Pedicled vastus lateralis myocutaneous flap for sacropelvic defects after wide oncologic resection: Wound complications and outcomes.

BACKGROUND AND OBJECTIVES: Adequate coverage of the soft tissue defects from wide resection of sacropelvic malignancies remains challenging. The vastus lateralis flap has been described for coverage in the setting of trauma and infection. This flap has not been described for coverage of sacropelvic tumor defects. METHODS: This is a retrospective cohort study of adult patients who underwent wide resection of a primary sacropelvic malignancy with reconstruction employing a pedicled vastus lateralis flap at two tertiary care centers. Patient demographics, tumor staging, and rate of complications were assessed. RESULTS: Twenty-eight patients were included, with a median age of 51 years. The most common primary tumor was chondrosarcoma followed by chondroblastic osteosarcoma. The median follow-up was 1.1 years. There were 10 cases of wound infection requiring re-operation and three cases of flap failure. CONCLUSIONS: We describe a pedicled vastus lateralis flap for coverage of defects after wide resection of sacropelvic malignancies. A large proportion of our cohort had independent risk factors for wound complications. Even with a cohort with high baseline risk for wound complications, we show that the use of a pedicled vastus lateralis flap is a safe reconstructive option with a wound complication rate in line with the literature.

Lumbar Spine Sagittal Mismatch Deformity Negatively Affects Total Knee Arthroplasty Outcomes.

There is currently a paucity of data regarding the potential relationships between preexisting spinal deformity and clinical outcomes following total knee arthroplasty (TKA). We sought to expand upon this deficit. We hypothesize that lumbar sagittal mismatch deformity (MD) will correlate with a decrease in functional outcomes after TKA. This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure sagittal parameters of interest: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, and deformity mismatch. Ninety-four TKAs were subsequently available for inclusion and divided into two groups: those with MD as defined by |PI-LL| > 10 degrees and those without MD. The following clinical outcomes were compared between the groups: total postoperative arc of motion (AOM), incidence of flexion contracture, and need for manipulation under anesthesia (MUA). In total, 53 TKAs met the MD criteria, while 41 did not have MD. There were no significant differences in demographics, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with MD were more likely to have MUA (p = 0.026), ROM <0 to 120 (p < 0.001), a decreased AOM by 16 degrees (p < 0.001), and a flexion contracture postoperatively (p = 0.01). Preexisting MD may adversely affect clinical results following TKA. Statistically and clinically significant decreases in postoperative ROM/AOM, increased likelihood of flexion contracture, and increased need for MUA were all noted in those with MD. This is a Level 3 study.

Analysis of Medical Malpractice Outcomes for Sports Orthopedic Procedures.

Orthopedic sports medicine surgeons are especially vulnerable to litigation, largely because of high patient expectations in the setting of complex surgeries. Understanding the factors associated with litigation may reduce physician risk as well as optimize patient satisfaction and outcomes. We used a national medicolegal database to search for medical malpractice verdicts and out-of-court settlements involving common sports injuries and their surgical management between January 1, 2000, and January 1, 2018. Univariate analysis was performed to identify predictors of case outcome and monetary awards. We identified 777 cases, but only 328 met the inclusion criteria. Of the 328 cases included in our study, 231 (70.4%) resulted in a defendant verdict, 75 (22.9%) resulted in a plaintiff verdict, and 22 (6.7%) resulted in a settlement. The most common reason for litigation was intraoperative error (183 cases, 55.8%). No statistically significant difference was found between monetary awards for plaintiff verdicts vs settlements (mean award of $1.29 million and $0.72 million, respectively, P=.07). Cases in which the plaintiff claimed neurovascular injury were significantly more likely to result in a higher monetary award (mean award of $2.37 million, P=.02). Cases involving an incorrect surgical site were significantly less likely to result in a defendant outcome, with 7 of 12 cases (58.3%) leading to a plaintiff outcome (P=.047). With more than two-thirds of cases resulting in a defendant verdict, many suits result in a favorable outcome for practitioners. Intraoperative error is the most common reason for litigation, and neurovascular injury resulted in the highest monetary payouts. Vigilance to avoid these events may improve patient outcomes and decrease liability to practitioners. [Orthopedics. 2022;45(1):e47-e52.].

Severity and location of lumbar spine stenosis affects the outcome of total knee arthroplasty.

BACKGROUND: Recent studies have noted that patients with pre-existing lumbar spinal stenosis (LSS) have lower functional outcomes after total knee arthroplasty (TKA). Given that LSS manifests heterogeneously in location and severity, its influence on knee replacement merits a radiographically targeted analysis. We hypothesize that patients with more severe LSS will have diminished knee mobility before and after TKA. METHODS: This retrospective case series assessed all TKAs performed at our institution for primary osteoarthritis from 2017-2020. Preoperative lumbar magnetic resonance image (MRI) with no prior lumbar spine surgery was necessary for inclusion. Stenosis severity was demonstrated by (1) anterior-posterior (AP) diameter of the thecal sac and (2) morphological grade. TKA outcomes in 103 cases (94 patients) were assessed by measuring preoperative and postoperative arc of motion (AOM), postoperative flexion contracture, and need for manipulation under anesthesia. RESULTS: Patients with mild stenosis did significantly better in terms of postoperative knee AOM. As AP diameter decreased at levels L1-2, L2-3, L3-4, and L4-5, there was a significant reduction in preoperative-AOM (p < 0.001 for each), with a 16 degree decrease when using patients' most stenotic level (p < 0.001). The same was noted with respect to increased morphological grade (p < 0.001), with a 5 degree decrease for patients' most stenotic level (p < 0.001). CONCLUSION: Severe LSS, which is readily demonstrated by a reduction in the AP diameter of the thecal sac or increased morphological grade on MRI, correlated with a significant reduction in preoperative AOM that was not improved after TKA. Persistent postoperative reductions in AOM may contribute to reduced patient satisfaction and recovery. LEVEL OF EVIDENCE: Level 4.

Point-of-care antimicrobial coating protects orthopaedic implants from bacterial challenge.

Implant related infections are the most common cause of joint arthroplasty failure, requiring revision surgeries and a new implant, resulting in a cost of $8.6 billion annually. To address this problem, we created a class of coating technology that is applied in the operating room, in a procedure that takes less than 10 min, and can incorporate any desired antibiotic. Our coating technology uses an in situ coupling reaction of branched poly(ethylene glycol) and poly(allyl mercaptan) (PEG-PAM) polymers to generate an amphiphilic polymeric coating. We show in vivo efficacy in preventing implant infection in both post-arthroplasty infection and post-spinal surgery infection mouse models. Our technology displays efficacy with or without systemic antibiotics, the standard of care. Our coating technology is applied in a clinically relevant time frame, does not require modification of implant manufacturing process, and does not change the implant shelf life.

Updated external validation of the SORG machine learning algorithms for prediction of ninety-day and one-year mortality after surgery for spinal metastasis.

BACKGROUND CONTEXT: Surgical decompression and stabilization in the setting of spinal metastasis is performed to relieve pain and preserve functional status. These potential benefits must be weighed against the risks of perioperative morbidity and mortality. Accurate prediction of a patient's postoperative survival is a crucial component of patient counseling. PURPOSE: To externally validate the SORG machine learning algorithms for prediction of 90-day and 1-year mortality after surgery for spinal metastasis. STUDY DESIGN/SETTING: Retrospective, cohort study PATIENT SAMPLE: Patients 18 years or older at a tertiary care medical center treated surgically for spinal metastasis OUTCOME MEASURES: Mortality within 90 days of surgery, mortality within 1 year of surgery METHODS: This is a retrospective cohort study of 298 adult patients at a tertiary care medical center treated surgically for spinal metastasis between 2004 and 2020. Baseline characteristics of the validation cohort were compared to the derivation cohort for the SORG algorithms. The following metrics were used to assess the performance of the algorithms: discrimination, calibration, overall model performance, and decision curve analysis. RESULTS: Sixty-one patients died within 90 days of surgery and 133 died within 1 year of surgery. The validation cohort differed significantly from the derivation cohort. The SORG algorithms for 90-day mortality and 1-year mortality performed excellently with respect to discrimination; the algorithm for 1-year mortality was well-calibrated. At both postoperative time points, the SORG algorithms showed greater net benefit than the default strategies of changing management for no patients or for all patients. CONCLUSIONS: With an independent, contemporary, and geographically distinct population, we report successful external validation of SORG algorithms for preoperative risk prediction of 90-day and 1-year mortality after surgery for spinal metastasis. By providing accurate prediction of intermediate and long-term mortality risk, these externally validated algorithms may inform shared decision-making with patients in determining management of spinal metastatic disease.

Predictors of Medical Malpractice Outcomes After Spine Surgery: A Comprehensive Analysis From 2010 to 2019.

STUDY DESIGN: Retrospective review of spine surgery malpractice cases. OBJECTIVES: The aim was to compare medical malpractice outcomes among different types of spine surgery and identify predictors of litigation outcomes. SUMMARY OF BACKGROUND DATA: Spine surgery is highly litigious in the United States with data suggesting favorable outcomes for defendant surgeons. However, factor specific data and explanations for plaintiff verdicts are lacking. METHODS: Westlaw legal database was queried for spine surgery malpractice outcomes from 2010 to 2019. Clinical data, reasons for litigation, and legal outcomes were tabulated. Statistical analysis was performed to identify factors associated with litigation outcomes. RESULTS: A total of 257 cases were identified for inclusion. There were 98 noninstrumented and 148 instrumented cases; 110 single-level and 99 multilevel; 83 decompressions, 95 decompression and fusions, and 47 fusion only. In all, 182 (71%) resulted in a defendant verdict, 44 (17%) plaintiff verdict, and 31 (12%) settlement. Plaintiff verdicts resulted in payouts of $2.03 million, while settlements resulted in $1.11 million (P=0.34). Common reasons for litigation were intraoperative error, hardware complication, and improper postoperative management. Cases were more likely to result for the plaintiff if postoperative cauda equina syndrome (55% vs. 26%, P<0.01), a surgical site infection (46% vs. 27%, P=0.03), or other catastrophic injury (40% vs. 26%, P=0.03) occurred. Higher monetary awards were associated with multi versus single-level (median: $2.61 vs. $0.92 million, P=0.01), improper postoperative management cited (median: $2.29 vs. $1.12 million, P=0.04), and permanent neurological deficits ($2.29 vs. $0.78 million, P<0.01). Plaintiff payouts were more likely if defendant specialty was neurosurgery versus orthopedic surgery (33% vs. 18%, P=0.01). CONCLUSIONS: Spine surgery is a litigious field with multiple factors associated with outcomes. Efforts to reduce intraoperative errors and complications may improve patient care and decrease the risk of litigation.

Comparison of two fluorescent probes in preclinical non-invasive imaging and image-guided debridement surgery of Staphylococcal biofilm implant infections.

Implant-associated infections are challenging to diagnose and treat. Fluorescent probes have been heralded as a technologic advancement that can improve our ability to non-invasively identify infecting organisms, as well as guide the inexact procedure of surgical debridement. This study's purpose was to compare two fluorescent probes for their ability to localize Staphylococcus aureus biofilm infections on spinal implants utilizing noninvasive optical imaging, then assessing the broader applicability of the more successful probe in other infection animal models. This was followed by real-time, fluorescence image-guided surgery to facilitate debridement of infected tissue. The two probe candidates, a labelled antibiotic that targets peptidoglycan (Vanco-800CW), and the other, a labelled antibody targeting the immunodominant Staphylococcal antigen A (1D9-680), were injected into mice with spine implant infections. Mice were then imaged noninvasively with near infrared fluorescent imaging at wavelengths corresponding to the two probe candidates. Both probes localized to the infection, with the 1D9-680 probe showing greater fidelity over time. The 1D9-680 probe was then tested in mouse models of shoulder implant and allograft infection, demonstrating its broader applicability. Finally, an image-guided surgery system which superimposes fluorescent signals over analog, real-time, tissue images was employed to facilitate debridement of fluorescent-labelled bacteria.

Evading the host response: Staphylococcus "hiding" in cortical bone canalicular system causes increased bacterial burden.

Extremity reconstruction surgery is increasingly performed rather than amputation for patients with large-segment pathologic bone loss. Debate persists as to the optimal void filler for this "limb salvage" surgery, whether metal or allograft bone. Clinicians focus on optimizing important functional gains for patients, and the risk of devastating implant infection has been thought to be similar regardless of implant material. Recent insights into infection pathophysiology are challenging this equipoise, however, with both basic science data suggesting a novel mechanism of infection of Staphylococcus aureus (the most common infecting agent) into the host lacunar-canaliculi network, and also clinical data revealing a higher rate of infection of allograft over metal. The current translational study was therefore developed to bridge the gap between these insights in a longitudinal murine model of infection of allograft bone and metal. Real-time Staphylococci infection characteristics were quantified in cortical bone vs metal, and both microarchitecture of host implant and presence of host immune response were assessed. An orders-of-magnitude higher bacterial burden was established in cortical allograft bone over both metal and cancellous bone. The establishment of immune-evading microabscesses was confirmed in both cortical allograft haversian canal and the submicron canaliculi network in an additional model of mouse femur bone infection. These study results reveal a mechanism by which Staphylococci evasion of host immunity is possible, contributing to elevated risks of infection in cortical bone. The presence of this local infection reservoir imparts massive clinical implications that may alter the current paradigm of osteomyelitis and bulk allograft infection treatment.

Venous Thromboembolism Chemoprophylaxis Within 24 Hours of Surgery for Spinal Cord Injury: Is It Safe and Effective?

OBJECTIVE: Current guidelines recommend initiation of venous thromboembolism (VTE) chemoprophylaxis within 72 hours of spinal cord injury (SCI). This study investigated the safety and efficacy of chemoprophylaxis within 24 hours of surgery for SCI. METHODS: A retrospective review of 97 consecutive patients who underwent surgery for acute traumatic SCI at a single level 1 trauma center from 2013-2018 was performed. VTE/postoperative bleeding rates during hospitalization, demographics, medical/surgical complications, drain output, length of stay, and disposition were obtained. Chi-square with odds ratios (ORs), 1-way analysis of variance, and logistic regression were performed to establish significant differences between groups. RESULTS: Seventy-nine patients were included, 49 received chemoprophylaxis within 24 hours and 20 within 24-72 hours. Cohort characteristics included an average age of 51.8 years, 77.2% male, 62.0% cervical, and 35.4% thoracic SCIs. Using the American Spinal Injury Association Impairment Scale (AIS), 39.2% were AIS-A injuries, 19.0% AIS-B, 25.3% AIS-C, and 16.5% AIS-D. Unfractionated heparin was administered in 88.6% of patients and 11.4% received low molecular weight heparin. Chemoprophylaxis within 24 hours of surgery was associated with a lower rate of VTE (6.1% vs. 35.0%; OR, 0.121; 95% confidence interval [CI], 0.027-0.535) and deep vein thrombosis (4.1% vs. 30.0%; OR, 0.099; 95% CI, 0.018-0.548) versus 24-72 hours. Pulmonary embolism rates were not significantly different (6.1% vs. 5.0%, p = 1.0). There were no postoperative bleeding complications and no significant difference in drain output between cohorts. CONCLUSION: Early VTE chemoprophylaxis is effective with lower VTE rates when initiated within 24 hours of surgery for SCI and is safe with no observed postoperative bleeding complications.

Delayed Diagnosis Is the Primary Cause of Sarcoma Litigation: Analysis of Malpractice Claims in the United States.

BACKGROUND: Sarcoma care is highly litigated in medical malpractice claims. Understanding the reasons for litigation and legal outcomes in sarcoma care may help physicians deliver more effective and satisfying care to patients while limiting their legal exposure. However, few studies have described malpractice litigation in sarcoma care. QUESTIONS/PURPOSES: (1) What percentage of sarcoma malpractice cases result in a defendant verdict? (2) What is the median indemnity payment for cases that result in a plaintiff verdict or settlement? (3) What are the most common reasons for litigation, injuries sustained, and medical specialties of the defendant physicians? (4) What are the factors associated with plaintiff verdicts or settlements and higher indemnity payments? METHODS: The national medicolegal database Westlaw was queried for medical malpractice cases pertaining to sarcomas that reached verdicts or settlements. Cases from 1982 to 2018 in the United States were included in the study to evaluate for trends in sarcoma litigation. Demographic and clinical data, tumor characteristics, reasons for litigation, injuries, and legal outcomes were recorded for each case. A univariate analysis was performed to identify factors associated with plaintiff verdicts or settlements and higher indemnity payments, such as tumor characteristics, defendant's medical or surgical specialty, reason for litigation, and injuries sustained. A total of 92 cases related to sarcomas were included in the study, of which 40 were related to bone sarcomas and 52 were related to soft-tissue sarcomas. Eighty-five percent (78 of 92) of cases involved adult patients (mean age ± SD: 40 ± 15 years) while 15% (14 of 92) of cases involved pediatric patients (mean age ± SD: 12.5 ± 5 years). RESULTS: Thirty-eight percent (35 of 92) of the included cases resulted in a defendant verdict, 30% (28 of 92) resulted in a plaintiff verdict, and 32% (29 of 92) resulted in a settlement. The median (interquartile range [IQR]) indemnity payment for plaintiff verdicts and settlements was USD 1.9 million (USD 0.5 to USD 3.5 million). Median (IQR) indemnity payments were higher for cases resulting in a plaintiff verdict than for cases that resulted in a settlement (USD 3.3 million [1.1 to 5.7 million] versus USD 1.2 million [0.4 to 2.4 million]; difference of medians = USD 2.2 million; p = 0.008). The most common reason for litigation was delayed diagnosis of sarcoma (91%; 84 of 92) while the most common injuries cited were progression to metastatic disease (51%; 47 of 92) and wrongful death (41%; 38 of 92). Malpractice claims were most commonly filed against primary care physicians (26%; 28 of 109 defendants), nononcology-trained orthopaedic surgeons (23%; 25 of 109), and radiologists (15%; 16 of 109). Cases were more likely to result in a ruling in favor of the plaintiff or settlement if a delay in diagnosis occurred despite suspicious findings on imaging or pathologic findings (80% versus 51%; odds ratio 3.84 [95% CI 1.34 to 11.03]; p = 0.02). There were no differences in indemnity payments with the numbers available in terms of tumor type, tumor location, defendant specialty, reason for litigation, and resulting injuries. CONCLUSIONS: Many lawsuits were made against primary care physicians, nononcology-trained orthopaedic surgeons, or radiologists for a delayed diagnosis of sarcoma despite the presence of imaging or histologic findings suspicious for malignancy. Although previous studies of bone and soft-tissue sarcomas have not shown a consistent association between time to diagnosis and decreased survival, our study suggests that physicians are still likely to lose these lawsuits because of the perceived benefits of an early diagnosis. CLINICAL RELEVANCE: Physicians can mitigate their malpractice risk while reducing delays in diagnosis of sarcomas by carefully reviewing all existing diagnostic studies, establishing closed-loop communication protocols to communicate critical findings from diagnostic studies, and developing policies to facilitate second-opinion consultation, particularly for imaging studies, with an experienced sarcoma specialist. Musculoskeletal oncologists may be able to help further reduce the rates of malpractice litigation in sarcoma care by helping patients understand that delays in diagnosis do not necessarily constitute medical malpractice.

Novel in vivo mouse model of shoulder implant infection.

BACKGROUND: Animal models are used to guide management of periprosthetic implant infections. No adequate model exists for periprosthetic shoulder infections, and clinicians thus have no preclinical tools to assess potential therapeutics. We hypothesize that it is possible to establish a mouse model of shoulder implant infection (SII) that allows noninvasive, longitudinal tracking of biofilm and host response through in vivo optical imaging. The model may then be employed to validate a targeting probe (1D9-680) with clinical translation potential for diagnosing infection and image-guided débridement. METHODS: A surgical implant was press-fit into the proximal humerus of c57BL/6J mice and inoculated with 2 µL of 1 × 103 (e3), or 1 × 104 (e4), colony-forming units (CFUs) of bioluminescent Staphylococcus aureus Xen-36. The control group received 2 µL sterile saline. Bacterial activity was monitored in vivo over 42 days, directly (bioluminescence) and indirectly (targeting probe). Weekly radiographs assessed implant loosening. CFU harvests, confocal microscopy, and histology were performed. RESULTS: Both inoculated groups established chronic infections. CFUs on postoperative day (POD) 42 were increased in the infected groups compared with the sterile group (P < .001). By POD 14, osteolysis was visualized in both infected groups. The e4 group developed catastrophic bone destruction by POD 42. The e3 group maintained a congruent shoulder joint. Targeting probes helped to visualize low-grade infections via fluorescence. DISCUSSION: Given bone destruction in the e4 group, a longitudinal, noninvasive mouse model of SII and chronic osteolysis was produced using e3 of S aureus Xen-36, mimicking clinical presentations of chronic SII. CONCLUSION: The development of this model provides a foundation to study new therapeutics, interventions, and host modifications.

Implications of sagittal alignment and complication profile with stand-alone anterior lumbar interbody fusion versus anterior posterior lumbar fusion.

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is commonly utilized in lumbar degenerative pathologies. Standalone ALIF (ST-ALIF) systems were developed to avoid added morbidity, surgical time, and cost of anterior and posterior fusion (APF). Controversy exists in the literature about which of these two techniques yields superior clinical and radiographic outcomes, and few studies have directly compared them. This study seeks to compare ST-ALIF and APF in terms of sagittal correction and surgical complications. METHODS: Ninty-two consecutive ALIF cases performed from 2013-2018 were retrospectively reviewed and separated into 2 groups. Radiographic measurements were performed on pre- and post-operative radiographs, including segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence-lumbar lordosis mismatch (PI-LL). Surgical complications were determined. Statistical analysis was performed using chi-square test of homogeneity, Fisher's exact test, and independent sample t-test. Comparisons between groups were deemed statistically significant at the P<0.05 threshold. RESULTS: Fifty-seven ST-ALIF, 35 APF were identified. There were no differences in age, gender, BMI, Charlson Comorbidity Index (CCI), preoperative diagnosis, or surgical level between the 2 cohorts. Bone Morphogenetic Protein (BMP) was utilized in 24.6% of ST-ALIF versus none of APF (P=0.001). No differences were detected in SL, LL, and PI-LL mismatch. ST-ALIF cohort had significantly greater risk of subsidence and revision surgery versus APF (12.3% vs. 0%, RD 95% CI: 3.8-20.8%, P=0.042). Recurrent spondylolisthesis occurred in 5 ST-ALIF cases, 3 cases with implant failure, and 2 nonunions versus none in the APF group. CONCLUSIONS: ST-ALIF was associated with significantly greater subsidence and revision surgery versus APF. Careful patient selection is paramount when considering ST-ALIF. The potential for revision surgery may offset the potential benefit in avoiding posterior fusion. Despite the greater risk of subsidence, sagittal alignment was not significantly affected.

Progress not panacea: vancomycin powder efficacy and dose evaluated in an in vivo mouse model of spine implant infection.

BACKGROUND: Intrawound vancomycin powder (VP) has been rapidly adopted in spine surgery with apparent benefit demonstrated in limited, retrospective studies. Randomized trials, basic science, and dose response studies are scarce. PURPOSE: This study aims to test the efficacy and dose effect of VP over an extended time course within a randomized, controlled in vivo animal experiment. STUDY DESIGN/SETTING: Randomized controlled experiment utilizing a mouse model of spine implant infection with treatment groups receiving vancomycin powder following bacterial inoculation. METHODS: Utilizing a mouse model of spine implant infection with bioluminescent Staphylococcus aureus, 24 mice were randomized into 3 groups: 10 infected mice with VP treatment (+VP), 10 infected mice without VP treatment (No-VP), and 4 sterile controls (SC). Four milligrams of VP (mouse equivalent of 1 g in a human) were administered before wound closure. Bioluminescence imaging was performed over 5 weeks to quantify bacterial burden. Electron microscopy (EM), bacterial colonization assays (Live/Dead) staining, and colony forming units (CFU) analyses were completed. A second dosing experiment was completed with 34 mice randomized into 4 groups: control, 2 mg, 4 mg, and 8 mg groups. RESULTS: The (+VP) treatment group exhibited significantly lower bacterial loads compared to the control (No-VP) group, (p<.001). CFU analysis at the conclusion of the experiment revealed 20% of mice in the +VP group and 67% of mice in the No-VP group had persistent infections, and the (+VP) treatment group had significantly less mean number of CFUs (p<.03). EM and Live/Dead staining revealed florid biofilm formation in the No-VP group. Bioluminescence was suppressed in all VP doses tested compared with sterile controls (p<.001). CFU analysis revealed a 40%, 10%, and 20% persistent infection rate in the 2 mg, 4 mg, and 8 mg dose groups, respectively. CFU counts across dosing groups were not statistically different (p=.56). CONCLUSIONS: Vancomycin powder provided an overall infection prevention benefit but failed to eradicate infection in all mice. Furthermore, the dose when halved also demonstrated an overall protective benefit, albeit at a lower rate. CLINICAL SIGNIFICANCE: Vancomycin powder is efficacious but should not be viewed as a panacea for perioperative infection prevention. Dose alterations can be considered, especially in patients with kidney disease or at high risk for seroma.

The Use of a Novel Antimicrobial Implant Coating In Vivo to Prevent Spinal Implant Infection.

STUDY DESIGN: A controlled, interventional animal study. OBJECTIVE: Spinal implant infection (SII) is a devastating complication. The objective of this study was to evaluate the efficacy of a novel implant coating that has both a passive antibiotic elution and an active-release mechanism triggered in the presence of bacteria, using an in vivo mouse model of SII. SUMMARY OF BACKGROUND DATA: Current methods to minimize the frequency of SII include local antibiotic therapy (vancomycin powder), betadine irrigation, silver nanoparticles, and passive release from antibiotic-loaded poly(methyl methacrylate) cement beads, all of which have notable weaknesses. A novel implant coating has been developed to address some of these limitations but has not been tested in the environment of a SII. METHODS: A biodegradable coating using branched poly(ethylene glycol)-poly(propylene sulfide) (PEG-PPS) polymer was designed to deliver antibiotics. The in vivo performance of this coating was tested in the delivery of either vancomycin or tigecycline in a previously established mouse model of SII. Noninvasive bioluminescence imaging was used to quantify the bacterial burden, and implant sonication was used to determine bacterial colony-forming units (CFUs) from the implant and surrounding bone and soft tissue. RESULTS: The PEG-PPS-vancomycin coating significantly lowered the infection burden from postoperative day 3 onwards (P < 0.05), whereas PEG-PPS-tigecycline only decreased the infection on postoperative day 5 to 10 (P < 0.05). CFUs were lower on PEG-PPS-vancomycin pins than PEG-PPS-tigecycline and PEG-PPS pins alone on both the implants (2.4 × 10, 8.5 × 10, and 1.0 × 10 CFUs, respectively) and surrounding bone and soft tissue (1.3 × 10, 4.8 × 10, and 5.4 × 10 CFUs, respectively) (P < 0.05). CONCLUSION: The biodegradable PEG-PPS coating demonstrates promise in decreasing bacterial burden and preventing SII. The vancomycin coating outperformed the tigecycline coating in this model compared to prior work in arthroplasty models, highlighting the uniqueness of the paraspinal infection microenvironment. LEVEL OF EVIDENCE: N/A.

Implant Engineering in the Age of Biologics.

Implants and their technological advances have been a critical component of musculoskeletal care for almost a century. Modern implants are designed to enhance bone ingrowth, promote soft-tissue healing, and prevent infection. Porous metals and short-stem fixation devices have rendered previously unreconstructable bony deficits reconstructable. Stem cells, growth factors, and novel biocompatible compounds have been designed to promote and enhance soft tissue attachment to implants. Antimicrobial modifications have been engineered onto implants to deter bacterial attachment, and innovative surface modifications and eluting technologies may be in our near future. Yet, given the enormous economic pressures in orthopaedics, marketing claims of innovation often exceed scientific accomplishment. Vigilance is thus required in distinguishing transformational discovery from unsubstantiated claims.

Multimodal imaging guides surgical management in a preclinical spinal implant infection model.

Spine implant infections portend disastrous outcomes, as diagnosis is challenging and surgical eradication is at odds with mechanical spinal stability. Current imaging modalities can detect anatomical alterations and anomalies but cannot differentiate between infection and aseptic loosening, diagnose specific pathogens, or delineate the extent of an infection. Herein, a fully human monoclonal antibody 1D9, recognizing the immunodominant staphylococcal antigen A on the surface of Staphylococcus aureus, was assessed as a nuclear and fluorescent imaging probe in a preclinical model of S. aureus spinal implant infection, utilizing bioluminescently labeled bacteria to confirm the specificity and sensitivity of this targeting. Postoperative mice were administered 1D9 probe dual labeled with 89-zirconium (89Zr) and a near infrared dye (NIR680) (89Zr-NIR680-1D9), and PET-CT and in vivo fluorescence and bioluminescence imaging were performed. The 89Zr-NIR680-1D9 probe accurately diagnosed both acute and subacute implant infection and permitted fluorescent image-guided surgery for selective debridement of infected tissue. Therefore, a single probe could noninvasively diagnose an infection and facilitate image-guided surgery to improve the clinical management of implant infections.

Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States.

BACKGROUND: Intraoperative neuromonitoring (ION), such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP), and electromyography (EMG), is used to detect impending neurological injuries during spinal surgery. To date, little is known about the trends in the use of ION for scoliosis surgery in the United States. METHODS: A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. RESULTS: There were 3618 patients who had scoliosis surgery during the study period. Intraoperative neuromonitoring was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (P < .0001). Multimodal ION was used more commonly than unimodal ION (64.6% versus 35.4%). The most commonly used modality was combined SSEP and EMG, while the least used modality was MEP only. Neurological injuries occurred in 1.8 and 2.0% of patients that had surgery with and without ION, respectively (P = .561). Intraoperative neuromonitoring was used most commonly in patients <65 years of age and in the Northeastern part of the United States (age P = .006, region P < .0001). CONCLUSIONS: The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in nonelderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.

A Comparison of Defense and Plaintiff Expert Witnesses in Orthopaedic Surgery Malpractice Litigation.

BACKGROUND: According to the American Academy of Orthopaedic Surgeons (AAOS) Standards of Professionalism, the responsible testimony of expert witnesses in orthopaedic surgery malpractice lawsuits is important to the public interest. However, these expert witnesses are recruited and compensated without established standards, and their testimony can potentially sway court opinion, with substantial consequences. The objective of this study was to characterize defense and plaintiff expert orthopaedic surgeon witnesses in orthopaedic surgery malpractice litigation. METHODS: Utilizing the WestlawNext legal database, defense and plaintiff expert witnesses involved in orthopaedic surgery malpractice lawsuits from 2013 to 2017 were identified. Each witness's subspecialty, mean years of experience, involvement in academic or private practice, fellowship training, and scholarly impact, as measured by the Hirsch index (h-index), were determined through a query of professional profiles, the Scopus database, and a PubMed search. Statistical comparisons were made for each parameter among defense and plaintiff expert witnesses. RESULTS: Between 2013 and 2017, 306 expert medical witnesses for orthopaedic cases were identified; 174 (56.9%) testified on behalf of the plaintiff, and 132 (43.1%) testified on behalf of the defense. Orthopaedic surgeons who identified themselves as general orthopaedists comprised the largest share of expert witnesses on both the plaintiff (n = 61) and defense (n = 25) sides. The plaintiff witnesses averaged 36 years of experience versus 31 years for the defense witnesses (p < 0.001); 26% of the plaintiff witnesses held an academic position versus 43% of the defense witnesses (p = 0.013). Defense witnesses exhibited a higher proportion of fellowship training in comparison to plaintiff expert witnesses (80.5% versus 64.5%, respectively, p = 0.003). The h-index for the plaintiff group was 6.6 versus 9.1 for the defense group (p = 0.04). Two witnesses testified for both the plaintiff and defense sides. CONCLUSIONS: Defense expert witnesses held higher rates of academic appointments and exhibited greater scholarly impact than their plaintiff counterparts, with both sides averaging >30 years of experience. These data collectively show that there are differences in characteristics between plaintiff and defense witnesses. Additional study is needed to illuminate the etiology of these differences.

Does approach matter? A comparative radiographic analysis of spinopelvic parameters in single-level lumbar fusion.

BACKGROUND CONTEXT: Lumbar fusion is a popular and effective surgical option to provide stability and restore anatomy. Particular attention has recently been focused on sagittal alignment and radiographic spinopelvic parameters that apply to lumbar fusion as well as spinal deformity cases. Current literature has demonstrated the effectiveness of various techniques of lumbar fusion; however, comparative data of these techniques are limited. PURPOSE: This study aimed to directly compare the impact of various lumbar fusion techniques (anterior lumbar interbody fusion [ALIF], lateral lumbar interbody fusion [LLIF], transforaminal lumbar interbody fusion [TLIF], and posterolateral fusion [PLF]) based on radiographic parameters. STUDY DESIGN/SETTING: A single-center retrospective study examining preoperative and postoperative radiographs was carried out. PATIENT SAMPLE: A consecutive list of lumbar fusion surgeries performed by multiple spine surgeons at a single institution from 2013 to 2016 was identified. OUTCOME MEASURES: Radiographic measurements used included segmental lordosis (SL), lumbar lordosis (LL), pelvic incidence (PI), pelvic incidence-lumbar lordosis (PI-LL) mismatch, anterior and posterior disc height (DH-A, DH-P, respectively), and foraminal height (FH). METHODS: Radiographic measurements were performed on preoperative and postoperative lateral lumbar radiographs on all single-level lumbar fusion cases. Demographic data were collected including age, gender, approach, diagnosis, surgical level, and implant lordosis. Paired sample t test, one-way analysis of variance (ANOVA), McNemar test, and independent sample t test were used to establish significant differences in the outcome measures. Multiple linear regression was performed to determine a predictive model for lordosis from implant lordosis, fusion technique, and surgical level. RESULTS: There were 164 patients (78 men, 86 women) with a mean age of 60.1 years and average radiographic follow-up time of 9.3 months. These included 34 ALIF, 23 LLIF, 63 TLIF, and 44 PLF surgeries. ALIF and LLIF significantly improved SL (7.9° and 4.4°), LL (5.5° and 7.7°), DH-A (8.8 mm and 5.8 mm), DH-P (3.4 mm and 2.3 mm), and FH (2.8 mm and 2.5 mm), respectively (p≤.003). TLIF significantly improved these parameters, albeit to a lesser extent: SL (1.7°), LL (2.7°), DH-A (1.1 mm), DH-P (0.8 mm), and FH (1.1 mm) (p≤.02). PLF did not significantly alter any of these parameters while significantly reducing FH (-1.3 mm, p=.01). One-way ANOVA showed no significant differences between ALIF and LLIF other than ALIF with greater ΔDH-A (3.0 mm, p=.02). Both ALIF and LLIF significantly outperformed PLF in preoperative to postoperative changes in all parameters p≤.001. Additionally, ALIF significantly outperformed TLIF in the change in SL (6.2°, p<.001), and LLIF significantly outperformed TLIF in the change in LL (5.0°, p=.02). Both outperformed TLIF in ΔDH-A (7.7 mm and 4.7 mm) and ΔDH-P (2.6 mm and 1.5 mm), respectively (p≤.02). ALIF was the only fusion technique that significantly improved the proportion of patients with a PI-LL<10° (0.410.66, p=.02). Lordotic cages had superior improvement of all parameters compared with non-lordotic cages (p<.001). Implant lordosis (m=1.1), fusion technique (m=6.8), and surgical level (m=6.9) significantly predicted postoperative SL (p<.001, R2=0.56). CONCLUSIONS: This study demonstrated that these four lumbar fusion techniques yield divergent radiographic results. ALIF and LLIF produced greater improvements in radiographic measurements postoperatively compared with TLIF and PLF. ALIF was the most successful in improving PI-LL mismatch, an important parameter relating to sagittal alignment. Lordotic implants provided better sagittal correction and surgeons should be cognizant of the impact that these differing implants and techniques produce after surgery. Surgical technique is an important determinant of postoperative alignment and has ramifications upon sagittal alignment in lumbar fusion surgery.