Three-stage correction of severe idiopathic scoliosis with limited skeletal traction during a humanitarian surgical mission: illustrative case.

BACKGROUND: Underprivileged and underserved patients from developing countries often present late with advanced, untreated spinal deformities. We report a three-stage all-posterior approach using limited skeletal traction with Gardner-Wells tongs (GWTs) for the management of severe idiopathic scoliosis during a humanitarian surgical mission trip. OBSERVATIONS: A 17-year-old high-school female was previously diagnosed with juvenile idiopathic scoliosis (diagnosed at age 8) and progressed to a severe 135° kyphoscoliosis. Procedural stage 1 involved spinal instrumentation and posterior releases via posterior column osteotomies from T3 to L4. She then underwent 7 days of skeletal traction with GWTs in the intensive care unit as stage 2. In stage 3, rod engagement, posterior spinal fusion, and partial T10 vertebral column resection were performed. There were no changes in intraoperative neuromonitoring during either surgery and she woke up neurologically intact after both stages of the surgical procedure. LESSONS: Skeletal traction with GWTs is a viable alternative to traditional halo-gravity traction in settings with limited resources. Three-stage spinal deformity correction using limited skeletal traction is a feasible and effective approach for managing severe scoliosis during humanitarian surgical mission trips.

Acute Traumatic Spondyloptosis: A Case Report.

Acute traumatic spondyloptosis (ATS) is a rare condition in the orthopedic literature, with few cases reported. We present a case of ATS in a 35-year-old Hispanic male with multilevel injury, without neurological deficits at the time of injury. The patient was treated in a two-stage method consisting of combined anterior and posterior spinal decompression and fusion. At the six-month follow-up, the patient had no motor/sensory deficits, he remained stable during the one-year period. Conclusion: ATS is rarely seen in patients without neurological deficits on presentation. Although surgical intervention presents significant risks of iatrogenic neurologic compromise, surgical fixation is warranted.

The Volume-Cost Relationship: How Does Surgical Volume Affect Cost and Value in AIS Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of this study was to evaluate and compare distribution of hospital and operating room charges and outcomes during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) patients by high-volume (HV) and standard-volume (SV) surgeons at one institution and examine potential cost savings. SUMMARY OF BACKGROUND DATA: Increased surgical volume has been associated with improved perioperative outcomes after spinal deformity correction. However, there is a lack of information on how this may affect hospital costs. METHODS: Retrospective study of AIS patients undergoing posterior spinal fusion between 2013 and 2019. Demographic, x-ray, chart review and hospital costs were collected and compared between HV surgeons (≥50 AIS cases/y) and SV surgeons (<50/y). Comparative analyses were computed using Wilcoxon rank-sum, Kruskal-Wallis, and the Fisher exact tests. Average values with corresponding minimum-maximum rages were reported. RESULTS: A total of 407 patients (HV: 232, SV: 175) operated by 4 surgeons (1 HV, 3 SV). Radiographic parameters were similar between the groups. HV surgeons had significantly lower estimated blood loss (385.3 vs. 655.6 mL, P <0.001), fewer intraoperative transfusions (10.8% vs. 25.1%, P <0.001), shorter surgery time (221.6 vs. 324.9 min, P <0.001), and lower radiation from intraoperative fluoroscopy (4.4 vs. 6.4 mGy, P <0.001). HV patients had a significantly lower length of stay (4.3 vs. 5.3, P <0.001) and complication rate (0.4% vs. 4%, P =0.04).HV surgeons had significantly lower total costs ($61,716.24 vs. $72,745.93, P <0.001). This included lower transfusion costs ( P <0.001), operative time costs ( P <0.001), screw costs ( P <0.001), hospital stay costs ( P <0.001), and costs associated with 30-day emergency department returns ( P <0.001). CONCLUSION: HV surgeons had significantly lower operative times, lower estimated blood loss and transfusion rates and lower perioperative complications requiring readmission or return to emergency department resulting in lower health care costs. LEVEL OF EVIDENCE: Level III.

In Scheuermann's kyphosis, a proximal UIV and postop kyphosis value close to patients' PI decreases the risk of PJK.

PURPOSE: Prevalence of proximal junctional kyphosis (PJK) in Scheuermann's kyphosis (SK) varies between 24 and 40%. Multiple factors have been implicated, including kyphosis overcorrection, failure to include proximal end vertebra, and implant choice. This study aimed to determine the goal correction parameters based upon patients' pelvic incidence, and UIV to decrease PJK in Scheuermann's kyphosis. METHODS: X-ray and chart review of SK patients operated with all pedicle screw (PS), hybrid fixation (HF), and anterior/posterior fusions with hybrid fixation (AP). T1/T2 were grouped together as proximal fusion groups compared to T3 and distal groups. RESULTS: 96 total patients: PS (n = 41), HF (n = 24), and AP (n = 31). Overall, at early postop 12 (12.5%) patients had PJK. At final follow-up, 33 (34.4%) had PJK. There was no significant difference between groups at early postop (p = 0.86) or final follow-up (p = 0.67). When correcting kyphosis-PI to > - 10.0° and UIV was chosen to be T1 or T2, PJK developed in 6.1% of patients at final follow-up; when fusing to T1/T2 but with kyphosis-PI < - 10.0°, 38.9% of patients developed PJK. With kyphosis-PI > - 10.0° and UIV at T3 or below, 37.0% of patients developed PJK at final follow-up. When fusing to T3 or below but failing to correct kyphosis-PI to > - 10.0°, 77.8% of patients developed PJK. CONCLUSION: Selecting proximal UIV and avoiding kyphosis-PI mismatch can significantly decrease the prevalence of PJK rather than surgical technique or implant choice. Surgeons treating SK should, therefore, aim to correct kyphosis closer to the patient's pelvic incidence and choose T2/T1 as UIV.

Predicting Elective Orthopaedic Sports Medicine Surgical Cancellations Based on Patient Demographics.

PURPOSE: To evaluate whether patient demographics are associated with cancellation of elective orthopaedic sports medicine surgical procedures. METHODS: We retrospectively reviewed the electronic medical records of 761 patients who were scheduled to undergo an elective sports medicine orthopaedic operation from January 1, 2015, to December 31, 2017. The patients were divided into 2 groups: those who underwent the scheduled procedure (group A) and those in whom the operation was canceled for any reason prior to the surgical date and not rescheduled (group B). Univariate analysis assessed patient factors consisting of age, sex, race, language, marital status, occupation status, type of insurance (Medicaid or Medicare vs private), smoking history, employment status, and history of surgery to determine which demographic factors led to an increased risk of elective case cancellation. RESULTS: Patients who canceled were significantly older (46.5 years vs 41.5 years, t = 2.432, P = .015) than those who do not. In addition, current smokers (22.5% vs 10.9%, χ2 = 10.85, P = .001), patients with Medicare or Medicaid versus private insurance (16.7% vs 10.0%, χ2 = 5.35, P = .021), non-English-speaking patients (29.5% vs 11.6%, χ2 = 11.43, P = .001), and patients without a history of surgery requiring anesthesia (18.8% vs 9.6%, χ2 = 9.96, P = .002) were all more likely to cancel. When all studied variables were examined in a logistic regression analysis, of the above demographic variables, only insurance status was no longer significant, given its correlation with age and language. CONCLUSIONS: Increased age (≥46.5 years), non-English speaking, smoking, lack of a history of surgery requiring anesthesia, and Medicaid or Medicare insurance were found to contribute to an increased risk of elective orthopaedic surgery cancellation. LEVEL OF EVIDENCE: Level III, case-control study.

Total Knee Arthroplasty in Patients with Familial Patellar Absentia Syndrome: A 40-Year Update: A Case Report.

CASE: Isolated patella absentia is an extremely rare phenomenon, with only a few published cases and even fewer follow-up reports. Nearly 40 years after the initial presentation of 2 brothers with bilateral congenital absence of the patella and the publication of a case report, we report the clinical and radiographic findings of their subsequent tibiofemoral osteoarthritis, which was treated with bilateral total knee arthroplasty. CONCLUSION: Understanding the biomechanical complications associated with congenital absence of the patella as it relates to a stable knee is vital; in the case of degenerative changes, total knee arthroplasty appears to provide a long-term solution for these patients.

Portal Vein Thrombosis due to Prothrombin Gene Mutation following Sleeve Gastrectomy.

Introduction. Portomesenteric thrombosis is increasingly recognized as a complication of laparoscopic sleeve gastrectomy (LSG). It often presents with abdominal pain. We present a mother and her son who both developed portal vein thrombosis (PVT) after LSG. Case Description. A 43-year-old woman presented complaining of sudden severe abdominal pain, two weeks after she had uncomplicated laparoscopic sleeve gastrectomy. CT scan of the abdomen and pelvis with IV contrast showed portal vein thrombosis and SMV thrombosis. Two weeks later her son had the same LSG for morbid obesity and presented with the same clinical picture. Thrombophilia workup showed heterozygous prothrombin gene mutation. Conclusions. A high index of suspicion is necessary to diagnose PVT; although rare, it can be potentially lethal. Anticoagulation therapy should be initiated immediately to limit the morbidities and improve the outcome. Patients with family history of thrombophilia should be investigated prior to any bariatric surgery and nonsurgical alternative treatments for morbid obesity should be strongly encouraged.

Simulated transanal NOTES sigmoidectomy training improves the responsiveness of surgical endoscopists.

BACKGROUND: There is no evidence demonstrating the feasibility of colorectal natural orifice transluminal endoscopic surgery (NOTES) resection with currently available endoscopic instrumentation. OBJECTIVE: This study aimed to evaluate the responsiveness of surgical endoscopists to simulated transanal NOTES sigmoidectomy training. DESIGN: Participants were trained in simulated NOTES sigmoidectomy by using disposable abdominal trays with tattooed sigmoid cancer in a hybrid simulator. SETTING: Endoscopy simulation laboratory in a university hospital. INTERVENTIONS: NOTES sigmoidectomy included 8 steps performed transanally with 2 colonoscopes, endoscopic scissors, and clip applier: (1) colonoscopic viscerotomy with a balloon; (2) retroperitoneal dissection; (3) left ureter identification, inferior mesenteric vessels division; (4) colonoscopy; (5) splenic flexure mobilization; (6) left side of the colon/rectal mobilization; (7) transanal specimen transection; (8) extracorporeal colorectal anastomosis. MAIN OUTCOME MEASUREMENTS: Responsiveness was defined as a change in performance over time and assessed comparing baseline testing with unmentored final testing. Content-valid measures included the length of the specimen, the distance of the anastomosis from the anal verge, and the proximal and distal resection margins and operating time (minutes). RESULTS: Four participants performed 21 resections. Tumor distance from the anal verge was 29.2 cm (range 26-2.5 cm). Operating time overall (127.5 vs 74 minutes, P = .068), viscerotomy (17.5 vs 9 minutes, P = .197), colonoscopy (4.5 vs 3.5 minutes, P = .655), flexure mobilization (19.5 vs 10 minutes, P = .144), colon mobilization (20 vs 14.5 minutes, P = .461), specimen extraction (9.5 vs 8.5 minutes, P = .465), and anastomosis (14 vs 11 minutes, P = .715) times improved. LIMITATIONS: Ceiling effects because of fixed anatomy. CONCLUSIONS: Simulated NOTES sigmoidectomy training affected responsiveness of surgical endoscopists with a 42% reduction in operating time.