Analysis of Complications in Sacroiliac Joint Fusions Using FDA 510(k) Cleared Devices.

STUDY DESIGN: This was a level III-retrospective cohort study. OBJECTIVE: The objective of this study was to present an unbiased report of the current rate of severe complications for Federal Drug Administration (FDA) 510(k) cleared sacroiliac joint (SIJ) fusions and investigate the underlying cause of these complications. SUMMARY OF BACKGROUND DATA: The number of yearly SIJ fusions is on an upward trend. Currently, the most utilized implants to fuse the SIJ have been FDA 510(k) cleared devices. Studies reporting on complications following SIJ fusions are mostly industry-sponsored. MATERIALS AND METHODS: The Manufacturer and User Facility Device Experience (MAUDE) database was searched for all reported FDA 510(k) cleared SIJ fusion device complications. Several data points were obtained from each report and recorded. The Hospital Inpatient National Statistics and the Center for Medicare and Medicaid Services (CMS) was also searched for the number of SIJ fusions performed each year. RESULTS: A search of the MAUDE database returned 1115 reports, with the first report on June 30, 2011, and the last report on July 28, 2020. Patient injury was the most common type of event reported at 97.5% (1080/1107). Death was reported in 3 patients (0.3%). Malposition was the most common device problem at 49.5% (548/1107). The root cause of these events was primarily user error at 58.2% (644/1107). Revision surgery or reoperation occurred in 92.8% (1028/1107) of reports. Data for SIJ fusions through CMS showed an overall trend of increasing yearly SIJ fusions. CONCLUSIONS: The majority of complications reported to MAUDE for FDA 510(k) cleared SIJ fusion devices are user error due to improper placement of implants. These complications are likely underreported, and there is currently no formal tracking system of total SIJ fusions performed to calculate accurate complication and revision rates. Patient injury and health care costs can potentially be reduced with improved education, training, and oversight, which is currently lacking.

American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) 2020 Summer Conference: Top Abstracts.

In a continuing collaboration between the American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the following 10 abstracts highlight the scientific research presented at AOA's virtual annual national meeting held this past June 2020. These abstracts embody CORD's purpose and mission:"The American Orthopaedic Association's Council of Orthopaedic Residency Directors (CORD) program strives to recognize best practices in orthopaedic residency education and fellowship education based on ACGME [Accreditation Council for Graduate Medical Education]-defined essential knowledge and skills in each of the residency education competency areas. CORD provides a forum for academic orthopaedic leaders to exchange ideas, discuss solutions to challenges, and find ways to teach residents in orthopaedic programs effectively." We hope that this education-related research will inspire further inquiry to advance the development of future orthopaedic surgeons.

Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation.

BACKGROUND: The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis. METHODS: Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software. RESULTS: On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond. CONCLUSION: Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most. CLINICAL RELEVANCE: This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.

Empathy Among Orthopaedic Surgery Trainees.

BACKGROUND: It has been postulated that the process of-and stresses associated with-medical training may cause a loss of empathy among trainees. Because empathy is considered an important value for clinicians and may even be associated with better patient outcomes, we assessed the empathy of orthopaedic surgery trainees and identified factors associated with empathy. METHODS: Between June and September 2020, an anonymous survey was distributed electronically to trainees in 23 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs via the Collaborative Orthopaedic Educational Research Group. The survey comprised the validated Short-Form 8-Item Empathy Quotient (EQ-8) questionnaire-scored on a scale of 0, least empathetic, to 16, most empathetic-and single-item measure of emotional exhaustion and depersonalization derived from the Maslach Burnout Index-scored using a frequency scale. In total, 438 of 605 (72%) trainees completed the survey. The scores were compared via one-way analysis of variance, with Bonferroni correction and Tukey post-hoc testing, α = 0.05. RESULTS: The mean (±SD) EQ-8 score among respondents was 11.3 ± 3.3. Women scored significantly higher (mean, 12.2 ± 2.8) than men (mean, 11.2 ± 3.3) (p = 0.02). Mean scores were significantly higher for trainees planning on a career in academic medicine (12.0 ± 2.9) than those intending to pursue private practice (10.9 ± 3.3) or those with a military commitment (10.4 ± 3.4) (p = 0.01). An inverse relationship was found between EQ-8 scores and single-item Maslach Burnout Index measures in depersonalization and emotional exhaustion (both, p < 0.01). No significant differences were found in EQ-8 scores across postgraduate year, program location, primary training setting, intended fellowship, relationship status, or whether they reported having children. CONCLUSIONS: We found no association between postgraduate year and EQ-8 score. Women and those intending to pursue a career in academic medicine had significantly higher levels of empathy. A significant inverse relationship was found between burnout and empathy. Respondents with higher levels of emotional exhaustion and depersonalization had lower levels of empathy.

American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) 2019 Summer Conference: Top Abstracts.

In a continuing collaboration between the American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the following 10 abstracts highlight the scientific research presented at AOA's annual national meeting that was held in June 2019 in San Diego, California. These abstracts embody CORD's purpose and mission:"The American Orthopaedic Association's Council of Orthopaedic Residency Directors (CORD) program strives to recognize best practices in orthopaedic residency education and fellowship education based on ACGME [Accreditation Council for Graduate Medical Education]-defined essential knowledge and skills in each of the residency education competency areas. CORD provides a forum for academic orthopaedic leaders to exchange ideas, discuss solutions to challenges, and find ways to teach residents in orthopaedic programs effectively." We hope that this education-related research will inspire further inquiry to advance the development of future orthopaedic surgeons.

Community Medical Leadership Workshop: An Introduction to Physician Leadership for Resident Physicians.

Objective The Community Medical Leadership Workshop (CMLW) aims to prepare residents to become effective physician leaders through medical leadership lectures and case scenario discussions. By the end of the CMLW, participants will be able to define leadership in medicine, employ strategies to manage conflict and differences of opinions in the workplace, demonstrate effective communication skills while working with others, and describe the role of power in effective leadership. Methods A total of 32 resident physicians participated in our workshop that is based on the leadership practice inventory (LPI) and the Medical Leadership Competency Framework (MLCF). Our evaluation assessed communication strength, conflict resolution, time management, negotiation, delegation, teamwork, and community service. Results Most participants were satisfied with the course. They rated the workshop's contents the highest. In addition, over 90% of learners would recommend this workshop to others. We found a statistically significant increase in learners' ability to provide opportunities to include patients in quality improvements. Conclusion Our workshop was designed and tailored for resident physicians to introduce them to physician leadership. The workshop was well received and could serve as a model to promote qualities in residents that define effective physician leaders.

Anatomy of the Intermetatarsal Facets of the Fourth and Fifth Metatarsals.

BACKGROUND: The intermetatarsal joint between the fourth and fifth metatarsals (4-5 IM) is important in defining fifth metatarsal fractures. The purpose of the current study was to quantify this joint in order to determine the mean cartilage area, the percentage of the articulation that is cartilage, and to give the clinician data to help understand the joint anatomy as it relates to fifth metatarsal fracture classification. METHODS: Twenty cadaver 4-5 IM joints were dissected. Digital images were taken and the articular cartilage was quantified by calibrated digital imaging software. RESULTS: For the lateral fourth proximal intermetatarsal articulation, the mean area of articulation was 188 ± 49 mm2, with 49% of the area composed of articular cartilage. The shape of the articular cartilage had 3 variations: triangular, oval, and square. A triangular variant was the most common (80%, 16 of 20 specimens). For the medial fifth proximal intermetatarsal articulation, the mean area of articulation was 143 ± 30 mm2, with 48% of the joint surface being composed of articular cartilage. The shape of the articular surface was oval or triangular. An oval variant was the most common (75%, 15 of 20 specimens). CONCLUSION: This study supports the notion that the 4-5 IM joint is not completely articular and has both fibrous and cartilaginous components. CLINICAL RELEVANCE: The clinical significance of this study is that it quantifies the articular surface area and shape. This information may be useful in understanding fifth metatarsal fracture extension into the articular surface and to inform implant design and also help guide surgeons intraoperatively in order to minimize articular damage.

American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) 2018 Conference: Top Abstracts.

This article is a continuation of the collaboration between the American Orthopaedic Association's (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS to highlight selected abstracts presented at the CORD Conference held at the AOA's annual national meeting in June 2018. These abstracts are representative in advancing CORD's purpose and mission:"The American Orthopaedic Association Council of Orthopaedic Residency Directors (CORD) program strives to recognize best practices in orthopaedic residency education and fellowship education based on ACGME [Accreditation Council for Graduate Medical Education]-defined essential knowledge and skills in each of the residency education competency areas. CORD provides a forum for academic orthopaedic leaders to exchange ideas, discuss solutions to challenges, and find ways to effectively teach residents in orthopaedic programs." The following studies were presented at the 2018 Summer CORD Conference in Boston, Massachusetts. They exemplify education-related research and are offered to inspire further inquiry to advance the development of future orthopaedic surgeons.

Case report of an abscess developing at the site of a hematoma following a direct lateral interbody fusion.

BACKGROUND CONTEXT: A direct lateral interbody fusion (DLIF) is relatively new, yet commonly performed procedure in spine surgery. This procedure is associated with risk, including damage to nerve or vascular structures. However, to our knowledge, there has not been a case of an abscess developing at the site of a postoperative hematoma after this procedure. PURPOSE: The objective was to document a case of the delayed presentation of an abscess at the site of a postoperative hematoma after a DLIF. STUDY DESIGN/SETTING: The study was designed to be a case report and literature review. METHODS: We present a case of a 63-year-old patient who developed a large retroperitoneal hematoma after an L2-L5 DLIF. The patient developed a postoperative urinary tract infection with cultures positive for Pseudomonas. The infection was treated with oral antibiotics. Eight months after her procedure, the patient was found to have developed an abscess (measuring 11.6 × 8.4 × 10.0 cm) at the site of the prior hematoma. RESULTS: After radiological-guided aspiration and a 2-week course of oral antibiotics, the abscess resolved and the patient recovered with no sequelae. CONCLUSION: Direct lateral interbody fusion is a minimally invasive procedure that may result in postoperative hematoma formation. We have reported a case of the development of an abscess at the site of a postoperative hematoma.

Return-to-play rates in National Football League linemen after treatment for lumbar disk herniation.

BACKGROUND: There is a paucity of evidence demonstrating clinical outcomes of high-end athletes sustaining a treatment for lumbar disk herniation. PURPOSE: To evaluate the ability of a National Football League lineman to return to play after lumbar diskectomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: National Football League offensive and defensive linemen diagnosed with a lumbar disk herniation were identified by previously published protocols using multiple sources of the public record. Demographic and statistical performance data were compiled for each player both before and after treatment. RESULTS: A total of 66 linemen (36 offensive and 30 defensive) met the inclusion criteria. Fifty-two were treated surgically, and 14 were treated nonsurgically. On average, this group had a body mass index of 35.4 and was 27.6 years old. Of those players treated surgically, 80.8% (42/52) successfully returned to play an average of 33 games over 3.0 years, with 63.5% (33/52) becoming starters after treatment. Conversely, only 28.6% (4/14) of linemen successfully returned to play after nonoperative intervention, which was significantly lower than those treated with a diskectomy (P < .05). Of the linemen in the surgical cohort, 13.5% (7/52) required revision decompression, and 85.7% (6/7) of these players successfully returned to play. CONCLUSION: National Football League linemen have high return-to-play rates after lumbar diskectomy. Furthermore, because those linemen requiring revision decompression successfully returned to play 85.7% of the time, this cohort should not be denied surgical treatment after recurrent problems. Although the data in our study suggest that National Football League linemen who are treated surgically have superior outcomes to those treated nonoperatively, because of the limitations with the methodology used in this study, further prospective studies are necessary to accurately compare treatment effects and to determine the long-term prognosis for these athletes after retirement.

Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients.

STUDY DESIGN: A retrospective study of complications with minimal 5-year follow-up of 50 adults with scoliosis with fusion from T10 or higher to S1. OBJECTIVES: To document the perioperative and long-term complications and instrumentation problems, and to attempt to determine variables which may influence these problems. It is not a study of curve correction, balance, or functional outcome. SUMMARY OF BACKGROUND DATA: Several previous studies from this and other centers have shown a relatively high complication rate for this select group of patients. Various fusion techniques (anterior, posterior, autograft, allograft), various instrumentation techniques, and various immobilization techniques have created confusion as to the best methodology to employ. Minimal 2-year follow-ups have been standard, but longer follow-ups have shown additional problems. METHODS: The study cohort consisted of 50 adult patients from a single center who had undergone corrective scoliosis surgery from T10 or higher to the sacrum and who had at least a 5-year minimum follow-up. The mean age was 54 years (range, 18-72), and the mean follow-up was 9.7 years (range, 5-26). All radiographs, office charts, and hospital charts were combed by an independent investigator for complications, which were divided into major and minor, as well as early, intermediate and late. The curvature values and corrections were the subject of a different article, and were not included in this study. RESULTS: There were no deaths or spinal cord injuries. Six patients had nerve root complications, 4 of which totally recovered. Pseudarthrosis was seen in 24% of the patients, only 25% of which were detected within the 2-year follow-up period. Pseudarthrosis was most common at the lumbosacral level. There was no statistical difference in the pseudarthrosis rate between patients with sacral-only fixation versus iliac fixation. Painful implants requiring removal were noted in 11 of the 50 patients. CONCLUSION: Long fusions to the sacrum in adults with scoliosis continue to have a high complication rate. As compared to the original publications in the 1980s (Kostuik and Hall, Spine 1983;8:489-500; Balderston et al, Spine 1986;11:824-9) the more recent articles have shown a reduction, but not elimination of the pseudarthrosis problem using segmental instrumentation and anterior fusion of the lumbar spine coupled with structural interbody grafting at L4-L5 and L5-S1. Two-year follow-up is inadequate as pseudarthrosis and painful implants often are detected later. Only 3 of the 12 patients with pseudarthrosis were detected within the first 2 years after surgery.

Femoral neck stress fractures: outcome analysis at minimum five-year follow-up.

INTRODUCTION: The complications associated with misdiagnosed or undertreated femoral neck stress fractures in young, active adults have been well documented in the orthopaedic literature. Less is known regarding the outcome of these injuries in patients whose diagnosis was timely and whose treatment was appropriate. METHODS: A sample of 25 patients previously involved in an unrelated study evaluating femoral neck stress fractures were contacted retrospectively 5 to 7 years after their injury. They were asked to complete a self-administered outcome evaluation, the Musculoskeletal Function Assessment (MFA), and answer several specific questions regarding their hips at the present time. Their MFA score was compared with treatment method, fracture type, and bone mineral density (BMD). RESULTS: All 25 patients responded to our inquiries. Of patients, 68% continued to feel "somewhat bothered" by their injury in at least one functional category. Nine patients felt "disabled." No patient has developed avascular necrosis, nonunion, malunion, or posttraumatic arthrosis or was currently under the care of an orthopaedic surgeon. Nine patients had developed stress fractures in other locations. The mean MFA score was 18.80 (range 0 to 63). A lower score corresponds to a patient's perceived higher level of function. Analysis of MFA scores did not reflect statistically significant differences between fracture location, treatment modality, or BMD. CONCLUSIONS: Femoral neck stress fractures can result in devastating problems for young adults. Appropriately treated patients, regardless of treatment method, may have persistent complaints.