant harm to American football players and complicate management when equipment is removed in the acute setting by inexperienced personnel. Spine imaging before removal of protective equipment mitigates this risk. There is no consensus regarding the ideal timing of equipment removal or whether current diagnostic imaging modalities are effective to detect such injuries without equipment removal. Prior data suggest that CT is a diagnostic modality for this purpose; however, radiologists' accuracy in detecting fractures in the presence of protective equipment requires additional study. QUESTIONS/PURPOSES: (1) Does the introduction of American football equipment result in a significant reduction in sensitivity for cervical spine fracture detection? (2) Absent specific guidance as to parameters needed to establish diagnostic quality, can a radiologist determine whether such CTs are of diagnostic quality by subjectively relying on the ability to identify anatomic landmarks? METHODS: A pendulum device was engineered to deliver a measured axial load to the crown of cadavers to produce a variety of cervical spine fractures in 13 cadaver specimens. The cadavers were then imaged using a standardized CT protocol first without and then with protective football equipment. The images were presented to three board-certified, fellowship-trained radiologists to (1) identify all fractures from the occiput to T1 and (2) subjectively assess the diagnostic quality of the resulting CTs. A sensitivity analysis was performed against a reference standard of fractures produced by the consensus of all radiologists in this study to determine whether there was any reduction in radiologists' ability to detect fractures once football equipment was in place. RESULTS: We found that CT scans obtained with football protective equipment in place resulted in lower sensitivity in diagnosing cervical spine injuries than CT scans obtained without pads. A total of 42 fractures were identified in the reference standard, allowing for a combined 126 possible fracture identifications between the three interpreters. Without football equipment, a combined 98 fractures were identified, whereas a combined 65 fractures were identified once the equipment was introduced. Overall, the sensitivity was reduced by 26% (52% [65 of 126] versus 78% [98 of 126] [95% CI 14.8% to 37.5%]; p < 0.001). Of the 78 total CT series imaged with football equipment, 92% (72 of 78) were considered to be of diagnostic quality. However, the study radiologists failed to identify 50% (53 of 105) of fractures present in those CT images. CONCLUSION: The sensitivity of cervical spine fracture detection using CT is diminished in the setting of protective American football equipment. Future studies in live subjects with cervical spine fracture may be warranted to support these conclusions. CLINICAL RELEVANCE: These findings contradict previous studies that determined CT to be a diagnostic imaging modality to image the cervical spine through equipment. Although the interpreting radiologists consistently deemed CTs performed in the presence of helmets and shoulder pads to have subjectively diagnostic quality, numerous fractures that had been detected in the absence of equipment were missed in their presence. Furthermore, this study established that subjective approval of the appearance of an imaging study based on the ability to recognize anatomic landmarks is insufficient to reliably determine the diagnostic quality of a CT study.

Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Injury to the recurrent laryngeal nerve (RLN) has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery. The purpose of this study is to determine the true incidence of voice hoarseness and RLN palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of RLN injury, and to evaluate factors related to the development of these symptoms. METHODS: All patients undergoing elective (primary or secondary) ACDF surgery at a single institution consented to and enrolled in the present study. All approaches were through the left side. Enrolled patients received both preoperative and postoperative (within 1 month following surgery) laryngoscopy by a fellowship-trained ENT physician for evaluation of RLN function. Patients also responded as to whether they were experiencing postoperative symptoms of dysphagia, aspiration, and voice changes. RESULTS: In total, 108 patients were included in this study. Mean age of the population was 59.2 ± 10.7 years and mean body mass index was 31.2 ± 7.1 kg/m2. Three patients had previously undergone a thyroidectomy, whereas 20 patients had undergone a previous ACDF. Average intubation time for ACDF surgery was 121.6 ± 38.5 minutes. After surgery and excluding patients who were experiencing preoperative symptoms, 19 patients (20.4%) complained of dysphagia, 2 patients (1.9%) complained of aspiration symptoms, and 5 patients (4.6%) complained of voice hoarseness. There was no incidence of vocal cord palsy from postoperative laryngoscopy. From multivariate analysis, endotracheal cuff pressure after retractor placement was correlated to postoperative voice hoarseness, dysphagia, and aspiration symptoms. CONCLUSIONS: From the results of this prospective study, the RLN remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes. Endotracheal cuff pressure, number of vertebral levels, body mass index, and intubation time were important variables related to postoperative symptoms. CLINICAL RELEVANCE: Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation. Laryngoscopy should be performed in cases with high clinical suspicion. LEVEL OF EVIDENCE: 2.

The Clinical Impact of Fracture Liaison Services: A Systematic Review.

INTRODUCTION: A fracture liaison service (FLS) is a coordinated system of care that streamlines osteoporosis management in the orthopaedic setting and can serve as an effective form of secondary preventative care in these patients. The present work reviews the available evidence regarding the impact of fracture liaison services on clinical outcomes. METHODS: The literature was reviewed for studies reporting changes in the rates of bone mineral density scanning (DXA), antiresorptive therapy, new minimum trauma fractures, and mortality between cohorts with access to an FLS or not. Studies including intention to treat level data were retained. A Medline search for "fracture liaison" OR "secondary fracture prevention" produced 146 results, 98 were excluded based on the abstract, 38 were excluded based on full-text review. Ten level III studies encompassing 48,045 patients were included, of which 5 studies encompassing 7,086 were analyzed. Odds-ratios for DXA and anti-osteoporosis pharmacotherapy rates were calculated from data. Fixed and random effects analyses were performed using the Mantel-Haenszel method. RESULTS: Four studies reported, on average, a 6-fold improvement in DXA scanning rates (Figure 1). Six studies reported, on average, a 3-fold improvement in antiresorptive therapy rates (Figure 2). Four large studies reported significant reductions in the rate of new fractures using time-dependent Cox proportional hazards models at 12 months (HR = 0.84, 0.95), 24 months (HR = 0.44, 0.65), and 36 months (HR = 0.67). Five large studies reported mortality improvements using time-dependent Cox proportional hazards models at 12 months (HR = 0.88, 0.84, 0.81) and 24 months (HR = 0.65, 0.67). CONCLUSIONS: The findings suggest that fracture liaison services improve rates of DXA scanning and antiresorptive therapy as well as reductions in the rates of new fractures and mortality among patients seen following minimum trauma fractures across many time points.

Pelvic Fragility Fractures: An Opportunity to Improve the Undertreatment of Osteoporosis.

BACKGROUND: Osteoporosis is often undiagnosed until patients experience fragility fractures. Pelvic fractures are common but underappreciated sentinel fractures. Screening patients with a pelvic fracture for osteoporosis may provide an opportunity to initiate appropriate treatments such as anti-osteoporosis therapy to prevent additional fractures. METHODS: This retrospective cohort review examined the management of osteoporosis after pelvic fractures at a large tertiary care center without an established secondary fracture prevention program. Data were extracted from electronic medical records of all new patients with a pelvic fracture who were ≥50 years of age from this center and its affiliated community hospitals from 2008 to 2014. Outcome measures included the initiation of anti-osteoporosis therapy before the fracture, within the year following the fracture, >1 year following the fracture, or never and new osteoporotic fractures within 2 years after a pelvic fracture. RESULTS: From 2008 to 2014, 947 patients presented with pelvic fractures. Of these patients, 27.1% (257 patients) were taking anti-osteoporosis medications before the fracture. Four percent of treatment-naïve patients began anti-osteoporosis therapy within 1 year of fracture, with 1.2% (11 patients) starting after 1 year. Of the treatment-naïve patients, 92.3% (637 patients) were never prescribed anti-osteoporosis therapy. Treatment rates were consistent over time. Within 2 years, 41.0% (388 patients) developed fragility fractures at secondary sites: 12.0% (114 patients) experienced a hip fracture, and 16.4% (155 patients) experienced a vertebral fracture. CONCLUSIONS: Osteoporosis screening and initiation of secondary fracture prevention after a pelvic fracture were inadequate in the study population. Of the patients in this study, 909 (96.0%) never underwent a dual x-ray absorptiometry (DXA) scan during the study period. Of the 690 treatment-naïve patients, 637 (92.3%) were never administered anti-osteoporosis medications. Within 2 years, 41.0% of all patients developed additional osteoporotic fractures. This study demonstrates an opportunity to improve bone health by screening for and treating osteoporosis in patients with a pelvic fragility fracture. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Passive stiffness characteristics and neutral zone quality of the scoliotic lumbar torso in the principle anatomical planes of motion.

BACKGROUND: The 1-10% prevalence rate of adult scoliosis frequently requires expensive therapy and surgical treatments and demands further research into the disease, especially with an aging population. Most studies examining the mechanics of scoliosis have focused on in vitro testing or computer simulations. This study quantitatively defined the passive stiffness properties of the in vivo scoliotic spine in three principle anatomical motions and identified differences relative to healthy controls. METHODS: Adult scoliosis (n = 14) and control (n = 17) participants with no history of spondylolisthesis, spinal fracture, or spinal surgery participated in three different tests (torso lateral side bending, torso axial rotation, and torso flexion/extension) that isolated mobility to the in vivo lumbar spine. The spinal stiffnesses and spinal neutral zone width were calculated. These parameters were statistically compared between factor of population and within factor of direction. FINDINGS: Torque-rotational displacement data were fit using a double sigmoid function, resulting an in excellent overall fit (Avg. R2 = 0.95). There was a significant interaction effect between populations when comparing axial twist neutral zone width vs. lateral bend neutral zone width and axial twist stiffness vs. lateral bend stiffness. The axial twist neutral zone width magnitude was significantly larger in scoliosis patients. INTERPRETATION: The present study is the first investigation to quantify the whole trunk neutral zone of the scoliotic lumbar spine. Future research is needed to determine if lumbar spine mechanical characteristics can help explain progression of scoliosis and complement scoliosis classification systems.

Proximal Humerus Fractures in the Geriatric Population Present an Opportunity to Improve Recognition and Treatment of Osteoporosis.

INTRODUCTION: Osteoporosis remains an undertreated disease entity causing substantial morbidity and mortality. Proximal humerus fractures are a common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more subsequent fractures occur. Despite the success of programs aimed to improve postfracture osteoporosis recognition and management, less than 30% of patients presenting with a fragility fracture are diagnosed or treated for osteoporosis nationally. Further elucidation of diagnosis and management of osteoporosis following humerus fracture is warranted. METHODS: This study is a retrospective cohort review intended to demonstrate the current state and clinical import of osteoporosis diagnosis and management following a humerus fracture at a large academic tertiary care center without an established secondary fracture prevention program. All patients 50 years of age or older who presented with a new humerus fracture between 2008 and 2014 were included. Outcome measures included: The initiation of antiresorptive therapy or screening before fracture, within the year following fracture, or not at all. RESULTS: One thousand seven hundred unique geriatric patients were seen for humerus fractures. Nineteen percent of these patients (n = 324) were already on an antiresorptive medication. Three percent of previously untreated patients were started on antiresorptive therapy during the year after their fracture, with 31 or 2% of untreated patients starting at any subsequent point. Seventy-six percent of patients (n = 1301) were never prescribed antiresorptive therapy. DISCUSSION AND CONCLUSION: In the absence of a dedicated program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients remained inadequate over time despite numerous calls to action on the topic in the orthopedic literature and public health initiatives. Undertreatment of osteoporosis puts patients at increased risk for additional fractures. This study underscores an opportunity to improve bone health by aggressively screening for and treating osteoporosis in geriatric humerus fracture patients.

Postoperative Anemia Predicts Length of Stay for Geriatric Patients Undergoing Minimally Invasive Lumbar Spine Fusion Surgery.

INTRODUCTION: We hypothesize that postoperative anemia will predict length of stay (LOS) for geriatric patients undergoing minimally invasive (MIS) lumbar spine fusions. MATERIALS AND METHODS: Patients who underwent MIS lateral and transforaminal lumbar interbody fusion between January 2017 and March 2018 at an academic tertiary care referral center were selected. Eighty-one patients were included. The primary outcome variable was LOS, measured in days. The predictors studied were preoperative hemoglobin (Hgb), postoperative day 1 Hgb, postoperative nadir Hgb, intraoperative Hgb decrement (preoperative Hgb-postoperative day 1 Hgb), perioperative Hgb decrement (preoperative Hgb-postoperative nadir Hgb), age, American Society of Anesthesiologists-Physical Status (ASA-PS) score, volume of perioperative intravenous (IV) fluids (IVFs), and number of levels fused. Simple linear regression and analysis of variance were used for statistical analysis. RESULTS: In the present study, preoperative anemia was not associated with longer LOS (P = .15). Postoperative anemia was associated with longer LOS as both postoperative day 1 Hgb (P = .05*) and postoperative nadir Hgb (P < .0001*) predicted longer LOS. Greater intraoperative Hgb decrement did not predict longer LOS (P = .36); however, greater perioperative Hgb decrement predicted longer LOS (P < .0001*). Older age (P = .01*) and greater number of levels fused (P = .03*) predicted longer LOS; however, a greater ASA-PS classification did not predict longer LOS. Greater IVF administration was associated with longer LOS (P < .0001*). DISCUSSION: Postoperative nadir Hgb (P < .0001*) was more predictive of longer LOS than postoperative day 1 Hgb (P = .05*). There is a perioperative Hgb decrement associated with longer LOS (P < .0001*). Geriatric patients may be more susceptible to the potential contributors to Hgb decrement, including occult bleeding post-op and hemodilution from IVF administration. CONCLUSION: Postoperative anemia, perioperative decrement in Hgb, older age, greater number of levels fused, and greater total IVFs administered predict longer LOS. Understanding the impact of these factors on LOS is critical as these procedures increasingly move to the outpatient setting.

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use.

OBJECTIVE: The aim of the study was to compare trends and differences in preoperative and prolonged postoperative opioid use following spinal cord stimulator (SCS) implantation and to determine factors associated with prolonged postoperative opioid use. METHODS: A database of private-payer insurance records was queried to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-C3655) from 2008-2015. Our resulting cohort was stratified into those with prolonged postoperative opioid use, opioid use between 3- and 6-month postoperation, and those without. Multivariate logistic regression was used to determine the effect preoperative opioid use and other factors of interest had on prolonged postoperative opioid use. Subgroup analysis was performed on preoperative opioid users to further quantify the effect of differing magnitudes of preoperative opioid use. RESULTS: A total of 2,374 patients who underwent SCS placement were identified. Of all patients, 1,890 patients (79.6%) were identified as having prolonged narcotic use. Annual rates of preoperative (p = 0.023) and prolonged postoperative narcotic use (p < 0.001) decreased over the study period. Significant independent predictors of prolonged postoperative opioid use were age < 65 years (odds ratio [OR], 1.52; p = 0.004), male sex (OR, 1.33; p = 0.037), preoperative anxiolytic (OR, 1.55; p = 0.004) and muscle relaxant (OR, 1.42; p = 0.033), and narcotic use (OR, 15.04; p < 0.001). Increased number of preoperative narcotic prescriptions correlated with increased odds of prolonged postoperative use. CONCLUSION: Patients with greater number of preoperative opioid prescriptions may not attain the same benefit from SCSs as patients with less opioid use. The most significant predictor of prolonged narcotic use was preoperative opioid use.

Demographic Trends in Paddle Lead Spinal Cord Stimulator Placement: Private Insurance and Medicare Beneficiaries.

OBJECTIVE: Although spinal cord stimulators (SCS) continue to gain acceptance as a viable nonpharmacologic option for the treatment of chronic back pain, recent trends are not well established. The aim of this study was to evaluate recent overall demographic and regional trends in paddle lead SCS placement and to determine if differences in trends exist between private-payer and Medicare beneficiaries. METHODS: A retrospective review of Medicare and private-payer insurance records from 2007-2014 was performed to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-63655). Each study cohort was queried to determine the annual rate of SCS placements and demographic characteristics. Yearly SCS implantation rates within the study cohorts were adjusted per 100,000 beneficiaries. A chi-square analysis was used to compare changes in annual rates. RESULTS: A total of 31,352 Medicare and 2,935 private-payer patients were identified from 2007 to 2014. Paddle lead SCS placements ranged from 5.9 to 17.5 (p<0.001), 1.9 to 5.9 (p<0.001), and 5.2 to 14.5 (p<0.001) placements per 100,000 Medicare, private-payer, and overall beneficiaries respectively from 2007 to 2014. SCS placements peaked in 2013 with 19.6, 7.1, and 16.8 placements per 100,000 Medicare, private-payer, and overall patients. CONCLUSION: There was an overall increase in the annual rate of SCS placements from 2007 to 2014. Paddle lead SCS placements peaked in 2013 for Medicare, private-payer, and overall beneficiaries. The highest incidence of implantation was in the Southern region of the United States and among females. Yearly adjusted rates of SCSs were higher among Medicare patients at all time points.

Timing of Bisphosphonate Initiation After Fracture: What Does the Data Really Say?

INTRODUCTION: Osteoporosis is often not clinically recognized until after a fracture occurs. Individuals who have 1 fracture are at increased risk of future fractures. Prompt initiation of osteoporosis treatment following fracture is critical to reducing the rate of future fractures. Antiresorptives are the most widely used class of medications for the prevention and treatment of osteoporosis. Many providers are hesitant to initiate antiresorptives in the acute post-fracture period. Concerns include interference with bone remodeling necessary for successful fracture healing, which would cause increased rates of non-union, malunion, and refracture. While such concerns should not extend to anabolic medications, physicians may also hesitate to initiate anabolic osteoporosis therapies due to high cost and/or lack of familiarity. This article aims to briefly review the available data and present a digestible narrative summary to familiarize practicing orthopaedic surgeons with the essential details of the published research on this topic. RESULTS: The results of 20 clinical studies and key pre-clinical studies related to the effect of anti-resorptive medications for osteoporosis on fracture healing are summarized in the body of this narrative review. DISCUSSION & CONCLUSIONS: While few level I studies have examined the impact of timing of initiation of osteoporosis medications in the acute post-fracture period, the few that have been published do not support these concerns. Specifically, data from level I clinical trials indicate that initiating bisphosphonates as early as 2 weeks post-fracture does not increase rates of non-union or malunion. By reviewing the available data, we hope to give clinicians the confidence to initiate osteoporosis treatment promptly post-fracture.

Orthopedic surgeons' views on the osteoporosis care gap and potential solutions: survey results.

INTRODUCTION: Osteoporosis is often not recognized until one or more fractures occur, yet post-fracture screening remains uncommon. Orthopedic surgeons are well situated to address this care gap. Both a protocol-based approach and fracture liaison services (FLS) have been proposed. The present surveys assess orthopedists' attitudes to these alternative models for addressing this care gap. METHODS: Two digital surveys were sent to all orthopedic surgeons and orthopedic midlevel providers at a large level 1 trauma center 1.5 years apart. RESULTS: Thirty-six of 47 survey recipients (77%) responded to the first survey; all 55 recipients (100%) responded to the second. Respondents recognized the importance of osteoporosis care, the inadequacy of current measures, and the potential of orthopedic surgeons to help address this gap. Respondents reported regular encounters with fragility fracture patients but limited familiarity with core aspects of osteoporosis screening and treatment, especially pharmacotherapy. While some respondents (40%) reported willingness to attempt a protocol-based approach to addressing this care gap, many others expressed reservations (60%) and support for a FLS-based approach was much higher (95%). CONCLUSIONS: A fracture liaison service model best fits the observed attitudes of orthopedic surgeons at this level 1 trauma center relative to a protocol-based approach. Protocol-based approaches may be preferable in alternate settings.

Rates of osteoporosis screening and treatment following vertebral fracture.

BACKGROUND CONTEXT: Osteoporosis remains an underrecognized and undertreated disease entity in the orthopaedic setting, accounting for substantial long-term morbidity and mortality. Osteoporosis is often not diagnosed or treated until multiple fractures have occurred. Vertebral compression fractures are the most common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more debilitating fractures occur. Little data has been published on osteoporosis screening and treatment following vertebral fractures. Further elucidation of the osteoporosis care gap in these patients is warranted. PURPOSE: To demonstrate the current state of post vertebral fracture osteoporosis management at a large tertiary care center with no established secondary fracture prevention program. STUDY DESIGN: Retrospective cohort study. SETTING: A large tertiary care hospital or one of its affiliated community hospitals. PATIENT SAMPLE: All 2,933 patients, 50 years of age or older, who presented to an emergency department with a new vertebral fracture between 2008 and 2014. OUTCOME MEASURES: The physiological measures are rates of new fractures within 2 years following first vertebral fracture. PATIENT CARE METRICS: Post vertebral fracture rates of dual energy X-ray absorptiometry (DXA) testing, calcium and vitamin D supplementation, and pharmacotherapy for osteoporosis within 1 year postfracture, and more than 1 year postfracture. Linear trend of the rate of new antiosteoporosis pharmacotherapy among previously antiosteoporosis medication naive patients within 1 year of fracture over time from 2008 to 2014. METHODS: All patients aged 50 years or older presenting to an emergency department with a vertebral fracture between 2008 and 2014 were included. Only an individual's first documented vertebral fracture was considered. Individuals were assessed for DXA screening, calcium and vitamin D supplementation, treatment with an antiosteoporosis medication, and additional fractures following incident vertebral fracture. Statistical analyses included descriptive statistics and a simple logistic regression. No specific funding was provided for this study. The authors of this study report no relevant financial conflicts of interests or associated biases. RESULTS: Between 2008 and 2014, 2,933 unique patients were seen at an included emergency department for one or more vertebral fracture encounters. Ninety-eight percent did not receive a DXA scan within the preceding 2 years or 1 year following fracture. Seven percent of patients were started on antiresorptive therapy after their fracture, with 341 (5%) starting within 1 year of fracture and 211 (2%) starting thereafter. Twenty-one percent (n=616) had taken an antiresorptive medication before their fracture. Seventy three percent (n=2,128) were never prescribed antiresorptive therapy. Treatment rates slightly decreased over time. Thirty eight percent of patients presenting with a vertebral fracture (n=1,115) went on to develop a second fragility fracture within 2 years. CONCLUSIONS: In the absence of a specific local program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients at this institution remained dismal over time despite numerous calls to action on the topic in the orthopaedic literature and elsewhere. Undertreatment of osteoporosis puts patients at increased risk of incurring additional fractures. Within 2 years, 38% of the patients in this sample developed an additional fragility fracture. This study demonstrates a profound post vertebral fracture osteoporosis care gap.

Unilateral S2 alar-iliac screws for spinopelvic fixation.

BACKGROUND: This study compared the clinical complications, radiographic measurements of deformity, and quality of life outcomes for patients with de novo scoliosis undergoing thoracolumbar fusions for spinopelvic fixation (SPF) utilizing unilateral S2 alar-iliac (S2AI) screw or unilateral iliac bolt fixation. METHODS: This retrospective review was performed in 29 patients who underwent SPF at one institution; 10 patients received unilateral S2AI screws, and 19 patients received unilateral iliac bolts. The following variables were studied: reoperation rates, pseudarthrosis, sacral insufficiency fracture, hardware prominence, infection, proximal junctional kyphosis (PJK), deformity correction (radiographs), windshield wipering, hardware fracture, and hardware removal. Outcomes were analyzed utilizing both the visual analog scale (VAS) and Oswestry Disability Index (ODI). The mean follow-up period was 27 months. RESULTS: The reoperation rate for unilateral S2AI screws was 30% vs. 53% for unilateral iliac bolts (P = 0.43); reoperations were performed with a 1:5 ratio for infection, a 1:4 ratio for pseudarthrosis, and 1:1 a ratio for PJK comparing S2AI screws to iliac bolts, respectively. CONCLUSION: There were no significant differences in postoperative complications and reoperation rates between unilateral S2AI screws and unilateral iliac bolts utilized for SPF. For the S2AI screw group, there were no instances of hardware prominence or need for removal. The use of unilateral S2AI screws resulted in adequate fixation and comparably low complication rates.

Anterior Cervical Discectomy With Fusion Using a Local Source for Cancellous Autograft: A Biomechanical Analysis of Vertebral Body Stability in an Osteopenic Bone Model.

BACKGROUND: Anterior cervical discectomy with fusion is an effective treatment for patients having cervical radiculopathy and myelopathy. To reduce morbidity associated with autograft taken from the iliac crest without sacrificing high fusion rates, a novel technique that harvests bone from the vertebral body adjacent to the operative disc space has been proposed. The effects of square and round bone graft harvest techniques on the mechanical stability of the osteopenic donor vertebrae are unknown. We analyzed the biomechanical implications of the technique by subjecting osteopenic models to uniaxial compression to compare yield strengths of surgically altered and unaltered specimens. METHODS: Biomechanical grade polyurethane foam was cut into 60 different 12 mm × 17 mm × 20 mm blocks. The foam had a density of 10 pounds per cubic foot, simulating osteoporotic bone. Rectangular prism (4 mm × 4 mm × 6 mm) and cylindrical cores (r = 2 mm, h = 8 mm) were removed from 20 blocks per group. Twenty samples were left intact as a control group. Anterior plate screws were applied to the models and a Polyether ether ketone (PEEK) interbody spacer was placed on top. Samples underwent uniaxial compression at 0.1 mm/s until mechanical failure. Points of structural failure were determined using a 0.1% offset on a force-displacement curve and compared to determine the reductions in compressive strength. RESULTS: The mean force eliciting structural failure for intact samples was 450.6 N. Average failure forces for rectangular prisms and cylindrical cores removed were 383.2 and 395.4 N, respectively. Removal of a rectangular prismatic core of the necessary volume resulted in a 15.0% reduction in compressive strength, while removal of a cylindrical core of comparable volume facilitated a reduction of 12.2%. CONCLUSION: Local autograft harvested from adjacent vertebrae reduces morbidity associated with a second surgical site while minimally reducing the compressive strength of the donor vertebra in an osteopenic model, lending credence to the efficacy of this technique in elderly patient populations.