Spine surgeon triage of new patient referrals: quantification of surgical conversion rate by clinic referral source.

BACKGROUND CONTEXT: In an effort to efficiently deliver high-value spine surgical care, spine surgery clinics may triage new patient referrals. A triage system with attending surgeon review of referred patient images may improve the surgical conversion rate (SCR) of a spine surgical clinic, and shift the distribution of new patients in clinic toward those most likely to derive benefit from surgery. PURPOSE: To quantify SCR and number of triage steps by referral source in a tertiary referral spine clinic where all referrals are triaged by attending surgeons. DESIGN: All spine surgery clinic patients seen for a new patient visit (NPV) at an academic medical center over a one-year period had their triage process and outcome (surgery or no surgery) reviewed. PATIENT SAMPLE: The 1398 new adult patients seen for elective spine pathology were queried. OUTCOME MEASURES: SCR was defined as the percentage of new patients who underwent elective spine surgery within 18 months of NPV. Triage steps were defined as an action item by triage staff (ie, obtaining patient records) or by the patient (ie, undergoing additional imaging). METHODS: All new patient visits were evaluated for referral source, number of triage steps, and triage outcome. Time from referral to NPV, and time from NPV to surgery were also recorded. SCR, triage steps, and time-intervals were calculated for each surgeon and referral source and compared. Statistical analysis of variance (ANOVA) was used to ascertain differences. RESULTS: The overall SCR for the 4-surgeon group was 41.6%. This ranged among the surgeons from 24.7% to 60.1%. The referral sources with the highest SCR were in-system spine advanced practice providers (APPs) and in-system physical medicine and rehabilitation providers. Spine APPs also demonstrated the smoothest referral process, requiring the fewest steps. CONCLUSIONS: Our findings provide a framework for assessment of triage processes at other institutions, as well as the impact of upgrades to our triage process as we work to improve triage efficiency. In the present study, referrals from providers familiar with spine pathology resulted in the highest SCR and fewest triage steps.

Management of Open Segmental Tibial Fractures.

SUMMARY: Open segmental tibial fractures are difficult injuries fraught with potential for complications. Delays or missteps in treatment and soft tissue coverage can lead to disastrous outcomes. This article and the accompanying video demonstrate an example of a timely, team-based approach for management of an open segmental tibial shaft fracture with complex osseous fixation and soft tissue reconstruction.

Ankle Arthrodesis Through an Anterior Approach.

Ankle arthritis occurs primarily because of trauma and has a huge impact on patient's quality of life. Ankle arthrodesis is indicated for patients with end-stage ankle arthritis who fail conservative management. High rates of fusion can be achieved through an anterior approach. This video demonstrates an ankle arthrodesis using an anterior approach to the ankle in a patient with posttraumatic ankle arthritis.

Is dental prophylaxis required following spinal fusion?-a systematic review and call for evidence.

BACKGROUND: Controversy exists regarding the need for antimicrobial prophylaxis prior to dental procedures following spinal fusion. In this review, we attempt to synthesize a comprehensive summary of the published literature to provide recommendations on the use of antimicrobial prophylaxis before dental procedures in patients with a history of spinal fusion. METHODS: We searched PubMed, Web of Science, Cochrane Library, and EMBASE databases from inception to February 2018. Eligible studies included patients with a history of spinal fusion treated with or without antimicrobial prophylaxis in preparation for dental procedures. Two reviewers independently assessed the eligibility of potential studies and extracted data. Outcomes of interest were the indications and efficacy of antimicrobial prophylaxis to protect against infection of spinal prostheses with dental origin. RESULTS: A total of 1,909 articles were initially screened. After inclusion and exclusion criteria were applied, one study was found specifically relating to dental prophylaxis and spine surgery. The survey, as well as objective studies and professional organization guidelines on dental prophylaxis in patients with total hip and knee replacements, were reviewed to add context to the controversy. CONCLUSIONS: There is a significant paucity of literature regarding dental prophylaxis in spine surgery patients. Although there has been a recent movement away from recommending antimicrobial prophylaxis before dental work in patients with other forms of orthopaedic prostheses, the gap in the literature addressing spine patients represents an important question that requires more targeted and specific research.

Percutaneous Fixation of Calcaneal Tuberosity Avulsion Fracture.

There are little data published regarding percutaneous fixation of calcaneal tuberosity avulsion fractures, but tongue-type calcaneal fracture literature can be extrapolated to these injuries because they can be considered the extra-articular form of a tongue-type calcaneus fracture. Both injuries involve similar considerations regarding skin compromise and need for urgent management with similar percutaneous techniques to minimize further soft-tissue injury. Percutaneous fixation of tongue-type calcaneus fractures was first reported by Weshues and Gissane in their description of the Essex Lopresti maneuver as an alternative to open approaches to minimize the risk of soft-tissue complications and flap necrosis and provide a means of improving reductions in smokers and diabetics who may not otherwise be good operative candidates.

Autologous Bone Graft Harvest Using the Reamer-Irrigator-Aspirator.

Initially developed to reduce intramedullary pressures during long bone intramedullary nail placement, the reamer-irrigator-aspirator (RIA) can be used to harvest large volume autologous bone graft from the intramedullary canal of a long bone. This case-based surgical technique video demonstrates the appropriate techniques that should be applied while using the RIA to obtain autologous bone graft from the femur. A large volume of bone graft, generally between 30 and 90 cm, can be obtained using a single RIA procedure. The bone graft harvested from the intramedullary canal is excellent regarding its biochemical properties, with several studies reporting higher levels of growth factors and stem cells when compared with iliac crest bone graft. Surgical technique is key to maximize bone graft harvest, as well as to avoid complications including iatrogenic fracture, intraarticular penetration, and fragmentation of either the reamer head from the drive shaft or the guide wire. Pearls and pitfalls regarding sizing of the reamer head, determination of starting point, guide wire placement, reamer advancement, and diligent use of fluoroscopic imaging are highlighted during this video. Finally, outcomes regarding healing of long bone defects when using RIA-derived autologous bone graft and reduction in postoperative pain at the graft donor site are briefly reviewed.