From Self-efficacy to Imposter Syndrome: The Intrapersonal Traits of Surgeons.

BACKGROUND: Demographic differences among surgical trainees regarding intrapersonal traits, such as imposter syndrome and assertiveness, have become widely acknowledged. However, many of these characteristics have not been examined in tandem, nor among both trainees and surgeons in practice. This study aimed to address these knowledge gaps. METHODS: This was an anonymous, voluntary survey study comprised of validated measures of (1) self-efficacy, (2) imposter syndrome, (3) assertiveness, (4) perfectionism, and (5) self-rated likeability. A multimodal recruitment strategy was used and surgeons across all subspecialties were eligible for inclusion. RESULTS: A total of 296 participants were included, with 54% identifying as female (n = 161) and 72% between the ages of 25 and 40 years of age (n = 212). Imposter syndrome, assertiveness, and perfectionism scales were normally distributed; self-efficacy and self-rated likeability scales demonstrated slight negative skew. Self-identified male sex was associated with less imposter syndrome (P < 0.001) and perfectionism (P = 0.035) and higher assertiveness (P < 0.001). Imposter syndrome was less common among older age groups (P = 0.001). CONCLUSIONS: Surgeons are a self-efficacious group of perfectionists with widespread variability in imposter syndrome and assertiveness. Female sex and younger age were associated with more imposter syndrome and less assertiveness, highlighting an opportunity for early career coaching.

Complications following posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective cohort study using the modified Clavien-Dindo-Sink system.

PURPOSE: Published complication rates after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) range from 1 to 22%. Complications are often minor and may be underestimated in registries. This study describes complications of PSF for AIS, classifies them according to a Clavien-Dindo-Sink (CDS) system, and investigates risk factors for occurrence of a complication. METHODS: This retrospective cohort study at two academic centers included all AIS patients aged 10-18 who underwent primary PSF 4/2014-12/2019. Data included demographics, comorbidities, curve magnitude, Lenke classification, levels osteotomized/fused, implant density, 90-day emergency department visits, readmissions, reoperations, and complications as defined by Harms Study Group. RESULTS: Among 424 patients, mean age was 14.7, mean BMI 22, 77% were female, and 57% had no comorbidities. There were 270 complications (0.64 per patient); 198 patients (47%) had ≥ 1 complication; and 63 patients (15%) had CDS grade ≥ II complications (deviation from standard postoperative course). Complications not related to persistent pain occurred in 103 patients (24%). Ninety-three percent of complications did not require readmission or reoperation (CDS I-II). Within 90 days, 8% presented to an ED, 2% required readmission, and 2% required reoperation. Common complications were back pain > 6 weeks postoperatively (26%), surgical site complications (7%), and ileus/prolonged constipation (3%). Risk factors for experiencing any complication were BMI ≥ 34 (OR 3.44) and Lenke 6 curve (OR 1.95). CONCLUSION: One in four AIS patients experiences a complication not related to persistent pain after primary PSF, higher than rates published from self-reported registries. Obesity and Lenke 6 curve may increase risk. While most do not require readmission or surgery, 15% of patients have their postoperative course altered by complications. LEVEL OF EVIDENCE: III-retrospective cohort study.

Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF. METHODS: Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost. RESULTS: Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP. CONCLUSION: Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis.

PURPOSE: The Clavien-Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population. METHODS: A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of "prolonged initial hospital stay" as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability. RESULTS: The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8-1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good). CONCLUSION: The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a "major" versus "minor" complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population. LEVEL OF EVIDENCE: IV case series.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

HYPOTHESIS: We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture. METHODS: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time. RESULTS: We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time. CONCLUSION: An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.

Telemedicine in the Evaluation and Management of Neurosurgical Spine Patients: Questionnaire Assessment of 346 Consecutive Patients.

STUDY DESIGN: Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution. OBJECTIVE: This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. SUMMARY OF BACKGROUND DATA: One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients. METHODS: An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. χ2 and the Wilcoxon Rank-Sum Test were performed to determine significance. RESULTS: Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient-reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P = 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. CONCLUSION: Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.Level of Evidence: 3.

Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems. METHODS: Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME). RESULTS: Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013). CONCLUSIONS: A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Insurance and Practice Type on Access to Orthopaedic Sports Medicine.

BACKGROUND: The Patient Protection Affordable Care Act has expanded Medicaid eligibility in recent years. However, the provisions of the act have not translated to improved Medicaid payments for specialists such as orthopaedic surgeons. The number of health care practitioners who accept Medicaid is already decreasing, with low reimbursement rates being cited as the primary reason for the trend. HYPOTHESIS: Private practice orthopaedic groups will see patients with Medicaid or Medicare at lower rates than academic orthopaedic practices, and business days until appointment availability will be higher for patients with Medicaid and Medicare than those with private insurance. STUDY DESIGN: Cross-sectional study. METHODS: Researchers made calls to 2 regular-sized orthopaedic practices, 1 small orthopaedic practice, and 1 academic orthopaedic practice in each of the 50 states in the United States. Callers described a scenario of a recent injury resulting in a bucket-handle meniscal tear and an anterior cruciate ligament tear seen on magnetic resonance imaging at an outside emergency department. For a total of 194 practices, 3 separate telephone calls were made, each with a different insurance type. Data regarding insurance acceptance and business days until appointment were tabulated. Student t tests or analysis of variance for continuous data and χ2 or Fisher exact tests for categorical data were utilized. RESULTS: After completing 582 telephone calls, it was determined that 31.4% (n = 59) did not accept Medicaid, compared with 2.2% (n = 4) not accepting Medicare and 1% (n = 1) not accepting private insurance (P < .001). There was no significant association between type of practice and Medicaid refusal (P = 0.12). Mean business days until appointment for Medicaid, Medicare, and private insurance were 5.3, 4.1, and 2.9, respectively (P < .001). CONCLUSIONS: Access to care remains a significant burden for the Medicaid population, given a rate of Medicaid refusal of 32.2% across regular-sized orthopaedic practices. If Medicaid is accepted, time until appointment was significantly longer when compared with private insurance.