Journal of the American Academy of Orthopaedic Surgeons最新文献

Anterior cruciate ligament (ACL) injuries continue to increase in incidence despite extensive research into prevention strategies. Many extrinsic and intrinsic risk factors for sustaining ACL injuries have been identified and continue to be investigated. Extrinsic risk factors for ACL injury relate to the athlete's environment, such as the shoe-surface interaction, weather conditions, and sport played. Intrinsic risk factors relate to the athlete's sex, hormones, knee anatomy, landing and pivoting biomechanics, and neuromuscular control. Recent research has highlighted the role of the bony morphology of the proximal tibia and distal femur on primary ACL injury risk, as well as the risk for ACL graft failure. Sex differences in bony and ligamentous morphology of the knee, neuromuscular control, and hormonal factors, such as serum relaxin levels and variations within the menstrual cycle, have been correlated with a higher risk of noncontact primary ACL injuries in female athletes compared with male athletes.

Osteoporosis is a global health problem affecting over 200 million people worldwide and 54 million adults in the United States. Approximately half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime. In the United States, the direct medical cost related to osteoporosis is expected to exceed $25 billion by 2025. Management of osteoporosis in vertebral fractures and elective spine surgery is of the utmost concern, given the high prevalence of osteoporosis in the general population and the increased risk of complication in this population. New pharmacologic treatment options such as anabolic medications and diagnostic tools including Hounsfield unit measurements on routine computed tomography scans are available to orthopaedic and spinal surgeons to help best manage this condition. This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery.

Introduction: The surgical management of severe scoliosis in patients with osteogenesis imperfecta (OI) is challenging because of curve rigidity, small stature, and inherent bone fragility. This study evaluated the midterm outcomes of our multimodal approach to address these issues, integrating perioperative bisphosphonate therapy, preoperative/intraoperative traction, various osteotomies, segmental pedicle screw instrumentation with cement augmentation, and bone morphogenetic protein-2 application.

Methods: A single-center retrospective review of 30 patients (average age 14.1 ± 2.2 years; 18 were female) diagnosed with OI and scoliosis was conducted. These patients underwent posterior spinal fusion between 2008 and 2020 and completed a minimum follow-up of 2 years. We measured radiographic parameters at each visit and reviewed the incidence of complications. A mixed-effects model was used to evaluate changes in radiographic parameters from preoperative measurements to the first and latest follow-ups.

Results: The patient cohort consisted of 2 individuals with type I OI, 20 with type III, 6 with type IV, and 2 with other types (types V and VIII). Surgical intervention led to a notable improvement in the major curve magnitude from 76° to 36°, with no notable correction loss. In addition, the minor curve, apical vertical translation, lowest instrumented vertebra tilt, and pelvic obliquity were also improved. In the sagittal plane, thoracic kyphosis and lumbar lordosis remained unchanged while thoracolumbar kyphosis markedly improved. Two patients experienced proximal junctional kyphosis with screw pullout, one of whom required revision surgery. One patient developed a superficial infection that was successfully treated with oral antibiotics. No instances of neurologic deficits or cement extravasation were observed.

Discussion: This study demonstrated the effectiveness and safety of our multimodal approach to treating scoliosis in patients with OI, achieving a 53% major curve correction with minimal complications over 2-year follow-up. These findings provide notable insights into managing scoliosis in this population.

Level of evidence: Level IV (case series).

Paired vertebral arteries (VAs) travel from the subclavian artery through the cervical spine and into the intracranial space where they contribute to posterior cerebral circulation. Blunt and penetrating injuries to the cervical spine risk injury to the VA. Among the most feared complications of vertebral artery injury (VAI) is posterior circulation stroke. Appropriate screening and treatment of these injuries in the trauma setting remain vitally important to aid in the prevention of devastating neurologic sequelae. A robust knowledge of the VA anatomy is required for spine surgeons to avoid VAI during cervical spine approaches and instrumentation. Both anterior and posterior cervical spine surgeries can place the VA at risk. Careful preoperative assessment with the appropriate advanced imaging studies is necessary to verify the course of the VA in the cervical spine and thus prevent iatrogenic injury because anatomic variations along the course of the artery can prove hazardous if not properly anticipated. Iatrogenic VAI can be treated successfully with tamponade. However, in some cases, ligation, repair, or endovascular procedures may be indicated.

Introduction: Double-crush syndrome (DCS) represents a condition that involves peripheral nerve compression in combination with spinal nerve root impingement. The purpose of this study was to compare electrodiagnostic study (EDS) results in patients undergoing carpal tunnel release (CTR) for carpal tunnel syndrome with those undergoing both CTR and anterior cervical diskectomy and fusion for DCS.

Methods: Patients receiving an isolated CTR were compared with those undergoing CTR and anterior cervical diskectomy and fusion within two years of CTR. The latter group was defined as our DCS cohort. Electrodiagnostic study results were collected which included sensory and motor nerve conduction data as well as electromyogram (EMG) findings. All electrodiagnostic studies were done before CTR in both sets of patients.

Results: Fifty-four patients with DCS and 137 CTR-only patients were included. Patients with DCS were found to have decreased sensory onset latency (3.51 vs 4.01; P = 0.015) and peak latency (4.25 vs 5.17; P = 0.004) compared with the CTR-only patients. Patients with DCS had slower wrist motor velocity (30.5 vs 47.7; P = 0.012), decreased elbow motor latency (9.62 vs 10.6; P = 0.015), and faster elbow motor velocity (56.0 vs 49.4; P = 0.031). EMG results showed that patients with DCS were more likely to have positive findings in the biceps (31.9% vs 1.96%; P < 0.001) and triceps (24.4% vs 2.97%; P < 0.001), but not abductor pollicis brevis (APB) (45.7% vs 37.9%; P = 0.459).

Conclusion: We identified changes on EDS between patients with and without DCS. In patients with DCS, sensory nerve studies showed shorter peak and onset latency than in CTR-only patients. Interestingly, DCS and CTR-only patients had different patterns of wrist and elbow motor nerve conduction. Providers observing positive EMG findings proximal to the APB should raise their suspicion for possible cervical radiculopathy and when present with carpal tunnel syndrome-like symptoms, should also consider DCS in their diagnostic differential.

Introduction: While perioperative nutritional, functional, and bone health status optimization in spine surgery is supported with ample evidence, the implementation and surgeon perception regarding such efforts in clinical practice remain largely unexplored. This study sought to assess the current perception of spine surgeons and implementation regarding the nutritional, functional status, and bone health perioperative optimization.

Methods: An anonymous 30-question survey was distributed to orthopaedic spine fellowship and neurosurgery program directors identified through the North American Spine Society and American Association of Neurological Surgeons contact databases.

Results: The questionnaire was completed by 51 surgeon survey respondents. Among those, 62% reported no current formal nutritional optimization protocols with 14% not recommending an optimization plan, despite only 10% doubting benefits of nutritional optimization. While 5% of respondents perceived functional status optimization as nonbeneficial, 68% of respondents reported no protocol in place and 46% noted a functional status assessment relying on patient dependency. Among the respondents, 85% routinely ordered DEXA scan if there was suspicion of osteoporosis and 85% usually rescheduled surgery if bone health optimization goals were not achieved while 6% reported being suspicious of benefit from such interventions.

Conclusion: While most responding spine surgeons believe in the benefit of perioperative nutritional and functional optimization, logistical and patient compliance challenges were noted as critical barriers toward optimization. Understanding surgeon perception and current practices may guide future efforts toward advancement of optimization protocols.

Selecting the lowest instrumented vertebra (LIV) in fusion for adolescent idiopathic scoliosis is potentially the most nuanced decision a surgeon has to make. This article reviews the literature on the range-of-motion loss related to the LIV, ability to return to sports based on LIV, correlation between LIV and disk degeneration, and short-term and long-term clinical outcomes related to LIV.

Introduction: The factors most important in the spine fellowship match may not ultimately correlate with quality of performance during fellowship. This study examined the spine fellow applicant metrics correlated with high application rank compared with the metrics associated with the strongest clinical performance during fellowship.

Methods: Spine fellow applications at three academic institutions were retrieved from the San Francisco Match database (first available to 2021) and deidentified for application review. Application metrics pertaining to research, academics, education, extracurriculars, leadership, examinations, career interests, and letter of recommendations were extracted. Attending spine surgeons involved in spine fellow selection at their institutions were sent a survey to rank (1) fellow applicants based on their perceived candidacy and (2) the strength of performance of their previous fellows. Pearson correlation assessed the associations of application metrics with theoretical fellow rank and actual performance.

Results: A total of 37 spine fellow applications were included (Institution A: 15, Institution B: 12, Institution C: 10), rated by 14 spine surgeons (Institution A: 6, Institution B: 4, Institution C: 4). Theoretical fellow rank demonstrated a moderate positive association with overall research, residency program rank, recommendation writer H-index, US Medical Licensing Examination (USMLE) scores, and journal reviewer positions. Actual fellow performance demonstrated a moderate positive association with residency program rank, recommendation writer H-index, USMLE scores, and journal reviewer positions. Linear regressions identified journal reviewer positions (ß = 1.73, P = 0.002), Step 1 (ß = 0.09, P = 0.010) and Step 3 (ß = 0.10, P = 0.002) scores, recommendation writer H-index (ß = 0.06, P = 0.029, and ß = 0.07, P = 0.006), and overall research (ß = 0.01, P = 0.005) as predictors of theoretical rank. Recommendation writer H-index (ß = 0.21, P = 0.030) and Alpha Omega Alpha achievement (ß = 6.88, P = 0.021) predicted actual performance.

Conclusion: Residency program reputation, USMLE scores, and a recommendation from an established spine surgeon were important in application review and performance during fellowship. Research productivity, although important during application review, was not predictive of fellow performance.

Level of evidence: III.

Study design: Cohort Study.

Introduction: The prevalence of sacroiliac joint (SIJ) pathology generating lower back pain is increasing, often requiring SI joint fusion in refractory cases. Similarly, total hip arthroplasty (THA) is an increasing procedure in the older growing population. Prior SIJ fusion in patients undergoing THA has increased hip dislocation. This study aims to determine the prevalence of preexisting THA in SIJ fusion patients at our institution.

Methods: After institutional review board approval, we completed a retrospective review of consecutive SIJ fusion cases performed by fellowship-trained orthopaedic spine surgeons between October 2019 and June 2022. The senior surgeon reviewed pelvis radiographs to determine whether a THA was present. Patient demographics, surgical history, SIJ fusion date, and laterality information from study participants' medical records were collected and analyzed.

Results: We screened 157 consecutive cases and excluded 45 not meeting the inclusion criteria. One hundred twelve radiographs were reviewed, with seven additional patients excluded. The final analysis consisted of 105 patients (33M:72F). The mean age was 50.4 ± 13.8 years, and the mean body mass index was 29.1 ± 6.1 kg/m 2 . SIJ fusion laterality included 51 right (48.6%), 44 left (41.9%), and 10 bilateral (9.5%). One patient (0.95%) had a preexisting right THA, and two patients (1.9%) underwent ipsilateral THA after SIJ fusion.

Conclusions: This study demonstrated a low prevalence (0.95%) of preexisting THA in SIJ fusion patients at our institution, similar to the THA prevalence of the total US population. Additional research is needed to determine the outcomes of patients with preexisting THA undergoing SIJ fusion.

Introduction: Although osteoporosis and low bone mineral density is thought to lead to poor fusion outcomes, few studies have adequately addressed the correlation, and they were limited by small sample size at a single institution.

Methods: We completed a secondary analysis of 182 patients enrolled at 26 spine centers across the United States in the EXO-SPINE FDA-approved clinical trial with 12-month CT-based fusion status determined by two independent, blinded radiologists. Using previously described CT-based techniques, we measured local and global Hounsfield units (HU) and examined the relationship with radiographic and clinical outcomes.

Results: CT scans were available for review from 95 patients, with a mean age of 56.2 years and mean global density of 153.0 HU. No relationship was observed between HU and radiographic fusion status or clinical outcomes. Although 12% of patients had lumbar vertebral body HU measurements consistent with osteoporosis, this classification had no relation with fusion or clinical outcomes. Patients with pseudarthrosis had higher Oswestry Disability Index (22.2 vs. 16.6, P = 0.037) and back pain visual analog scale (7.0 vs. 4.9, P = 0.014) scores than patients with at least unilateral fusion at the 12-month follow-up.

Discussion: In this large, multicenter study, lower vertebral body HU was not associated with worse fusion status after single-level instrumented posterolateral lumbar fusion using only local autologous bone graft. However, there was an association between radiographic fusion status and clinical outcomes, validating the importance of determining predictors of successful fusion. Assessment of fusion status with CT scans yielded a much lower fusion success rate with local bone graft than previously reported and may warrant additional investigation.