A Patient-specific Approach to Alignment and Proximal Junctional Kyphosis Risk Assessment in Adult Spinal Deformity Surgery: Development and Validation of a Predictive Tool.

STUDY DESIGN: This was a single-institution, retrospective cohort study. OBJECTIVE: We aimed to develop a predictive model for proximal junctional kyphosis (PJK) severity that considers multiple preoperative variables and modifiable surgical alignment. SUMMARY OF BACKGROUND DATA: PJK is a common complication following adult deformity surgery. Current alignment targets account for age and pelvic incidence but not other risk factors. MATERIALS AND METHODS: This is a single-institution, retrospective cohort study of adult deformity patients with a minimum 2-year follow-up undergoing instrumented fusion between 2009 and 2018. A proportional odds regression model was fit to estimate PJK probability and Hart-International Spine Study Group (ISSG) PJK severity score. Predictors included preoperative Charlson Comorbidity Index, vertebral Hounsfield Units near the upper instrumented vertebrae, pelvic incidence, T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis. Predictor effects were assessed using adjusted odds ratios and a nomogram constructed for estimating PJK probability. Bootstrap resampling was used for internal validation. RESULTS: Of 145 patients, 47 (32%) developed PJK. The median PJK severity score was 6 (interquartile range, 4-7.5). After adjusting for predictors, Charlson Comorbidity Index, Hounsfield Units, preoperative T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis were significantly associated with PJK severity ( P <0.05). After adjusting for potential overfitting, the model showed acceptable discrimination [ C -statistic (area under the curve)=0.75] and accuracy (Brier score=0.10). CONCLUSIONS: We developed a model to predict PJK probability, adjusted for preoperative alignment, comorbidity burden, vertebral bone density, and modifiable postoperative L1-L4 and L4-S1 lordosis. This approach may help surgeons assess the patient-specific risk of developing PJK and provide a framework for future predictive models assessing PJK risk after adult deformity surgery. LEVEL OF EVIDENCE: Level III.

Optimal Trajectory and Length of S2 Alar Iliac Screws: A 3-Dimensional Computed-aided Design Study.

STUDY DESIGN: A radiographic study of computed tomography scans of the pelvis converted to 3-dimensional imaging. OBJECTIVE: The objective of this study was to determine the optimal length and trajectory of S2 alar iliac (S2AI) screws. SUMMARY OF BACKGROUND DATA: Solid pelvic fixation is a necessary component in thoracolumbar deformity surgery to protect sacral fixation and promote arthrodesis. The S2AI technique has been promoted as a way to reduce hardware prominence and instrumentation issues associated with traditional iliac fixation. MATERIALS AND METHODS: In total, 64 of 100 patients randomly selected from our institution's spine registry were able to be converted to 3-dimensional imaging. Virtual screws were then placed in the optimal position for an S2AI screw on each side of the pelvis. The lateral and inferior angles were measured off-axial and sagittal planes, respectively. The distances from the notch and the remaining available screw length were also recorded. RESULTS: The average patient age was 38±16 years. The average lateral angle was 42.5±2.0 degrees and the inferior angle was 18.2±1.8 degrees. The screws fit bilaterally in all 64 patients without cortical breach. The remaining available screw distance was measured in all patients and found to be 40.5±8.7 mm. The average distance from the sciatic notch was 13.8±4.1 mm. Men had significantly more potential screw length when compared with women. CONCLUSIONS: We found an average inferior angle of 18.2 degrees, which is less than the previously described angle range of 20-40 degrees. These findings suggest that an ideal trajectory may be significantly different than the previously described trajectory. We found that with the optimal trajectory, a 100 mm screw can fit in all patients without concern for cortical breach of the pelvis or violation of the hip joint.

Utility of Anxiety/Depression Domain of EQ-5D to Define Psychological Distress in Spine Surgery.

BACKGROUND: Prospective patient-reported outcomes (PROs) registries are central to emerging evidence-driven reform models. These registries entail significant operator and responder burden to capture PROs data. It is important to limit the number of PROs administered. We sought to determine whether the anxiety/depression domain of EQ-5D could be used to define preoperative psychological distress in patients undergoing elective spine surgery. METHODS: Patients undergoing elective spine surgery and enrolled into a prospective registry were analyzed. The 12-Item Short-Form Health Survey Mental Component Summary, Zung depression scale, Modified Somatic Perception Questionnaire, and EQ-5D were completed. The anxiety/depression domain of EQ-5D was used to define psychological distress; responses were captured as 1) not anxious or depressed, 2) moderately anxious or depressed, or 3) extremely anxious or depressed. Univariate correlation and proportional odds logistic regression analyses were conducted. RESULTS: Of 2470 included patients undergoing elective spine surgery, 45% (n = 1109) reported no psychological distress, 47% (n = 1168) reported moderate psychological distress, and 8% (n = 193) reported extreme psychological distress on EQ-5D. Psychological distress on EQ-5D had positive correlation with Zung depression scale (P < 0.0001, r = 0.620) and Modified Somatic Perception Questionnaire (P < 0.0001, r = 0.450) and negative correlation with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, r = -0.662). In proportional odds logistic regression models, EQ-5D psychological distress had significant correlations with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, C-index = 0.831), Zung depression scale (P < 0.0001, C-index = 0.802), and Modified Somatic Perception Questionnaire (P < 0.0001, C-index = 0.711). CONCLUSIONS: The anxiety/depression domain of EQ-5D could be used to categorize preoperative psychological distress. Spine registries could use this information to potentially limit the number of validated PROs administered.

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy.

STUDY DESIGN: This study retrospectively analyzes prospectively collected data. OBJECTIVE: Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored. METHODS: The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest. RESULTS: We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001). CONCLUSION: Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction. LEVEL OF EVIDENCE: 3.

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures.

OBJECTIVE: To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures. DESIGN: Retrospective; Setting: ACS level 1 trauma center. PATIENTS/PARTICIPANTS: We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time. INTERVENTION: Open tibia fractures treated with an SP tibial nail. MAIN OUTCOME MEASUREMENTS: Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis. RESULTS: In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis. CONCLUSIONS: Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury Rate and Patterns Among CrossFit Athletes.

BACKGROUND: CrossFit is a type of competitive exercise program that has gained widespread recognition. To date, there have been no studies that have formally examined injury rates among CrossFit participants or factors that may contribute to injury rates. PURPOSE: To establish an injury rate among CrossFit participants and to identify trends and associations between injury rates and demographic categories, gym characteristics, and athletic abilities among CrossFit participants. STUDY DESIGN: Descriptive epidemiology study. METHODS: A survey was conducted, based on validated epidemiologic injury surveillance methods, to identify patterns of injury among CrossFit participants. It was sent to CrossFit gyms in Rochester, New York; New York City, New York; and Philadelphia, Pennsylvania, and made available via a posting on the main CrossFit website. Participants were encouraged to distribute it further, and as such, there were responses from a wide geographical location. Inclusion criteria included participating in CrossFit training at a CrossFit gym in the United States. Data were collected from October 2012 to February 2013. Data analysis was performed using Fisher exact tests and chi-square tests. RESULTS: A total of 486 CrossFit participants completed the survey, and 386 met the inclusion criteria. The overall injury rate was determined to be 19.4% (75/386). Males (53/231) were injured more frequently than females (21/150; P = .03). Across all exercises, injury rates were significantly different (P < .001), with shoulder (21/84), low back (12/84), and knee (11/84) being the most commonly injured overall. The shoulder was most commonly injured in gymnastic movements, and the low back was most commonly injured in power lifting movements. Most participants did not report prior injury (72/89; P < .001) or discomfort in the area (58/88; P < .001). Last, the injury rate was significantly decreased with trainer involvement (P = .028). CONCLUSION: The injury rate in CrossFit was approximately 20%. Males were more likely to sustain an injury than females. The involvement of trainers in coaching participants on their form and guiding them through the workout correlates with a decreased injury rate. The shoulder and lower back were the most commonly injured in gymnastic and power lifting movements, respectively. Participants reported primarily acute and fairly mild injuries.

Articular shear of the anterior-inferior quadrant of the glenoid: a glenolabral articular disruption lesion variant.

Traumatic cartilage lesions of the shoulder, such as glenolabral articular disruption (GLAD), have previously been recognized in patients with shoulder instability. We describe a new lesion in which the entire anteroinferior quadrant of the glenoid articular cartilage is sheared off in association with an adjacent labral tear. Both patients were teenage athletes who were being treated arthroscopically for shoulder instability. Preoperative imaging showed some evidence of an articular cartilage lesion. One patient was treated with removal of an irreparable fragment and microfracture, while in the other case the cartilage flap was reattached to the glenoid with a chondral fixation device. This GLAD lesion variant is a serious cartilage injury to the shoulder in young athletes that may be subtle, but needs to be recognized for proper arthroscopic treatment.

Relation between thrombolysis in myocardial infarction risk score and one-year outcomes for patients presenting at the emergency department with potential acute coronary syndrome.

The Thrombolysis in Myocardial Infarction (TIMI) score, derived from unstable angina/non-ST-segment elevation acute myocardial infarction patient population, predicts 14-day cardiovascular events. It has been validated in emergency department (ED) patients with potential acute coronary syndrome with respect to 30-day outcomes. Our objective was to determine whether the initial TIMI score could risk stratify ED patients with potential acute coronary syndrome with respect to the 1-year outcomes. This was a prospective cohort study of patients presenting to the ED with chest pain who underwent electrocardiography. Patients with ST-segment elevation myocardial infarction (acute myocardial infarction) were excluded. Follow-up was conducted by telephone and record review >1 year after the index visit. The main outcome was the 1-year mortality, nonfatal acute myocardial infarction, or revascularization stratified by the TIMI score. Of 2,819 patients, 253 (9%) met the composite outcome. The overall incidence of the composite 1-year outcome of death (n = 119), acute myocardial infarction (n = 96), and revascularization (n = 90) according to TIMI score was TIMI 0 (n = 1,162), 4%; TIMI 1 (n = 901), 8%; TIMI 2 (n = 495), 13%; TIMI 3 (n = 193), 23%; TIMI 4 (n = 60), 28%; and TIMI 5 to 7 (n = 8), 88% (p <0.001). In conclusion, in addition to risk stratifying ED patients with chest pain at the initial ED evaluation, the TIMI score can also predict the 1-year cardiovascular events in this patient population.