Evaluation of a Slipped Capital Femoral Epiphysis Virtual Reality Surgical Simulation for the Orthopaedic Trainee.

OBJECTIVE: The purpose of this study was to compare outcomes between orthopaedic trainees using various preoperative training platforms (physical simulation [PS], virtual reality [VR], and reading/videos) in a slipped capital femoral epiphysis model. METHODS: Participants were randomly assigned to one of the three groups: (1) reading/video control group (n = 7), (2) VR group (n = 7), or (3) PS group (n = 7). Participants in the VR group completed a VR slipped capital femoral epiphysis module while participants in the PS group practiced the placement of a screw in the physical module before evaluation of percutaneous screw placement in the PS model. Outcomes evaluated included overall surgical time, amount of fluoroscopy, Global Rating Scale score, radiographic screw position, physical screw accuracy, presence of breeching of the articular surface or femoral neck, and overall platform rating (0 to 10). RESULTS: No difference was observed in surgical time, Global Rating Scale score, radiographic or physical accuracy of screw position, or articular surface breaching between the groups. Subjectively, there was a difference in utility of platform rating between the groups (PS: 10 ± 0, VR: 7 ± 2, and control: 6 ± 1, P = 0.001). CONCLUSION: Training with VR was subjectively rated higher in value compared with reading/video methods and had similar performance outcomes compared with training with PS.

Treatment of an Extruded Middle Phalanx Epiphysis in a 6-Year-Old Boy: A Case Report.

CASE: A Salter-Harris II fracture of the small finger middle phalanx with complete extrusion of the epiphyseal fragment in a 6-year-old boy is described. Closed reduction was unsuccessful. Open reduction was performed, the epiphysis was reduced, and a single Kirschner wire was placed obliquely across the fracture and joint. CONCLUSION: This is an extremely rare injury. Open reduction and pinning was successful in preserving functional range of motion. Despite eventual growth arrest, there was no clinically significant angular deformity, and the joint was preserved. Surgical technique and early hand therapy allowed the patient to return to high-level activity without pain or functional limitation thus far at the 27-month follow-up.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA). SUMMARY OF BACKGROUND DATA: Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication. METHODS: AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared. RESULTS: There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation. CONCLUSION: This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Interlocking Fixation in Fassier-Duval Rods: Performance and Success Factors.

INTRODUCTION: Pediatric patients with osteogenesis imperfecta (OI) can be treated with intramedullary Fassier-Duval rod (FDR) systems for limb deformity or recurrent fractures. Single-interlocking pins can improve epiphyseal fixation, but there is a paucity of literature examining incidence of rod migration or pin backout long-term. The purpose of this study is to quantify rates of rod migration and pin backout in OI patients treated with single-interlocking FDRs. METHODS: A retrospective chart review was performed on pediatric patients treated at a tertiary care center across a 15-year period. Inclusion criteria to select patients was: (1) Pediatric patients (below 18 y of age); (2) Patients with confirmed OI; and (3) Patients with lower extremity fractures or deformity treated with FDRs with distal interlocking pins. Age at time of surgery, rates of obturator migration and pin backout and prominence were collected. We recorded if pin tips were bent by the surgeon during the procedure. Bivariate statistics were used to analyze risk factors for pin backout and prominence. RESULTS: Twenty-four single-interlocking pin FDRs (21 tibia, 3 femur) were identified. The mean age at index surgery was 5.7±3.4 years, with the mean follow-up time of 7.2±4.7 years. Fourteen (58%) rods underwent revision surgery. Obturator proximal migration was observed in 3/24 rods (13%). No cases of obturator distal migration were observed (0/24, 0%). Mean proximal obturator migration was 2.16±1.8 cm. Revision for pin backout was observed in 10 (42%) rods and pin prominence in 11 (46%) extremities. Bending interlocking pins on at least 1 end was associated with decreased pin backout (P=0.01) and prominence (P=0.04). CONCLUSIONS: Even with distal interlocking pins, the obturator of FDRs can still migrate over time. Pin backout is a common indication for revision surgery. Bending interlocking pins can decrease rates of pin backout and prominence. LEVEL OF EVIDENCE: Level III.

Association of Disposable Perioperative Jackets With Surgical Site Infections in a Large Multicenter Health Care Organization.

Importance: To help prevent surgical site infections (SSIs), recommendations by a national organization led to implementation of a mandatory operating room policy in a large multicenter health care organization of required use of disposable perioperative jackets. Objective: To assess whether the use of perioperative disposable jackets is associated with the incidence of SSIs. Design, Setting, and Participants: Surgical site infection data for patients undergoing clean surgical procedures were retrospectively reviewed from 12 hospitals in a large multicenter health care organization during a 55-month period from January 1, 2014, to July 31, 2018. The incidence of SSI was analyzed for all National Healthcare Safety Network monitored and reported procedures. The patient population was split into 2 groups; the preintervention group consisted of 29 098 patients within the 26 months before the policy starting March 1, 2016, and the postintervention group consisted of 30 911 patients within 26 months after the policy. Main Outcome and Measures: Comparison of the incidence of SSIs before and after intervention periods underwent statistical analysis. The total number of disposable jackets purchased and total expenditures were also calculated. Exposures: Implementation of the mandated perioperative attire policy. Results: A total of 60 009 patients (mean [SD] age, 62.8 [13.9] years; 32 139 [53.6%] male) were included in the study. The overall SSI incidence for clean wounds was 0.87% before policy implementation and 0.83% after policy implementation, which was not found to be significant (odds ratio [OR], 0.96; 95% CI, 0.80-1.14; P = .61). After accounting for possible confounding variables, a multivariable analysis demonstrated no significant reduction in SSIs (OR, 0.85; 95% CI, 0.71-1.01; P = .07). During the postintervention study period (26 months), a total of 2 010 040 jackets were purchased, which amounted to a cost of $1 709 898.46. Conclusions and Relevance: The results of this study suggest that the use of perioperative disposable jackets is not associated with reductions in SSI for clean wounds in a large multicenter health care organization and presents a fiscal burden.

Impact of a Resident-Guided Rounding Initiative on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey Scores in Orthopaedic Surgery Inpatients.

Patient-centered medicine is becoming the main focus of many healthcare systems, and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a tool used to track patient satisfaction. In this study, we evaluate the HCAHPS scores in orthopaedic surgery inpatients before and after implementation of a resident-guided rounding protocol. Analyses of the HCAHPS surveys for 154 orthopaedic surgical inpatients at one community hospital were compared 6 months before and after implementation of a resident-guided rounding initiative. Specific questions of the HCAHPS survey were analyzed using the top box, mean, and positive scores. Implementation of the rounding initiative resulted in an increase in the top box, mean, and positive scores for all questions evaluated; however, no significance was noted in the results, with the exception of the positive score for a staff cohesiveness question (P = 0.046). Physician and hospital recommendation questions showed a 5-point increase (91st to 96th percentile) compared with 42-point increase (21st to 63rd percentile) by publicly reported national data. Implementation of the rounding initiative resulted in increases in HCAHPS scores across multiple questions and domains; however, these were not significant. These results suggest that simple interventions can help increase the overall patient satisfaction and promote future investigations.

A comparison of lumbar transverse pedicle angles between ethnic groups: a retrospective review.

BACKGROUND: Spinal surgery requires an intimate understanding of pedicle morphology to provide safe and effective outcomes. Although current research has attempted to identify morphological vertebral pedicle trends, no study has utilized computed tomography (CT) scans to compare the lumbar transverse pedicle angle (TPA) with patient demographics factors in a diverse population throughout multiple hospital centers. METHODS: Analysis of randomly selected CT scans from L1-L5 of 97 individuals who underwent imaging over a two-week period for non-back pain related complaints was conducted. Measuring 970 TPAs in total allowed for comparison of each patients' pedicle angle with important patient specific demographics including ethnicity, age, gender, height and weight. Statistical analysis utilized multiple comparisons of demographics at each level with post-hoc Bonferroni correction analysis to compare demographics at each level. RESULTS: With relation to gender, age, height or weight, no statistically significant differences were identified for TPAs at any vertebral level. However, when stratified by ethnicity, the differences in transverse pedicle angles averages (TPA -Avg) at L2 and L3 were found to be statistically significant (p < 0.05). CONCLUSION: We have identified a previously unknown and significant relationship between ethnicity and TPA at lumbar vertebral levels. These findings provide critical information that may be added to the operating surgeons' knowledge of pedicle morphology. We hope this novel information can assist in preoperative planning of pedicle screw placement and potentially help improve surgical outcomes.

Demographic Analysis of Lumbar Pedicle Diameters in a Diverse Population.

STUDY DESIGN: Retrospective chart review. PURPOSE: We sought to determine the differences in pedicle diameter (PD) in the lumbar spine between various races: 'Asian,' 'Black,' 'White,' and 'Other.' These data could aid in perioperative planning during instrumented spinal fusion. OVERVIEW OF LITERATURE: Recent literature underscores the importance of understanding diverse pedicle isthmus morphology to perform successful transpedicular procedures. These studies suggest that more detailed and reliable measurements of pedicles should be undertaken. However, none of the current literature comprehensively compares average PDs between diverse racial populations with a standardized study design. METHODS: Coronal cuts of 5,060 lumbar spine pedicles were inspected to obtain their transverse outer cortical PD as measured through the isthmus at L1-L5. Data were collected and categorized on the basis of patient-reported race. We examined average PD and PD range at each level for each race. To determine the significance, we used a mixed analysis of variance and a post hoc analysis. RESULTS: The Asian cohort consistently had a significantly smaller PD at L1-L5 than Blacks or Whites (p<0.001), as did the 'Other' group compared with Blacks (p<0.001) and Whites (p=0.032). At L1-L2, the 'Other' group showed the least variability in PD. At L3-L5, the Asian population showed the smallest range, and the Black population had the largest variability in PD except at L5. There was a significant difference in PD between the various races. CONCLUSIONS: The Asian population consistently has significantly smaller pedicles in the lumbar spine than the Black or White populations. This information could prove useful for surgical planning. We suggest using preoperative computed tomography for pedicle screw templating as a safe method for pedicle screw instrumentation with the highest pullout strength given the wide range of PD in the Black population and the variability of PD between races.