Utilizing a comprehensive machine learning approach to identify patients at high risk for extended length of stay following spinal deformity surgery in pediatric patients with early onset scoliosis.

PURPOSE: Early onset scoliosis (EOS) patient diversity makes outcome prediction challenging. Machine learning offers an innovative approach to analyze patient data and predict results, including LOS in pediatric spinal deformity surgery. METHODS: Children under 10 with EOS were chosen from the American College of Surgeon's NSQIP database. Extended LOS, defined as over 5 days, was predicted using feature selection and machine learning in Python. The best model, determined by the area under the curve (AUC), was optimized and used to create a risk calculator for prolonged LOS. RESULTS: The study included 1587 patients, mostly young (average age: 6.94 ± 2.58 years), with 33.1% experiencing prolonged LOS (n = 526). Most patients were female (59.2%, n = 940), with an average BMI of 17.0 ± 8.7. Factors influencing LOS were operative time, age, BMI, ASA class, levels operated on, etiology, nutritional support, pulmonary and neurologic comorbidities. The gradient boosting model performed best with a test accuracy of 0.723, AUC of 0.630, and a Brier score of 0.189, leading to a patient-specific risk calculator for prolonged LOS. CONCLUSIONS: Machine learning algorithms accurately predict extended LOS across a national patient cohort and characterize key preoperative drivers of increased LOS after PSIF in pediatric patients with EOS.

Improvement in axial rotation with bracing reduces the risk of curve progression in patients with adolescent idiopathic scoliosis.

PURPOSE: New evidence highlights the significance of 3D in-brace correction for Adolescent Idiopathic Scoliosis (AIS) patients. This study explores how axial parameters relate to treatment failure in braced AIS patients. METHODS: AIS patients (Sanders 1-5) undergoing Rigo-Chêneau bracing at a single institution were included. Axial vertebral rotation (AVR) was determined by utilizing pre-brace and in-brace 3D reconstructions from EOS® radiographs. The primary outcome was treatment failure: surgery or coronal curve progression > 5°. Minimum follow-up was two years. RESULTS: 75 patients (81% female) were included. Mean age at bracing initiation was 12.8 ± 1.3 years and patients had a pre-brace major curve of 31.0° ± 6.5°. 25 patients (76% female) experienced curve progression > 5°, and 18/25 required surgical intervention. The treatment failure group had larger in-brace AVR than the success group (5.8° ± 4.1° vs. 9.9° ± 7.6°, p = 0.003), but also larger initial coronal curve measures. In-brace AVR did not appear to be associated with treatment failure after adjusting for the pre-brace major curve (Hazard Ratio (HR):0.99, 95% Confidence Interval (CI):0.94-1.05, p = 0.833). Adjusting for pre-brace major curve, patients with AVR improvement with bracing had an 85% risk reduction in treatment failure versus those without (HR:0.15, 95% CI:0.02-1.13, p = 0.066). At the final follow-up, 42/50 (84%) patients without progression had Sanders ≥ 7. CONCLUSIONS: While in-brace rotation was not an independent predictor of curve progression (due to its correlation with curve magnitude), improved AVR with bracing was a significant predictor of curve progression. This study is the first step toward investigating the interplay between 3D parameters, skeletal maturity, compliance, and brace efficacy, allowing a future prospective multicenter study. LEVEL OF EVIDENCE: Retrospective study; Level III.

Evaluating the Readability of Patient Education Materials for Anterior Vertebral Body Tethering, Distraction-Based Methods, and Posterior Spinal Fusion for the Treatment of Pediatric Spinal Deformity.

BACKGROUND: The Internet is an important source of information for patients, but its effectiveness relies on the readability of its content. Patient education materials (PEMs) should be written at or below a sixth-grade reading level as outlined by agencies such as the American Medical Association. This study assessed PEMs' readability for the novel anterior vertebral body tethering (AVBT), distraction-based methods, and posterior spinal fusion (PSF) in treating pediatric spinal deformity. METHODS: An online search identified PEMs using the terms "anterior vertebral body tethering," "growing rods scoliosis," and "posterior spinal fusion pediatric scoliosis." We selected the first 20 general medical websites (GMWs) and 10 academic health institution websites (AHIWs) discussing each treatment (90 websites total). Readability tests for each webpage were conducted using Readability Studio software. Reading grade levels (RGLs), which correspond to the US grade at which one is expected to comprehend the text, were calculated for sources and independent t tests compared with RGLs between treatment types. RESULTS: The mean RGL was 12.1 ± 2.0. No articles were below a sixth-grade reading level, with only 2.2% at the sixth-grade reading level. AVBT articles had a higher RGL than distraction-based methods (12.7 ± 1.6 vs 11.9 ± 1.9, P = 0.082) and PSF (12.7 ± 1.6 vs 11.6 ± 2.3, P = 0.032). Materials for distraction-based methods and PSF were comparable (11.9 ± 1.9 vs 11.6 ± 2.3, P = 0.566). Among GMWs, AVBT materials had a higher RGL than distraction-based methods (12.9 ± 1.4 vs 12.1 ± 1.8, P = 0.133) and PSF (12.9 ± 1.4 vs 11.4 ± 2.4, P = 0.016). CLINICAL RELEVANCE: Patients' health literacy is important for shared decision-making. Assessing the readability of scoliosis treatment PEMs guides physicians when sharing resources and discussing treatment with patients. CONCLUSION: Both GMWs and AHIWs exceed recommended RGLs, which may limit patient and parent understanding. Within GMWs, AVBT materials are written at a higher RGL than other treatments, which may hinder informed decision-making and patient outcomes. Efforts should be made to create online resources at the appropriate RGL. At the very least, patients and parents may be directed toward AHIWs; RGLs are more consistent.

Reliability of Preoperative Supine Versus Bending Radiographs in Estimating the Structural Nature of Curves in EOS.

BACKGROUND: The study sought to evaluate the utility of a single supine radiograph in determining curve flexibility in early-onset scoliosis (EOS) patients. METHODS: EOS patients with upright (standing/seated), supine, and side-bending radiographs who underwent spinal deformity surgery were identified. Coronal parameters included: proximal thoracic (PT) curve, main thoracic (MT) curve, and thoracolumbar/lumbar (TL/L) curve. Each radiograph was measured twice by 2 different raters. Correlation coefficients were utilized to investigate associations between the different radiographs. Interrater Correlation Coefficient (ICC) assessed intrarater and interrater reliability. RESULTS: Thirty-seven EOS patients were identified (age at diagnosis: 7.0±2.9 y, preoperative age: 13.0±2.9 y; 73% female; etiologies: 54% idiopathic, 30% syndromic, and 16% neuromuscular). Supine PT and MT curve measurements were highly associated with corresponding side-bending measurements (PT: r=0.75, P<0.001; MT: r=0.80, P<0.001), and TL/L curves were very highly associated (TL/L: r=0.92, P<0.001). The mean absolute differences between supine and side-bending measurements were PT: 11.3±7.8 degrees, MT: 14.8±8.3 degrees, and TL/L: 16.2±7.6 degrees, where the side-bending was on average smaller than the supine measurement. The intrarater reliabilities were excellent, with an ICC ranging from 0.93 to 0.96 for side-bending films and 0.94 to 0.97 for supine films. The interrater reliability was excellent with ICC value of 0.88 for side-bending films and 0.93 for supine films. CONCLUSIONS: A single, preoperative supine radiograph was highly predictive of side-bending radiographs in patients with EOS. Supine curves measured an average of 15 degrees larger than bending curves in the MT and TL/L region. A single supine film may eliminate the need for effort-related, dual side-bending radiographs. LEVEL OF EVIDENCE: Level II-retrospective study.

How common is acute pelvic fixation failure after adult spine surgery? A single-center study of 358 patients.

OBJECTIVE: There is a paucity of literature on pelvic fixation failure after adult spine surgery in the early postoperative period. The purpose of this study was to determine the incidence of acute pelvic fixation failure in a large single-center study and to describe the lessons learned. METHODS: The authors performed a retrospective review of adult (≥ 18 years old) patients who underwent spinal fusion with pelvic fixation (iliac, S2-alar-iliac [S2AI] screws) at a single academic medical center between 2015 and 2020. All patients had a minimum of 3 instrumented levels. The minimum follow-up was 6 months after the index spine surgery. Patients with prior pelvic fixation were excluded. Acute pelvic fixation failure was defined as revision of the pelvic screws within 6 months of the primary surgery. Patient demographics and operative, radiographic, and rod/screw parameters were collected. All rods were cobalt-chrome. All iliac and S2AI screws were closed-headed screws. RESULTS: In 358 patients, the mean age was 59.5 ± 13.6 years, and 64.0% (n = 229) were female. The mean number of instrumented levels was 11.5 ± 5.5, and 79.1% (n = 283) had ≥ 6 levels fused. Three-column osteotomies were performed in 14.2% (n = 51) of patients, and 74.6% (n = 267) had an L5-S1 interbody fusion. The mean diameter/length of pelvic screws was 8.5/86.6 mm. The mean number of pelvic screws was 2.2 ± 0.5, the mean rod diameter was 6.0 ± 0 mm, and 78.5% (n = 281) had > 2 rods crossing the lumbopelvic junction. Accessory rods extended to S1 (32.7%, n = 117) or S2/ilium (45.8%, n = 164). Acute pelvic fixation failure occurred in 1 patient (0.3%); this individual had a broken S2AI screw near the head-neck junction. This 76-year-old woman with degenerative lumbar scoliosis and chronic lumbosacral zone 1 fracture nonunion had undergone posterior instrumented fusion from T10 to pelvis with bilateral S2AI screws (8.5 × 90 mm); i.e., transforaminal lumbar interbody fusion L4-S1. The patient had persistent left buttock pain postoperatively, with radiographically confirmed breakage of the left S2AI screw 68 days after surgery. Revision included instrumentation removal at L2-pelvis and a total of 4 pelvic screws. CONCLUSIONS: The acute pelvic fixation failure rate was exceedingly low in adult spine surgery. This rate may be the result of multiple factors including the preference for multirod (> 2), closed-headed pelvic screw constructs in which large-diameter long screws are used. Increasing the number of rods and screws at the lumbopelvic junction may be important factors to consider, especially for patients with high risk for nonunion.

Degree of Postoperative Curve Correction Decreases Risks of Postoperative Pneumonia in Patients Undergoing Both Fusion and Growth-friendly Surgical Treatment of Neuromuscular Scoliosis.

INTRODUCTION: Due to a combination of poor respiratory muscle control and mechanical lung compression secondary to spine and chest wall deformities, patients with neuromuscular (NM) early-onset scoliosis (EOS) are at a high risk for pulmonary complications including pneumonia. The purpose of this study is to examine the effect of surgical intervention on the prevalence and risk of postoperative pneumonia in patients with NM EOS. METHODS: In this retrospective cohort study, pediatric (18 y old and below) patients with NM EOS undergoing index fusion or growth-friendly instrumentation from 2000 to 2018 were identified. Patients were then categorized into 2 groups: those with ≥50% curve correction and those with <50% curve correction of the coronal deformity at the first postoperative visit. The primary outcome of interest was postoperative pneumonia occurring between 3 weeks and 2 years postoperatively. Manual chart review was supplemented with phone call surveys to ensure all occurrences of preoperative/postoperative pneumonia (ie, in-institution and out-of-institution visits) were accounted for. RESULTS: A total of 35 patients (31% female, age at surgery: 10.3±4.3 y) with NM EOS met inclusion criteria. Twenty-three (66%) patients experienced at least 1 case of preoperative pneumonia. Twenty-six (74%) patients had ≥50% and 9 (26%) patients had <50% immediate postoperative curve correction. In total, 12 (34%) patients experienced at least 1 case of postoperative pneumonia (7 in-institution, 5 out-of-institution). Seven (27%) patients with ≥50% curve correction versus 5 (56%) with <50% curve correction experienced postoperative pneumonia. Relative risk regression demonstrated that patients with <50% curve correction had increased risk of postoperative pneumonia by 2.1 times compared with patients with ≥50% curve correction (95% confidence interval: 0.9; 4.9, P =0.099). CONCLUSION: The prevalence of preoperative and postoperative pneumonia is high in patients with NM EOS. This study presents preliminary evidence suggesting that percent curve correction is associated with the occurrence of postoperative pneumonia in patients with NM EOS undergoing surgical correction.

Malpractice litigation following orthopaedic surgery of the hip: Frequency, reasons for lawsuit, and outcomes.

Medical malpractice litigation in the United States has resulted in the widespread adoption of defensive medicine practices. Orthopaedic surgery is among the specialties most likely to face a malpractice lawsuit, and hip-related surgeries are commonly involved. This study aimed to analyse malpractice litigation as it relates to hip surgery in the United States. The purpose of this study was to seek answers to the following questions: Has there been an increase or a decrease in the number of hip surgery malpractice cases in recent years? What are the most common reasons for a patient to pursue litigation? Which surgical complications are most likely to result in a lawsuit? What trends do we see in terms of outcomes? The Westlaw legal database was queried for all relevant cases from 2008 to 2018. A retrospective review of cases was conducted and descriptive analyses were performed in order to identify factors associated with hip surgery malpractice litigation. A total of 82 cases were analysed. There was a downtrend in the number of cases per year. Total hip arthroplasty (47 cases, 57.3%) was the procedure most often involved. Procedural error was noted as a reason for litigation in 71 (86.6%) cases. Neurological injury (22 cases, 26.8%), malpositioned hardware (15 cases, 18.3%) and leg length discrepancy (8 cases, 9.8%) were the most common complications listed. The majority of cases resulted in a verdict in favour of the defendant orthopaedic surgeon (48 cases, 58.5%). The mean payout for a plaintiff verdict (20 cases, 24.4%) was $1,647,981 (range, $1,852-$7,000,000) and the mean payout for a settlement (13 cases, 15.9%) was $657,823 (range, $49,000-$3,000,000) (p = 0.063). The study concluded that, within the 10-year period, there was a significant downtrend in hip surgery malpractice cases filed per year. Orthopaedic surgeons were found liable in the minority of cases. As expected, verdicts in favour of plaintiffs resulted in seemingly higher payouts than settlements.

Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons.

The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.

The Impact of Unplanned Return to the Operating Room on Health-related Quality of Life at the End of Growth-friendly Surgical Treatment for Early-onset Scoliosis.

BACKGROUND: Limiting complications, especially unplanned return to the operating room (UPROR), is a major focus in the surgical management of early-onset scoliosis (EOS). Although UPROR remains common in this population, its effect on long-term health-related quality of life (HRQoL) remains unclear. The purpose of this study was to investigate the association between UPROR and end-of-treatment HRQoL in EOS patients treated with growth-friendly instrumentation. METHODS: Patients with EOS who underwent growth-friendly instrumentation at age less than 10 years from 1993 to 2018, and completed treatment, were identified in a multicenter EOS registry. UPROR events were recorded, and end-of-treatment (defined as skeletal maturity and/or definitive spinal fusion) HRQoL was assessed via the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24). RESULTS: A total of 825 patients were identified, and 325 patients (age at surgery: 6.4 y, follow-up: 8.1 y) had end-of-treatment HRQoL data necessary for our investigation. Overall, 129/325 (39.7%) patients experienced 264 UPROR events; the majority (54.2%) were implant-related. Aside from age and etiology, no other variables were determined to be confounders or effect modifiers. Congenital patients with UPROR had worse pain/discomfort by 10.4 points (P=0.057) and worse pulmonary function by 7.8 points (P=0.102) compared with non-UPROR patients adjusting for age. Neuromuscular patients with UPROR had worse pulmonary function by 10.1 points compared with non-UPROR patients adjusting for age (P=0.037). Idiopathic and syndromic patients with UPROR reported consistently worse domain scores than their non-UPROR counterparts, but smaller (<5-point) differences were seen. CONCLUSIONS: UPROR during growth-friendly surgical treatment for EOS is associated with worse HRQoL in all patients, but particularly in those with neuromuscular or congenital etiologies. Ongoing efforts to avoid UPROR are critical. LEVEL OF EVIDENCE: Level II. This is a multicenter retrospective cohort study investigating the effect of UPROR on HRQoL (prognostic study).

Shoulder balance in patients with Lenke type 1 and 2 idiopathic scoliosis appears satisfactory at 2 years following anterior vertebral body tethering of the spine.

BACKGROUND: Shoulder balance is an important factor for patient satisfaction following surgery for idiopathic scoliosis (IS). There is no literature reporting the effect of anterior vertebral body tethering (AVBT) on shoulder balance. The purpose of this study was to report the prevalence of postoperative shoulder imbalance in patients undergoing AVBT for IS. METHODS: In this retrospective case series, patients enrolled in a multicenter scoliosis registry who underwent AVBT from 2013 to 2017 in two Canadian centers were identified. The primary outcome was shoulder imbalance, defined as an absolute radiographic shoulder height of > 2 cm, at 2 years postoperatively (follow-up range: 22-30 months). Clavicular angle and T1 tilt angle were also investigated. RESULTS: Of the 50 patients identified (92% female; preoperative age: 11.9 ± 1.4 years), there were 43 (86%) patients with Lenke 1 and 7 (14%) patients with Lenke 2 curves. The mean Cobb angles of the proximal thoracic and main thoracic curves were 22.8° ± 8.8° and 49.4° ± 8.5° preoperatively and 13.1° ± 7.5° and 24.9° ± 9.5° at a mean follow-up time of 2.1 years. Absolute clavicular angle and T1 tilt angle were 2.8° ± 2.2° and 4.8° ± 3.5° preoperatively and 2.2° ± 1.7° and 4.7° ± 4.2° at 2-year follow-up. Preoperatively, absolute shoulder height averaged 15.6 ± 10.4 mm, and 15 (30%) patients had shoulder imbalance. At 2-year follow-up, absolute shoulder height averaged 11.2 ± 8.3 mm, and 8 (16%) patients had shoulder imbalance. Of the patients who had acceptable shoulder balance preoperatively, 4 (11.4%) became imbalanced at 2 years postoperatively. CONCLUSION: Postoperative shoulder imbalance in this early group of patients with IS undergoing AVBT was seen in 16% of patients, a reduction from 30% preoperatively. These results likely reflect the potential of the proximal thoracic curve to correct spontaneously following AVBT. LEVEL OF EVIDENCE: Level III.

Completion of a formal physiotherapeutic scoliosis-specific exercise training program for adolescent idiopathic scoliosis increases patient compliance to home exercise programs.

INTRODUCTION: Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP). METHODS: Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions). RESULTS: 81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140). CONCLUSION: Patients who completed PSSE training maintained higher HEP compliance.

Complications in the treatment of EOS: Is there a difference between rib vs. spine-based proximal anchors?

INTRODUCTION: Currently, there is significant equipoise regarding the selection and placement of growing spinal instrumentation when treating patients with early-onset scoliosis (EOS). The primary purpose of this study was to compare complications following surgery in patients receiving rib-based versus spine-based proximal anchors as a part of posterior growing instrumentation in the management of EOS. METHODS: Retrospective cohort study. Inclusion criteria required: age 3-10 years old, diagnosis of EOS, treatment with a growing construct that utilized rib- or spine-based proximal anchors, and a major coronal curve larger than 40 degrees. The primary outcome analyzed was postoperative complications. Secondary outcomes included coronal major curve correction and patient reported outcomes measured by the Early-Onset Scoliosis 24-item Questionnaire (EOSQ-24). Subjects were categorized into rib- or spine-based proximal fixation groups for comparison. RESULTS: Of 104 patients included in the study, 76 (73.1%) were treated with rib-based constructs and 28 (26.9%) were treated with spine-based constructs. 24 (31.6%) patients with rib-based constructs and 9 (32.1%) patients with spine-based constructs experienced at least one implant related complication (p = 0.956). Rod fracture was observed more often in spine-based groups than rib-based groups for both patients with congenital/idiopathic EOS (rib: 0 (0%) vs. spine: 3 (13.6%), p = 0.009) and neuromuscular/syndromic EOS (rib: 0 (0%) vs. spine: 2 (33.3%), p = 0.002). Furthermore, surgical site infection was found to be more frequent in rib-based than spine-based groups for neuromuscular/syndromic patients (rib: (13) 27.15 vs. spine: (1) 4.5%, p = 0.029). The most commonly reported complication was device migration. In patients with rib-based constructs, 2 (12.5%) patients with ≥ 5 anchors and 13 (21.7%) patients with < 5 anchors experienced device migration (p = 0.413). In patients with spine-based constructs, 1 (11.1%) patient with ≥ 5 anchors and 4 (21.1%) patients with < 5 anchors experienced device migration (p = 0.064). Spine-based anchors had significantly higher% correction (42.0%) compared to rib-based anchors (20.6%) (p = 0.003) at the most recent follow-up. There were no significant differences in the change of patient reported outcomes as measured by the EOSQ-24 between patients who received rib or spine-based anchors. DISCUSSION: The number of patients with at least one implant related complication was similar between the rib- and spine-based groups. Having 5 or more proximal anchors appeared protective against proximal device migration; however, this result was not statistically significant. Spine-based anchors had better overall correction than rib-based anchors. There were no differences in the change in patient reported outcomes between spine- and rib-based cohorts.

Cervical Spinal Fusion in Adult Patients With Rheumatoid Arthritis: A National Analysis of Complications and 90-day Readmissions.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to utilize the National Readmission Database to determine the national estimates of complication and 90-day readmission rates associated with cervical spinal fusion in adult patients with rheumatoid arthritis (RA). SUMMARY OF BACKGROUND: RA patients who undergo cervical spine surgery are known to be at high risk for readmissions, which are costly and may not be reimbursed by Medicare. METHODS: The National Readmission Database was queried for adults (>18 years) diagnosed with RA undergoing cervical spine fusion. Patient, operative, and hospital factors were assessed in bivariate analyses. Independent risk factors for readmissions were identified using stepwise multivariate logistic regression. RESULTS: From 2013 to 2014, a total of 5597 RA patients (average age: 61.5 ±â€Š11.2 years, 70.9% female) underwent cervical spine fusion. A total of 691 (12.3%) patients were readmitted within 90 days (). Index inpatient complications included dysphagia (readmitted: 7.9% vs. non-readmitted: 5.1%; P = 0.003), urinary tract infection (UTI) (8.8% vs. 3.7%; P < 0.001), respiratory-related complications (7.6% vs. 3.4%; P < 0.001), and implant-related complications (5.4% vs. 2.7%; P < 0.001). Multivariate logistic regression demonstrated the following as the strongest independent predictors for 90-day readmission: intraoperative bleeding (odds ratio [OR]: 3.6, P = 0.001), inpatient Deep Vein Thrombosis (DVT) (OR 4.1, P = 0.004), and patient discharge against medical advice (OR 33.5, P = 0.001). CONCLUSION: Readmission rates for RA patients undergoing cervical spine surgery are high and most often due to postoperative infection (septicemia, UTI, pneumonia, wound). Potential modifiable factors which may improve outcomes include minimizing intraoperative blood loses, postoperative DVT prophylaxis, and discharge disposition. LEVEL OF EVIDENCE: 3.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk.

PURPOSE: The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome. METHODS: The 2012-2015 NRD databases were queried for all pediatric (< 19 years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions. RESULTS: A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90 days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%). CONCLUSION: This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

The risks, reasons, and costs for 30- and 90-day readmissions after fusion surgery for adolescent idiopathic scoliosis.

OBJECTIVE: With the continued evolution of bundled payment plans, there has been a greater focus within orthopedic surgery on quality metrics up to 90 days of care. Although the Centers for Medicare and Medicaid Services does not currently penalize hospitals based on their pediatric readmission rates, it is important to understand the drivers for unplanned readmission to improve the quality of care and reduce costs. METHODS: The National Readmission Database provides a nationally representative sample of all discharges from US hospitals and allows follow-up across hospitals up to 1 calendar year. Adolescents (age 10-18 years) who underwent idiopathic scoliosis surgery from 2012 to 2015 were included. Patients were separated into those with and those without readmission within 30 days or between 31 and 90 days. Demographics, operative conditions, hospital factors, and surgical outcomes were compared using the chi-square test and t-test. Independent predictors for readmissions were identified using stepwise multivariate logistic regression. RESULTS: A total of 30,677 patients underwent adolescent idiopathic scoliosis surgery from 2012 to 2015. The rates of 30- and 90-day readmissions were 2.9% and 1.4%, respectively. The mean costs associated with the index admission and 30- and 90-day readmissions were $60,680, $23,567, and $16,916, respectively. Common risk factors for readmissions included length of stay > 5 days, obesity, neurological disorders, and chronic use of antiplatelets or anticoagulants. The index admission complications associated with readmissions were unintended durotomy, syndrome of inappropriate antidiuretic hormone, and superior mesenteric artery syndrome. Hospital factors, discharge disposition, and operative conditions appeared to be less important for readmission risk. The top reasons for 30-day and 90-day readmissions were wound infection (34.7%) and implant complications (17.3%), respectively. Readmissions requiring a reoperation were significantly higher for those that occurred between 31 and 90 days after the index readmission. CONCLUSIONS: Readmission rates were low for both 30- and 90-day readmissions for adolescent idiopathic scoliosis surgery patients. Nevertheless, readmissions are costly and appear to be associated with potentially modifiable risk factors, although some risk factors remain potentially unavoidable.

Serial casting for early onset scoliosis and its effects on health-related quality of life during and after discontinuation of treatment.

INTRODUCTION: Serial body casting plays an important role in the treatment of early onset scoliosis (EOS), serving as a safer method compared to surgical intervention. There is no published evidence documenting the impact of casting on health-related quality of life (HRQoL) of patients and their caregivers. The purpose of this study was to utilize the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) to compare the HRQoL of patients with EOS and the burden of care for their caregivers before, during, and after treatment with Mehta casting. METHODS: In this multicenter retrospective cohort study, two EOS databases were queried for patients with EOS who underwent serial casting from 2005 to 2016. Patients who had treatment prior to their initial cast application, including bracing or surgical intervention, were excluded from the study. Patients were stratified into two subgroups and analyzed separately: those with idiopathic etiology, and those with non-idiopathic etiology. HRQoL and burden of care were assessed using the EOSQ-24 completed before, during, and after cast treatment. RESULTS: 91 patients were identified in this study (mean age at the index casting: 2.1 ± 1.2 years, mean age at final cast removal: 4.1 ± 1.3 years). 59 (64.8%) had EOS of idiopathic etiology, while 32 (35.2%) had EOS of non-idiopathic etiology, including 10 congenital, 6 neuromuscular, and 16 syndromic. Idiopathic patients and non-idiopathic patients experienced an improvement in the coronal deformity from 45° pre-cast to 26° post-cast, and from 59° pre-cast to 34° post-cast, respectively. Patients with idiopathic scoliosis experienced a decrease from baseline in nearly all EOSQ-24 sub-domain scores except for general health. Furthermore, even after the removal of the cast, patients with idiopathic etiology suffered residual negative effects of casting on emotion and transfer sub-domains. Among patients with non-idiopathic etiology, decreased scores from baseline were observed only in transfer and emotion sub-domains during the casting intervention. After brace removal, patients with non-idiopathic etiology had increased scores compared to their baseline scores in most sub-domains. DISCUSSION: Serial body casting can prevent curve correction in patients with EOS. However, the psychosocial stresses secondary to this non-operative intervention can have significant negative impacts on HRQoL for both idiopathic and non-idiopathic patients during the course of treatment. Although non-idiopathic patients experience improved HRQoL following treatment, idiopathic patients do not seem to exhibit much improvement in HRQoL from baseline even years after the final cast removal.

The Association Between the Utilization of Traction and Postoperative Complications Following Growing Rod Instrumentation for Early-onset Scoliosis.

BACKGROUND: Preoperative and/or intraoperative traction have been proposed as adjunctive methods to limit complications associated with growth-friendly instrumentation for early-onset scoliosis (EOS). By gradually correcting the deformity before instrumentation, traction can, theoretically, allow for better overall correction without the complications associated with the immediate intraoperative correction. The purpose of this multicenter study was to investigate the association between preoperative/intraoperative traction and complications following growth-friendly instrumentation for EOS. METHODS: Patients with EOS who underwent growth rod instrumentation before 2017 were identified from 2 registries. Patients were divided into 2 groups: preoperative traction group versus no preoperative traction group. A subgroup analysis was done to compare intraoperative traction only versus no traction. Data was collected on any postoperative complication from implantation to up to 2 years postimplantation. RESULTS: Of 381 patients identified, 57 (15%) and 69 (18%) patients received preoperative and intraoperative traction, respectively. After adjusting for etiology and degree of kyphosis, there was no evidence to suggest that preoperative halo traction reduced the risk of any complication following surgical intervention. Although not statistically significant, a subgroup analysis of patients with severe curves demonstrated a trend toward a markedly reduced hardware failure rate in patients undergoing preoperative halo traction [preoperative traction: 1 (3.1%) vs. no preoperative traction: 11 (14.7%), P=0.083]. Nonidiopathic, hyperkyphotic patients treated with intraoperative traction were 61% less likely to experience any postoperative complication (P=0.067) and were 74% (P=0.091) less likely to experience an unplanned return to the operating room when compared with patients treated without traction. CONCLUSIONS: This multicenter study with a large sample size provides the best evidence to date of the association between the use of traction and postoperative complications. Our results justify the need for future Level I studies aimed at characterizing the complete benefit and risk profile for the use of traction in surgical intervention for EOS. LEVEL OF EVIDENCE: Level III.

Variability in stable sagittal vertebra (SSV) during full-length biplanar xrays can affect the choice of fusion levels in patients with adolescent idiopathic scoliosis (AIS).

PURPOSE: Surgical planning for Adolescent Idiopathic Scoliosis (AIS) relies on the coronal and sagittal plane to determine the lowest instrumented vertebra (LIV). Failure to include the stable sagittal vertebra (SSV) within the construct can increase the incidence of postoperative distal junctional kyphosis (DJK). The purpose of this study is to assess the variability of SSV within patients and to identify positional parameters that may lead to its change. METHODS: This is a case-control study of AIS patients with changes in SSV throughout serial radiographs. Radiographic sagittal parameters and hand positioning for the patients with changes in SSV were compared to patients with stable SSV. Additionally, a subgroup analysis was conducted to compare the positional parameters of only the patients with changes in SSV. RESULTS: 46 patients with a mean age of 15 ± 1.8 years old at the time of surgery were included in this study. 33/76 (43.4%) image pairs were found to have a change in SSV. Positional parameters associated with the more distally measured SSV were found to have a more negative sagittal vertebral axis (p = 0.001), more positive pelvic shift (p = 0.023), and more negative Global Sagittal Axis (p = 0.001) when compared to the more proximally measured SSV. CONCLUSION: Significant variability exists in the determination of SSV in AIS patients undergoing serial radiographs. Positional parameters associated with the proximal and distally measured SSV also have variability which indicates that posture has a significant impact on this measure. Surgeons need to be aware of SSV variability during preoperative planning and must consider multiple parameters for the determination of LIV. LEVEL OF EVIDENCE: 3.

Is rod diameter associated with the rate of rod fracture in patients treated with magnetically controlled growing rods?

INTRODUCTION: Few risk factors for fracture in magnetically controlled growing rods (MCGR) have been identified. We hypothesize an increased rate of rod fracture in small diameter rods compared to large diameter rods in patients with early-onset scoliosis (EOS). The purpose of this study was to determine the association between the diameter of MCGR constructs and the rate of rod fracture. METHODS: Patients with EOS who underwent MCGR implantation-primary or conversion-from 2013 to 2018 were identified from two registries including 40 centers. Rod diameter sizes greater than 5.0 mm or less than or equal to 5.0 mm were defined as "Large" and "Small" rods, respectively. Only dual-rod constructs were included. The primary outcome measure collected was rod fracture at any point in treatment up to the most recent follow-up. Cox regression was utilized for unequal follow-up to compare rate of breakage at the last follow-up between cohorts. RESULTS: 527 patients with 1,054 rods were included. 552 (52.4%) rods had a diameter of less than or equal to 5.0 mm and 461 (43.7%) rods had a diameter of greater than 5.0 mm. 41 (3.9%) rods were missing a recorded rod diameter and were not included in the analysis to determine the association between the rate of fracture and rod diameter. 20 (1.9%) total rod fractures occurred: 9 (1.6%) rods with diameters of ≤ 5.0 mm, 10 (2.2%) rods with diameters of > 5.0 mm, and 1 uncategorized rod (p = 0.529). No difference in the rate of rod fracture or survival distribution was found between rod diameters of > 5.0 mm and ≤ 5.0 mm even after stratification by ambulatory status, major coronal curve, weight, or location of anchors. DISCUSSION: Rod fracture appears to be a rare event in dual MCGR constructs and rod diameter does not seem to be associated with the incidence or rate of rod fracture. Surgeons may consider other criteria for selecting rod diameter in their patients such as patient size, amount of surgical correction, single vs. dual constructs, and risk of hardware prominence.