Jayme Koltsov, PhD

All Publications

• Patient-Level Patterns in Daily Prescribed Opioid Dosage in Single Level Lumbar Fusion are Associated with Postoperative Opioid Dosage and Adverse Events: A Retrospective Analysis of Claims Data. The spine journal : official journal of the North American Spine Society Koltsov, J. C., Sambare, T. D., Kleimeyer, J. P., Alamin, T. F., Wood, K. B., Carragee, E. J., Hu, S. S. 2024

  Abstract

  Patients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively.Determine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events.Retrospective analysis of an administrative claims database (MeritiveTM Marketscan® Research Databases 2007-2015).9,768 patients undergoing primary single level lumbar fusion OUTCOME MEASURES: Primary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition.Distinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors.Among primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively: (1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day; (2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day; (3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day; (4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery; (5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery. These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High-dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain. Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0-5 MME/day, 29.1%), medium (10-15 MME/day, 12.0%) or high (70-75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids.Identification of a patient's pre-operative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts.III.

  View details for DOI 10.1016/j.spinee.2024.03.011

  View details for PubMedID 38521464

• Primary Total Hip Arthroplasty in Juvenile Idiopathic Arthritis: Survivorship after a Median Follow-up of 12 Years. The Journal of arthroplasty Warren, S. I., Hwang, K. L., Lee, J. J., Murrietta, A., Koltsov, J. C., Goodman, S. B. 2023

  Abstract

  Juvenile idiopathic arthritis (JIA) is a chronic inflammatory condition of childhood that frequently affects the hip. Total hip arthroplasty (THA) in JIA can be challenging due to the patient's young age, small proportion, complex anatomy, and bone loss. Outcome data is limited.We reviewed prospectively collected data in 57 JIA patients (83 hips) who underwent THA between 1986 and 2020 by a single surgeon. The median patient age at surgery was 26 years (range, 14 to 62). Reoperation-free survival was assessed via the cumulative incidence function, accounting for the competing risk of death. Relationships between patient and implant factors and survivorship were evaluated by stratification of the cumulative incidence function and Gray's tests. Wilcoxon signed rank tests were used to assess the preoperative to latest postoperative change in patient reported outcomes measures (PROMs).At a median (interquartile range) of 12 (4, 20) years follow-up, 13 (16%) patients underwent reoperation, most commonly for polyethylene wear and osteolysis (7 hips). The estimated incidence of 10-, 20-, and 30-year revision (95% confidence interval) were 11.3% (4.5, 21.6%), 18.5% (8.9, 30.9%), and 40.6% (19.4, 60.9%), respectively. There were no differences in survival based on patient age, sex, implant fixation method, polyethylene type, or thickness. All PROMs improved from preoperative to latest follow up.Primary THA is a durable and effective treatment for JIA patients with severe hip involvement and results in major improvements in pain and function. We did not identify any factors predictive of failure.

  View details for DOI 10.1016/j.arth.2023.12.021

  View details for PubMedID 38104785

• Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA network open Welch, J. M., Gomez, G. I., Chatterjee, M., Shapiro, L. M., Morris, A. M., Gardner, M. J., Sox-Harris, A. H., Baker, L., Koltsov, J. C., Castillo, T., Giori, N., Salyapongse, A., Kamal, R. N. 2023; 6 (12): e2347834

  Abstract

  Importance: Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.Objective: To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.Design, Setting, and Participants: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.Main Outcomes and Measures: Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).Results: A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.Conclusions and Relevance: In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.

  View details for DOI 10.1001/jamanetworkopen.2023.47834

  View details for PubMedID 38100104

• Using 3D MRI Bone Shape to Predict Pre-Osteoarthritis of the Knee 2 Years After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine Williams, A. A., Koltsov, J. C., Brett, A., He, J., Chu, C. R. 2023: 3635465231207615

  Abstract

  Anterior cruciate ligament (ACL) injury increases risks for osteoarthritis (OA), a poorly modifiable and disabling condition. Joint changes of potentially reversible pre-OA have been described just 2 years after ACL reconstruction (ACLR) when early bone shape changes have also been reported.This study evaluates relationships between interlimb differences in tibiofemoral bone shape derived from statistical shape modeling (SSM) of magnetic resonance imaging (MRI) and participant factors on patient-reported outcomes 2 years after unilateral ACLR.Cross-sectional study; Level of evidence, 3.SSM-derived tibiofemoral bone shape and subchondral bone area were assessed from bilateral knee MRI scans of 72 participants with unilateral ACLR (mean age, 34 ± 11 years; 32 women) and compared with a reference cohort of 398 older individuals without OA (mean age, 50 ± 3 years; 213 women). Multivariable logistic regression models examined relationships between participant and surgical factors with interlimb differences in bone shapes or subchondral bone areas. Relationships between patient-reported outcomes and the interlimb differences in bone shape and subchondral area were examined using similar models.Bone shape scores and subchondral bone areas were greater (more OA-like) in ACLR knees than uninjured contralateral knees in every bone metric tested (P≤ .001). Interlimb differences in femur shape scores of participants with ACLR were 65% greater (P < .001) than those of the significantly older reference cohort. Taller height, medial meniscal tears, and decreasing age were associated with larger interlimb differences in shape scores and subchondral areas (P < .05). Bone-patellar tendon-bone (BPTB) autograft recipients demonstrated greater interlimb subchondral area differences compared with allograft recipients (P < .05). Interlimb differences for hamstring autograft recipients did not differ from those with BPTB or allograft. Greater interlimb differences in medial femur subchondral areas were associated with worse patient-reported Knee injury and Osteoarthritis Outcome Score Symptoms (R = 0.27; P = .040).Even in the absence of radiographic OA, just 2 years after unilateral ACLR patients showed greater bone shape scores and subchondral areas consistent with pre-OA in their ACLR knees. Furthermore, greater medial femur bone areas were weakly associated with worse symptoms. Patients who are younger, are taller, have meniscal tears, or have BPTB grafts may be at increased risk for bony asymmetries 2 years after ACLR.

  View details for DOI 10.1177/03635465231207615

  View details for PubMedID 37936374

• Validation of Inertial Measurement Units for Analyzing Golf Swing Rotational Biomechanics. Sensors (Basel, Switzerland) Kim, S. E., Burket Koltsov, J. C., Richards, A. W., Zhou, J., Schadl, K., Ladd, A. L., Rose, J. 2023; 23 (20)

  Abstract

  Training devices to enhance golf swing technique are increasingly in demand. Golf swing biomechanics are typically assessed in a laboratory setting and not readily accessible. Inertial measurement units (IMUs) offer improved access as they are wearable, cost-effective, and user-friendly. This study investigates the accuracy of IMU-based golf swing kinematics of upper torso and pelvic rotation compared to lab-based 3D motion capture. Thirty-six male and female professional and amateur golfers participated in the study, nine in each sub-group. Golf swing rotational kinematics, including upper torso and pelvic rotation, pelvic rotational velocity, S-factor (shoulder obliquity), O-factor (pelvic obliquity), and X-factor were compared. Strong positive correlations between IMU and 3D motion capture were found for all parameters; Intraclass Correlations ranged from 0.91 (95% confidence interval [CI]: 0.89, 0.93) for O-factor to 1.00 (95% CI: 1.00, 1.00) for upper torso rotation; Pearson coefficients ranged from 0.92 (95% CI: 0.92, 0.93) for O-factor to 1.00 (95% CI: 1.00, 1.00) for upper torso rotation (p < 0.001 for all). Bland-Altman analysis demonstrated good agreement between the two methods; absolute mean differences ranged from 0.61 to 1.67 degrees. Results suggest that IMUs provide a practical and viable alternative for golf swing analysis, offering golfers accessible and wearable biomechanical feedback to enhance performance. Furthermore, integrating IMUs into golf coaching can advance swing analysis and personalized training protocols. In conclusion, IMUs show significant promise as cost-effective and practical devices for golf swing analysis, benefiting golfers across all skill levels and providing benchmarks for training.

  View details for DOI 10.3390/s23208433

  View details for PubMedID 37896527

  View details for PubMedCentralID PMC10611231

• Polymethyl methacrylate augmentation and proximal junctional kyphosis in adult spinal deformity patients. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Bartolozzi, A. R., Oquendo, Y. A., Koltsov, J. C., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2023

  Abstract

  Proximal junctional kyphosis (PJK) is a complication following surgery for adult spinal deformity (ASD) possibly ameliorated by polymethyl methacrylate (PMMA) vertebroplasty of the upper instrumented vertebrae (UIV). This study quantifies PJK following surgical correction bridging the thoracolumbar junction ± PMMA vertebroplasty.ASD patients from 2013 to 2020 were retrospectively reviewed and included with immediate postoperative radiographs and at least one follow-up radiograph. PMMA vertebroplasty at the UIV and UIV + 1 was performed at the surgeons' discretion.Of 102 patients, 56% received PMMA. PMMA patients were older (70 ± 8 vs. 66 ± 10, p = 0.021), more often female (89.3% vs. 68.2%, p = 0.005), and had more osteoporosis (26.8% vs. 9.1%, p = 0.013). 55.4% of PMMA patients developed PJK compared to 38.6% of controls (p = 0.097), and the rate of PJK development was not different between groups in univariate survival models. There was no difference in PJF (p > 0.084). Reoperation rates were 7.1% in PMMA versus 11.4% in controls (p = 0.501). In multivariable models, PJK development was not associated with the use of PMMA vertebroplasty (HR 0.77, 95% CI 0.38-1.60, p = 0.470), either when considered overall in the cohort or specifically in those with poor bone quality. PJK was significantly predicted by poor bone quality irrespective of PMMA use (HR 3.81, p < 0.001).In thoracolumbar fusions for adult spinal deformity, PMMA vertebroplasty was not associated with reduced PJK development, which was most highly associated with poor bone quality. Preoperative screening and management for osteoporosis is critical in achieving an optimal outcome for these complex operations.4, retrospective non-randomized case review.

  View details for DOI 10.1007/s00586-023-07966-0

  View details for PubMedID 37812256

  View details for PubMedCentralID 3508213

• The Influence of Race, Income, and Sex on Treatment and Complications of Common Pediatric Fractures ORTHOPEDICS Montgomery, B. K., Joseph, G., Segovia, N., Koltsov, J., Thomas, T. L., Vorhies, J. S., Tileston, K. R. 2023; 46 (3): E156-+

  Abstract

  Despite best intentions, health care disparities exist and can consequently impact patient care. Few studies have examined the impact of disparities in pediatric orthopedic populations. The current study aimed to determine if the treatment type or complication rates of supracondylar, both-bone forearm, or femur fractures are associated with race, ethnicity, sex, or socioeconomic status. The New York Healthcare Cost and Utilization Project's database was used to identify all pediatric patients treated for supracondylar humerus fractures, both-bone forearm fractures, and femoral shaft fractures in 2016. Risk-adjusted relationships with race, ethnicity, sex, hospital location, and median income by zip code were assessed with multivariable logistic regression. Patients who were non-White, resided in the zip codes with the lowest median income (<$42,999 annually), and were treated in metropolitan areas were more likely to receive nonoperative treatments for supracondylar humerus fractures. Female patients with a femoral shaft fracture were less likely to be treated with open reduction and internal fixation vs intramedullary fixation. Finally, complications were not associated with patient race, sex, or socioeconomic statuses. These findings bring attention to health care disparities in the treatment of common pediatric orthopedic fractures. Further studies investigating the underlying etiology behind these disparities are warranted. [Orthopedics. 2023;46(3):e156-e160.].

  View details for DOI 10.3928/01477447-20230104-06

  View details for Web of Science ID 000995876400007

  View details for PubMedID 36623278

• Patient-Level Payment Patterns Prior to Single Level Lumbar Decompression are Associated with Resource Utilization, Postoperative Payments, and Adverse Events. The spine journal : official journal of the North American Spine Society Koltsov, J. C., Sambare, T. D., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2022

  Abstract

  BACKGROUND: Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.PURPOSE: 1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.STUDY DESIGN/SETTING: Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015).PATIENT SAMPLE: Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).OUTCOME MEASURES: Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.RESULTS: We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<0.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=0.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=0.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.CONCLUSIONS: There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1016/j.spinee.2022.10.002

  View details for PubMedID 36241040

• Complication risks and costs associated with Ponte osteotomies in surgical treatment of adolescent idiopathic scoliosis: insights from a national database. Spine deformity Shaheen, M., Koltsov, J. C., Cohen, S. A., Langner, J. L., Kaur, J., Segovia, N. A., Vorhies, J. S. 2022

  Abstract

  PURPOSE: Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients.METHODS: Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (±PO) between 2007 and 2015 in the IBM MarketScan Commercial Databases. Costs and trends of POs were evaluated. Odds of neurological complications and readmissions within 90days and reoperations within 90days and 2years were assessed.RESULTS: We identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p<0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p=0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p<0.001) and reoperation (2.03 [1.13-3.59]; p=0.015) within 90days, but there were no differences in the odds of reoperation within 2years (p=0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p<0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p<0.001).CONCLUSION: Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90days. By 2years, differences in reoperation rate were not significant.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1007/s43390-022-00534-4

  View details for PubMedID 35810408

• Healthcare Resource Utilization and Costs Two Years Pre and Post Lumbar Spine Surgery for Stenosis: A National Claims Cohort Study of 22,182 Cases. The spine journal : official journal of the North American Spine Society Koltsov, J. C., Sambare, T. D., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2022

  Abstract

  BACKGROUND: Improved understanding of the pre and postoperative trends in costs and healthcare resource utilization (HCRU) is needed to better inform patient expectations and aid in the development of strategies to minimize the significant healthcare burden associated with lumbar spine surgery.PURPOSE: Examine the time course of costs and HCRU in the two years preceding and following elective lumbar spine surgery for stenosis in a large national claims cohort STUDY DESIGN/SETTING: Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015) PATIENT SAMPLE: Adult patients undergoing elective primary single-level lumbar surgery for stenosis with at least 2 years of continuous health plan enrollment pre- and postoperatively OUTCOME MEASURES: Functional measures, including monthly rates of HCRU (15 categories), monthly gross covered payments (including payments made by the health plan and deductibles and coinsurance paid by the patient) overall, by HCRU category, and by spine versus non-spine-related METHODS: All available patients were utilized for analysis of HCRU. For analysis of payments, only patients on non-capitated health plans providing accurate financial information were analyzed. Payments were converted to 2015 United States dollars using the medical care component of the consumer price index. Trends in payments and HCRU were plotted on a monthly basis pre- and post-surgery and assessed with regression models. Relationships with demographics, surgical factors, and comorbidities were assessed with multivariable repeated measures generalized estimating equations.RESULTS: Median monthly healthcare payments 2 years prior to surgery were $275 ($22, $868). Baseline HCRU at 2 years preoperatively was stable or only gradually rising (office visits, prescription drug use), but began an increasingly steep rise in many categories 6 to 12 months prior to surgery. Monthly payments began an increasingly steep rise 6 months prior to surgery, reaching a peak of $1,402 ($634, $2,827) in the month prior to surgery. This was driven by an increase in radiology, office visits, PT, injections, prescription medications, ER encounters, and inpatient admissions. Payments dropped dramatically immediately following surgery. Over the remainder of the 2 years, the median total payments declined only slightly, as a continued decline in spine-related payments was offset by gradually increased non-spine related payments as patients aged. By 2 years postoperatively, the percentage of patients using PT and injections returned to within 1% of the baseline levels observed 2 years preoperatively; however, spine-related prescription medication use remained elevated, as did other categories of HCRU (radiology, office visits, lab/diagnostic services, and also rare events such as inpatient admissions, ER encounters, and SNF/IRF). Patients with a fusion component to their surgeries had higher payments and HCRU preoperatively, and this did not resolve postoperatively. Variations in payments and HCRU were also evident among plan types, with patients on comprehensive medical plans-predominantly employer-sponsored supplemental Medicare coverage-utilizing more inpatient, ER, and inpatient rehabilitation & skilled nursing facilities. Patients on high-deductible plans had fewer payments and HCRU across all categories; however, we are unable to distinguish whether this is because they used fewer of these services or if they were paying for these services out of pocket without submitting to the payer. By 2 years postoperatively, 51% of patients had no spine-related monthly payments, while 33% had higher and 16% had lower monthly payments relative to 2 years preoperatively.CONCLUSIONS: This is the first study to characterize time trends in direct healthcare payments and HCRU over an extended period preceding and following spine surgery. Differences among plan types potentially highlight disparities in access to care and plan-related financial mediators of patients' healthcare resource utilization.LEVEL OF EVIDENCE: III.

  View details for DOI 10.1016/j.spinee.2022.01.020

  View details for PubMedID 35123048

• Does Navigation Make Spinal Fusion for Adolescent Idiopathic Scoliosis Safer? Insights From a National Database. Spine Kaur, J., Koltsov, J. C., Kwong, J. W., Cheng, I., Vorhies, J. S. 2021; 46 (19): E1049-E1057

  Abstract

  STUDY DESIGN: Retrospective Cohort.OBJECTIVE: To evaluate the effect of computer-assisted navigation (NAV) on rates of complications and reoperations after spinal fusion (SF) for adolescent idiopathic scoliosis (AIS) using a nationally representative claims database.SUMMARY OF BACKGROUND DATA: Significant controversy surrounds the reported benefits of NAV in SF for AIS. Previous studies have demonstrated decreased rates of pedicle screw breaches with NAV compared to free-hand methods but no impact on complication rates. Thus, the clinical utility of NAV remains uncertain.METHODS: Analyses were performed using the IBM MarketScan databases. Patients aged 10 to 18 undergoing SF for AIS were grouped by use of NAV. Patients with nonidiopathic scoliosis were excluded. Univariate and risk-adjusted multivariate analyses were performed. Primary outcomes were neurological complications, any medical complications, and reoperations. Secondary outcomes included adjusted total reimbursements and length of stay.RESULTS: A total of 12,046 patients undergoing SF for AIS were identified, and 8640 had 90-day follow-up. NAV was used in 467 patients (5.4%), increasing from 2007 to 2015. After risk adjustment, the odds for any complication within 90 days were lower with NAV (OR = 0.61, P = 0.025), but neurological complications were unrelated to NAV (P = 0.742). NAV was not associated with reoperation within 90 days (P = 0.757) or 2 years (P = 0.095). We observed a $25,038 increase in adjusted total reimbursements (P < 0.001) and a 0.32-day decrease in length of stay (P = 0.022) with use of NAV.CONCLUSION: In this national sample, NAV was associated with a lower rate of total complications but no change in rates of neurological complications or reoperations. In addition, NAV was associated with a large increase in total payments, despite a modest decrease in hospital stay. Considering the increasing popularity of NAV, this study provides important context regarding the utility of NAV for AIS.Level of Evidence: 3.

  View details for DOI 10.1097/BRS.0000000000004037

  View details for PubMedID 34517402

• One surgeon's learning curve with single position lateral lumbar interbody fusion: perioperative outcomes and complications. Journal of spine surgery (Hong Kong) Warren, S. I., Wadhwa, H., Koltsov, J. C., Michaud, J. B., Cheng, I. 2021; 7 (2): 162-169

  Abstract

  Background: Single position (SP) lateral transpsoas lumbar interbody fusion (LLIF) with posterior pedicle screw fixation (PPSF) reduces operative time compared to dual positioning. However, the learning curve has not yet been described. The purpose of this study was to define the learning curve SP LLIF with PPSF.Methods: This retrospective case series included the first 161 consecutive patients who underwent SP LLIF and PPSF with the senior author. Primary analysis of operative time versus case number included single level cases without adjacent level procedures. Secondary analyses included 1-3 level cases without adjacent level procedures. Operative time for 2 and 3 level procedures was normalized to single-level cases. The learning curve was assessed with linear regression, which was found to fit the data better than logarithmic regression as judged by R2 values and data visualization. Perioperative outcomes as a function of case number were analyzed by least squares linear regression and Mann Whitney U-tests.Results: For single level surgeries without adjacent procedures (n=87), operative time decreased by a total of 28.7 (95% CI, 9.6, 47.9) minutes over the series (P<0.001). For 1-3 level cases with no adjacent procedures (n=131), normalized operative time decreased by 23.1 (7.6, 38.6) minutes (P<0.001). Post-operative change in hematocrit, length of hospital stay, post-operative change in lordosis, 90-day complications, suboptimal screw placement, and 6-week post-operative Oswestry Disability Index (ODI) score did not correlate with case number. Intraoperative fluids decreased 3.7 mL (95% CI, 0.7, 6.7) per case (P=0.015).Conclusions: In SP LLIF with PPSF, case number correlated with decreased operative time, but not complications. The surgeon's prior experience with dual position (DP) LLIF likely contributed to the minimal learning curve observed. Surgeons adopting SP LLIF with minimal prior DP LLIF experience may experience a steeper curve.

  View details for DOI 10.21037/jss-21-13

  View details for PubMedID 34296028

• Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Wadhwa, H., Tigchelaar, S. S., Chen, M. J., Koltsov, J. C., Bellino, M. J., Bishop, J. A., Gardner, M. J. 2021

  Abstract

  PURPOSE: Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.METHODS: We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.RESULTS: Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p<0.01) and intraoperative IV fluids (p<0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.CONCLUSION: In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

  View details for DOI 10.1007/s00590-021-02985-3

  View details for PubMedID 33891154

• Extensor Digitorum Brevis Bulk and Associations with Fibular Motor Nerve Conduction Amplitude. PM & R : the journal of injury, function, and rehabilitation Levin, J., Lowe, A., Tamura, L., Miller, E., Koltsov, J., Kenrick, A., Barrette, K., Richardson, J. 2021

  Abstract

  INTRODUCTION: Prior work demonstrates that fibular compound motor action potential (CMAP) amplitude <4.0 mV predicts impairment of ankle proprioceptive precision and increased fall risk. Extensor digitorum brevis (EDB) inspection may present a simple clinical surrogate for CMAP amplitude.OBJECTIVE: 1) To estimate the inter-rater reliability of assessment of EDB bulk. 2) To determine whether inspection of EDB bulk is associated with fibular CMAP amplitude.DESIGN: Independently and prior to nerve conduction studies (NCS), two investigators graded EDB bulk. Next, fibular NCS were completed.SETTING: An academic center's outpatient Physical Medicine & Rehabilitation EMG clinics.PARTICIPANTS: 52 adult participants (102 feet) PREDICTOR: EDB bulk graded as 1)normal, 2)diminished, or 3)atrophied MAIN OUTCOME MEASURES: 1. Inter-rater reliability of assessment of EDB bulk. 2. Mean fibular CMAP amplitude. 3. A binary measure of fibular CMAP amplitude above or below a 4.0 mV threshold.RESULTS: Inter-rater reliability of EDB bulk grading was moderate (kappa: 0.65 [95% C.I. 0.48 - 0.82]). The mean CMAP value was 5.9 ±2.2 mV when bulk was normal, 3.4 ±2.1 mV when diminished, and 0.6 ±0.9 mV when atrophied. A multivariable analysis demonstrated that EDB bulk, distal symmetric polyneuropathy (DSP), and lumbar radiculopathy were all associated with CMAP amplitude. The sensitivity and specificity of grading muscle bulk as normal vs abnormal in detecting CMAP amplitude above or below 4.0mV were 0.86 [95% C.I. 0.78 - 0.94] and 0.71 [95% C.I. 0.54 - 0.88], respectively. An atrophied EDB was a highly specific indicator that CMAP amplitude was abnormal (<4.0 mV) in 100% of cases (8/8).CONCLUSIONS: EDB bulk was associated with fibular CMAP amplitude. Atrophy was a highly specific indicator for CMAP amplitude below 4.0 mV. Evaluation of EDB bulk may represent a quick and easy clinical surrogate marker for CMAP amplitude and distal neuromuscular impairment.

  View details for DOI 10.1002/pmrj.12608

  View details for PubMedID 33876583

• Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C. n., Segovia, N. n., McMains, C. n., Falakassa, J. n., Ratliff, J. n., Wood, K. B., Alamin, T. n., Cheng, I. n., Hu, S. S. 2021; 34 (2): E121–E125

  Abstract

  This was a retrospective cohort study.The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

  View details for DOI 10.1097/BSD.0000000000001058

  View details for PubMedID 33633069

• Advanced Age Does Not Impact Outcomes After 1-level or 2-level Lateral Lumbar Interbody Fusion. Clinical spine surgery Wadhwa, H., Oquendo, Y. A., Tigchelaar, S. S., Warren, S. I., Koltsov, J. C., Desai, A., Veeravagu, A., Alamin, T. F., Ratliff, J. K., Hu, S. S., Cheng, I. 2021

  Abstract

  This was a retrospective comparative study.The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF).LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF.Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+.In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation.LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion.Level III.

  View details for DOI 10.1097/BSD.0000000000001270

  View details for PubMedID 34724454

• Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C., Segovia, N., McMains, C., Falakassa, J., Ratliff, J., Wood, K. B., Alamin, T., Cheng, I., Hu, S. S. 2020

  Abstract

  STUDY DESIGN: This was a retrospective cohort study.OBJECTIVE: The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.SUMMARY OF BACKGROUND DATA: Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).METHODS: Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.RESULTS: A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).CONCLUSION: We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

  View details for DOI 10.1097/BSD.0000000000001058

  View details for PubMedID 32925188

• Preoperative epidural steroid injections are not associated with increased rates of infection and dural tear in lumbar spine surgery. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Koltsov, J. C., Smuck, M. W., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2020

  Abstract

  PURPOSE: The study objectives were to use a large national claims data resource to examine rates of preoperative epidural steroid injections (ESI) in lumbar spine surgery and determine whether preoperative ESI or the timing of preoperative ESI is associated with rates of postoperative complications and reoperations.METHODS: A retrospective longitudinal analysis of patients undergoing lumbar spine surgery for disc herniation and/or spinal stenosis was undertaken using the MarketScan databases from 2007-2015. Propensity-score matched cohorts were constructed to compare rates of complications and reoperations in patients with and without preoperative ESI.RESULTS: Within the year prior to surgery, 120,898 (46.4%) patients had a lumber ESI. The median time between ESI and surgery was 10weeks. 23.1% of patients having preoperative ESI had more than one level injected, and 66.5% had more than one preoperative ESI treatment. Patients with chronic pain were considerably more likely to have an ESI prior to their surgery [OR 1.62 (1.54, 1.69), p<0.001]. Patients having preoperative ESI within in close proximity to surgery did not have increased rates of infection, dural tear, neurological complications, or surgical complications; however, they did experience higher rates of reoperations and readmissions than those with no preoperative ESI (p<0.001).CONCLUSION: Half of patients undergoing lumbar spine surgery for stenosis and/or herniation had a preoperative ESI. These were not associated with an increased risk for postoperative complications, even when the ESI was given in close proximity to surgery. Patients with preoperative ESI were more likely to have readmissions and reoperations following surgery.

  View details for DOI 10.1007/s00586-020-06566-6

  View details for PubMedID 32789696

• Cervical Epidural Steroid Injections: Incidence and Determinants of Subsequent Surgery. The spine journal : official journal of the North American Spine Society Kleimeyer, J. P., Koltsov, J. C., Smuck, M. W., Wood, K. B., Cheng, I., Hu, S. S. 2020

  Abstract

  BACKGROUND CONTEXT: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.PURPOSE: This study sought to determine: 1) the proportion of patients having surgery following CESI, and 2) the timing of and factors associated with subsequent surgery.STUDY DESIGN: Retrospective analysis of a large, national administrative claims database.PATIENT SAMPLE: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.OUTCOME MEASURES: The primary outcome was the time from index CESI to surgery.METHODS: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year prior to CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.RESULTS: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35-54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.CONCLUSIONS: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

  View details for DOI 10.1016/j.spinee.2020.06.012

  View details for PubMedID 32565316

• Single Assessment Numeric Evaluation (SANE) in Hand Surgery: Does a One-Question Outcome Instrument Compare Favorably? The Journal of hand surgery Gire, J. D., Koltsov, J. C., Segovia, N. A., Kenney, D. E., Yao, J., Ladd, A. L. 2020

  Abstract

  PURPOSE: Patient-reported outcome measures are increasingly used to measure patient status, impairments, and disability, but often require lengthy surveys and place a considerable burden on patients. We hypothesized that the Single Assessment Numeric Evaluation (SANE), composed of a single question, would be a valid and responsive instrument to provide a global assessment of hand function.METHODS: The SANE, Patient-Reported Outcomes Measurement Information System-Upper Extremity (PROMIS-UE), and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) data are routinely collected electronically in our hand and upper-extremity center. To identify our cohort, we used Current Procedural Terminology codes to query our electronic medical record research data repository for the 7 most common hand surgery procedures performed over 2 years from December 2016 to 2018. These procedures included carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, wrist arthroscopy, distal radius fracture fixation, first dorsal compartment release, and cubital tunnel release. Patients undergoing a single isolated procedure with questionnaires obtained in the preoperative and/or postoperative period were included in the analysis. Convergent validity, coverage, and responsiveness for each instrument were assessed.RESULTS: We identified 214 patients for inclusion. The SANE score had a moderate to strong correlation with the QuickDASH and PROMIS-UE. Floor and ceiling effects for the SANE were less than 10% at baseline and follow-up. Overall, the QuickDASH was the most responsive, followed by SANE and PROMIS-UE; all 3 instruments exceeded the acceptable thresholds for responsiveness and demonstrated significant changes before to after surgery. Responsiveness of the SANE varied by procedure and was acceptable for carpal tunnel release, carpometacarpal arthroplasty, wrist arthroscopy, and trigger finger release.CONCLUSIONS: The single-item SANE is a reasonable measure of global function in patients undergoing common hand procedures and demonstrates psychometric properties comparable to those of the PROMIS-UE and QuickDASH outcome scores.CLINICAL RELEVANCE: The SANE score is a reasonable outcome measure of global hand function that may have utility in demonstrating response to treatment in a practice setting and may provide a useful adjunct to multiple-item measures in clinical research studies.

  View details for DOI 10.1016/j.jhsa.2020.03.024

  View details for PubMedID 32482496

• Local anesthetic with sedation is a viable alternative to general anesthesia for lumbar spinal decompressions: A retrospective cohort feasibility study and short-term analysis of outcomes CURRENT ORTHOPAEDIC PRACTICE Ziino, C., Guzman, R. A., Koltsov, J., Montgomery, B. K., McMains, C., Alamin, T. 2020; 31 (3): 252–57

  View details for DOI 10.1097/BCO.0000000000000855

  View details for Web of Science ID 000529951800007

• Cost-effectiveness of Operative Versus Non-operative Management of Acute Achilles Tendon Ruptures. HSS journal : the musculoskeletal journal of Hospital for Special Surgery Koltsov, J. C., Gribbin, C. n., Ellis, S. J., Nwachukwu, B. U. 2020; 16 (1): 39–45

  Abstract

  The management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.The purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.A Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.In the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.For acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

  View details for DOI 10.1007/s11420-019-09684-0

  View details for PubMedID 32015739

  View details for PubMedCentralID PMC6974171

• Computer-assisted surgical navigation is associated with an increased risk of neurological complications: a review of 67,264 posterolateral lumbar fusion cases. Journal of spine surgery (Hong Kong) Ajiboye, R. M., Koltsov, J. C., Karamian, B., Swinford, S., Montgomery, B. K., Arzeno, A., Ziino, C., Cheng, I. 2019; 5 (4): 457–65

  Abstract

  Background: Pedicle screw malposition may result in neurological complications following posterolateral lumbar fusions (PLF). While computer-assisted navigation (NAV) and intraoperative neuromonitoring (ION) have been shown to improve safety in deformity surgeries, their use in routine PLFs remain controversial. This study assesses the risk of complications and reoperation for pedicle screw revision following PLF with and without ION and/or NAV surgery.Methods: Retrospective analyses were performed using the Truven Health MarketScan databases to identify patients that had primary PLF with and without NAV and/or ION for degenerative lumbar disorders from years 2007-2015. Patients undergoing concomitant interbody fusions, spinal deformity surgery or fusion to the thoracic spine were excluded. Complications and reoperation for pedicle screw revision within 90 days of surgery were assessed.Results: During the study period, 67,264 patients underwent PLFs. NAV only was used in 3.5% of patients, ION only in 17.9% and both NAV and ION in 0.8% of patients. In univariate analyses, there was a difference in the risk of neurological injuries among groups (NAV only: 1.4%, ION only: 0.8%, NAV and ION: 0.5%, No NAV or ION: 0.6%, P<0.001). In multivariable models, the use of NAV was associated with a higher risk of neurological complications when compared to ION only or no ION or NAV [NAV vs. ION only: odds ratio (OR) and 95% confidence interval (CI) =2.1 (1.4, 3.2), P=0.002; NAV vs. no ION or NAV: OR and 95% CI =2.5 (1.7, 3.5), P<0.001]. There was no difference in reoperation rates among the groups (P=0.135).Conclusions: Although the overall risk of neurological complications following PLFs is low, the use of NAV only was associated with an increased risk of neurological complications. No differences were observed in the rates of pedicle screw revision among groups.

  View details for DOI 10.21037/jss.2019.09.21

  View details for PubMedID 32042996

• A Prospective, Psychometric Validation of National Institutes of Health Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Upper Extremity Computer Adaptive Testing in Cervical Spine Patients: Successes and Key Limitations. Spine Iyer, S., Koltsov, J. C., Steinhaus, M., Ross, T., Stein, D., Yang, J., LaFage, V., Albert, T., Kim, H. J. 2019; 44 (22): 1539–49

  Abstract

  STUDY DESIGN: Prospective Cohort Study OBJECTIVE.: The aim of this study was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) against existing patient-reported outcomes in the cervical spine.SUMMARY OF BACKGROUND DATA: Current patient-reported outcomes in cervical spine have substantial limitations. PROMIS offers the potential for improved psychometric properties with reduced questionnaire burden.METHODS: Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (36-Item Short Form Health Survey [SF-36], Neck Disability Index (NDI), Visual Analog Scale arm/neck, and PROMIS pain Interference [PI], physical Function [PF], and Upper Extremity [UE]) preoperatively and at 6 months postoperatively. Demographic data, diagnosis, and procedural data were recorded. Validation of the instruments was completed with a Rasch Model as well as measurement of coverage, efficiency, test-retest reliability, responsiveness, and convergent validity.RESULTS: Of 197 patients who completed the preoperative survey, 164 were eligible for 6-month follow-up and 139 completed 6-month postoperative surveys. The most common diagnoses were radiculopathy (37.6%), myeloradiculopathy (30.5%), and myelopathy (28.4%). All studied instruments had acceptable fit to a Rasch model. PROMIS computer adaptive testings (CATs) demonstrated improved average time to completion for PI (39 seconds), PF (47 seconds), and UE (54  seconds), compared to NDI (117 s) and SF-36 PCS (175 seconds). Responsiveness for PROMIS CATs was similar to NDI and SF-36, test-retest reliability was lower for PI (intraclass correlation: 0.68), PF (0.70), and UE (0.59), compared to NDI (0.86) and PCS (0.85). For convergent validity, PI was strongly correlated to NDI and PF to SF-36 PCS. There were no significant floor or ceiling effects for the PROMIS domains, although UE had preoperative clustering (n = 18) at a high score (56.4) and PI had postoperative clustering (n = 27) at a low score (38.7).CONCLUSION: PROMIS CATs demonstrate several advantages, including efficiency and responsiveness, while demonstrating good convergent validity with legacy instruments. Nevertheless, CATs had lower test-retest reliability and had significant clustering at higher levels of function for the PI and UE CATs. These limitations must be considered before broad adoption of CATs in cervical spine patients.LEVEL OF EVIDENCE: 3.

  View details for DOI 10.1097/BRS.0000000000003133

  View details for PubMedID 31689249

• Short-Term Outcomes of Staged Versus Same-Day Surgery for Adult Spinal Deformity Correction. Spine deformity Arzeno, A. H., Koltsov, J., Alamin, T. F., Cheng, I., Wood, K. B., Hu, S. S. 2019; 7 (5): 796-804

  Abstract

  Retrospective cohort study.Assess differences between staged (≤3 days) and same-day surgery in perioperative factors, radiographic measures, and complications. Surgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (≥7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals.Retrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney U tests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics.In univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p < .001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p < .001 for each). Staged surgery had a higher rate of thrombotic events (p = .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p = .028), lumbar lordosis (average 14° vs. 23°, p = .019), and PI-LL mismatch (average 10° vs. 2° p = .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group. After risk adjustment, taking into account the procedural specifics including longer fusion constructs and greater number of osteotomies, LOS no longer differed between staged and same-day surgery; however, the total operative time was 98 minutes longer for staged surgery (p < .001). Differences in blood loss between groups was accounted for by differences in operative time and patient and surgical characteristics.Although univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed.Level III.

  View details for DOI 10.1016/j.jspd.2018.12.008

  View details for PubMedID 31975196

• Short-Term Outcomes of Staged Versus Same-Day Surgery for Adult Spinal Deformity Correction. Spine deformity Arzeno, A. H., Koltsov, J., Alamin, T. F., Cheng, I., Wood, K. B., Hu, S. S. 2019; 7 (5): 796

  Abstract

  STUDY DESIGN: Retrospective cohort study.OBJECTIVES: Assess differences between staged (≤3 days) and same-day surgery in perioperative factors, radiographic measures, and complications.SUMMARY OF BACKGROUND DATA: Surgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (≥7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals.METHODS: Retrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney U tests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics.RESULTS: In univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p < .001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p < .001 for each). Staged surgery had a higher rate of thrombotic events (p = .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p = .028), lumbar lordosis (average 14° vs. 23°, p = .019), and PI-LL mismatch (average 10° vs. 2° p = .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group. After risk adjustment, taking into account the procedural specifics including longer fusion constructs and greater number of osteotomies, LOS no longer differed between staged and same-day surgery; however, the total operative time was 98 minutes longer for staged surgery (p < .001). Differences in blood loss between groups was accounted for by differences in operative time and patient and surgical characteristics.CONCLUSIONS: Although univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed.LEVEL OF EVIDENCE: Level III.

  View details for DOI 10.1016/j.jspd.2018.12.008

  View details for PubMedID 31495481

• Platelet-Rich Plasma (PRP) From Older Males With Knee Osteoarthritis Depresses Chondrocyte Metabolism and Upregulates Inflammation JOURNAL OF ORTHOPAEDIC RESEARCH O'Donnell, C., Migliore, E., Grandi, F., Koltsov, J., Lingampalli, N., Cisar, C., Indelli, P. F., Sebastiano, V., Robinson, W. H., Bhutani, N., Chu, C. R. 2019; 37 (8): 1760–70

  View details for DOI 10.1002/jor.24322

  View details for Web of Science ID 000501249400010

• Decreased estimated blood loss in lateral trans-psoas versus anterior approach to lumbar interbody fusion for degenerative spondylolisthesis. Journal of spine surgery (Hong Kong) Goodnough, L. H., Koltsov, J., Wang, T., Xiong, G., Nathan, K., Cheng, I. 2019; 5 (2): 185–93

  Abstract

  Background: The goal of the current study was to compare the perioperative and post-operative outcomes of eXtreme lateral trans-psoas approach (XLIF) versus anterior lumbar interbody fusion (ALIF) for single level degenerative spondylolisthesis. The ideal approach for degenerative spondylolisthesis remains controversial.Methods: Consecutive patients undergoing single level XLIF (n=21) or ALIF (n=54) for L4-5 degenerative spondylolisthesis between 2008-2012 from a single academic center were retrospectively reviewed. Groups were compared for peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), radiographic measurements (L1-S1 cobb angle, disc height, fusion grade, subsidence), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index).Results: Estimated blood loss was significantly lower for XLIF [median 100; interquartile range (IQR), 50-100 mL] than for ALIF (median 250; IQR, 150-400 mL; P<0.001), including after adjusting for significantly higher rates of posterior decompression in the ALIF group. There were no significant differences in rates of complications within 30 days, radiographic outcomes, or in re-operation rates. Both groups experienced significant pain relief post-operatively.Conclusions: The lateral trans-psoas approach is associated with diminished blood loss compared to the anterior approach in the treatment of degenerative spondylolisthesis. We were unable to detect differences in radiographic outcomes, complication rates, or patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. Further studies will continue to define indications for lateral versus anterior approach to lumbar spine for degenerative spondylolisthesis.

  View details for DOI 10.21037/jss.2019.05.08

  View details for PubMedID 31380471

• Platelet-Rich Plasma (PRP) from Older Males with Knee Osteoarthritis Depresses Chondrocyte Metabolism and Upregulates Inflammation. Journal of orthopaedic research : official publication of the Orthopaedic Research Society O'Donnell, C., Migliore, E., Grandi, F. C., Koltsov, J., Lingampalli, N., Cisar, C., Indelli, P. F., Sebastiano, V., Robinson, W. H., Bhutani, N., Chu, C. R. 2019

  Abstract

  There is intense clinical interest in the potential effects of platelet-rich plasma (PRP) for the treatment of osteoarthritis (OA). This study tested the hypotheses that (1) 'lower' levels of the inflammatory mediators (IM) interleukin-1-beta (IL-1beta) and tumor-necrosis-factor-alpha (TNF-alpha), and (2) 'higher' levels of the growth factors (GF) insulin-like-growth-factor-1 and transforming-growth-factor-beta-1 within leukocyte-poor PRP correlate with more favorable chondrocyte and macrophage responses in vitro. Samples were collected from ten 'healthy' young male (23-33 years old) human subjects (H-PRP) and nine older (62-85 years old) male patients with severe knee OA (OA-PRP). The samples were separated into groups of 'high' or 'low' levels of IM and GF based on multiplex cytokine and ELISA data. Three-dimensional (3D) alginate bead chondrocyte cultures and monocyte-derived macrophage cultures were treated with 10% PRP from donors in different groups. Gene expression was analyzed by qPCR. Contrary to our hypotheses, the effect of PRP on chondrocytes and macrophages was mainly influenced by the age and disease status of the PRP donor as opposed to the IM or GF groupings. While H-PRP showed similar effects on expression of chondrogenic markers (Col2a1 and Sox9) as the negative control group (p>0.05), OA-PRP decreased chondrocyte expression of Col2a1 and Sox-9 mRNA by 40% and 30%, respectively (Col2a1, p=0.015; Sox9, p=0.037). OA-PRP also upregulated TNF-alpha and MMP-9 (p<0.001) gene expression in macrophages while H-PRP did not. This data suggests that PRP from older individuals with OA contain factors that may suppress chondrocyte matrix synthesis and promote macrophage inflammation in vitro. This article is protected by copyright. All rights reserved.

  View details for PubMedID 31042308

• Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery SPINE JOURNAL Koltsov, J. B., Smuck, M. W., Zagel, A., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2019; 19 (2): 199–205

  View details for DOI 10.1016/j.spinee.2018.05.034

  View details for Web of Science ID 000455917700011

• The Effects of Varenicline on Lumbar Spinal Fusion in a Rat Model. The spine journal : official journal of the North American Spine Society Kang, J. n., Glaeser, J. D., Karamian, B. n., Kanim, L. n., NaPier, Z. n., Koltsov, J. n., Thio, T. n., Salehi, K. n., Bae, H. W., Cheng, I. n. 2019

  Abstract

  Smoking is detrimental to obtaining a solid spinal fusion mass with previous studies demonstrating its association with pseudoarthrosis in patients undergoing spinal fusion. Varenicline is a pharmacologic adjunct used in smoking cessation which acts as a partial agonist of the same nicotinic receptors activated during tobacco use. However, no clinical or basic science studies to date have characterized if varenicline has negative effects on spinal fusion and bone healing by itself.Our study aim was to elucidate whether varenicline affects the frequency or quality of posterolateral spinal fusion in a rodent model at an endpoint of 12 weeks.Randomized control trial PATIENT SAMPLE: 14 male Lewis rats randomly separated into two experimental groups OUTCOME MEASURES: Manual palpation of fusion segment, radiography, μCT imaging, 4-point bend.Fourteen male Lewis rats were randomly separated into two experimental groups undergoing L4-5 posterior spinal fusion procedure followed by daily subcutaneous injections of human dose varenicline or saline (control) for 12 weeks post-surgery. Spine samples were explanted, and fusion was determined via manual palpation of segments by two independent observers. High-resolution radiographs were obtained to evaluate bridging fusion mass. μCT imaging was performed to characterize fusion mass and consolidation. Lumbar spinal fusion units were tested in 4-point bending to evaluate stiffness and peak load. Study funding sources include $5000 OREF Grant. There were no applicable financial relationships or conflicts of interest.At three months post-surgery, 12 out of 14 rats demonstrated lumbar spine fusion (86% fused) with no difference in fusion frequency between the varenicline and control groups as detected by manual palpation. High resolution radiography revealed six out of seven rats (86%) having complete fusion in both groups. μCT showed no significant difference in bone mineral density or bone fraction volume between groups in the region of interest. Biomechanical testing demonstrated no significant different in the average stiffness or peak loads at the fusion site of the varenicline and control groups.Based on the results of our rat study, there is no indication that varenicline itself has a detrimental effect on the frequency and quality of spinal fusion.

  View details for DOI 10.1016/j.spinee.2019.07.015

  View details for PubMedID 31377475

• Have large femoral heads reduced prosthetic impingement in total hip arthroplasty? HIP INTERNATIONAL Waddell, B. S., Koch, C., Trivellas, M., Burket, J. C., Wright, T., Padgett, D. 2019; 29 (1): 83–88

  Abstract

  Prosthetic impingement is implicated in dislocation after total hip arthroplasty (THA). While use of larger diameter femoral heads reduces the incidence of dislocation, the effect of larger heads upon impingement rate is unknown. We assessed retrieved THA components for evidence of impingement to determine if large femoral heads reduced the rate of impingement in primary THA and what factors might influence impingement.Liners from 97 primary THAs retrieved at revision arthroplasty were scored for evidence of impingement, defined as wear or deformation on the rim of the component. Component inclination and version were measured from anteroposterior and cross-table lateral radiographs.Independent of revision diagnosis, 77% of liners demonstrated evidence of impingement. Impingement was less prevalent and less severe as head size increased. Severe impingement was observed in 50% of the liners with 28-mm heads, 15% of liners with 32-mm heads, and 21% of liners with 36-mm heads. Regardless of head size, 76% of liners revised for instability demonstrated impingement. Decreased head-neck ratio, use of an elevated liner, increased length of implantation, and increased version were associated with increased severity of impingement.We showed that larger head sizes are associated with decreased incidence of impingement on retrieved acetabular liners when compared to smaller head sizes. Larger heads have reduced but not eliminated impingement, which remains a potential source of instability.

  View details for DOI 10.1177/1120700018761153

  View details for Web of Science ID 000454318500013

  View details for PubMedID 29734855

• Single position versus lateral-then-prone positioning for lateral interbody fusion and pedicle screw fixation. Journal of spine surgery (Hong Kong) Ziino, C., Konopka, J. A., Ajiboye, R. M., Ledesma, J. B., Koltsov, J. C., Cheng, I. 2018; 4 (4): 717–24

  Abstract

  Background: To compare perioperative and radiographic outcomes following lateral lumbar interbody fusions in two cohorts of patients who either underwent single position or dual position surgery.Methods: Patients over the age of 18 with degenerative lumbar pathology who underwent a lumbar interbody fusion via lateral access from 2012-2015 from a single surgeon met inclusion criteria. Patients who underwent combined procedures, had a history of retroperitoneal surgery, or had inadequate preoperative imaging were excluded. Patients who remained in the lateral decubitus position for pedicle screw fixation [single-position (SP)] were compared to those turned prone [dual-position (DP)]. Demographics, surgical details, and perioperative outcomes were compared between groups.Results: A total of 42 SP and 24 DP patients were analyzed. The DP group had a 44.4-minute longer operating room time compared to the SP group (P<0.001) after adjusting for the number of levels operated (P<0.001) and unilateral versus bilateral screw placement (P=0.048). Otherwise, no differences were observed in peri-operative outcomes. Lordosis was not different between groups pre-operatively (P>0.999) or post-operatively (P=0.479), and neither was the pre- to post-operative change (P=0.283).Conclusions: Lateral pedicle screw fixation following lateral interbody fusion decreases operating room time without compromising post-operative lordosis, complication rates, or perioperative outcomes.

  View details for PubMedID 30714003

• Evaluation of peritalar subluxation in adult acquired flatfoot deformity using computed tomography and weightbearing multiplanar imaging FOOT AND ANKLE SURGERY Kunas, G. C., Probasco, W., Haleem, A. M., Burket, J. C., Williamson, E. C., Ellis, S. J. 2018; 24 (6): 495–500

  Abstract

  The aim of this study was to assess the inferior talus-superior talus (inf-tal-sup-tal) angle (previously proven reliable in multiplanar-weight bearing imaging (MP-WB)) on both computed tomography (CT) and MP-WB scans. We sought to compare the angle between the two modalities in both AAFD and control groups, as well as to compare the groups to each other.Inf-tal-sup-tal angles were compared between a stage II AAFD group (n=38) with routine MP-WB and CT scans and a control group (n=20) with preoperative CT scans for lisfranc injuries and normal hindfoot alignment after healing.The CT inf-tal-sup-tal angle was significantly greater in AAFD compared to control (AAFD, 12±6; control, 5±4; p<0.001), but was even greater with MP-WB. There was no significant correlation between inf-tal-sup-tal angles on MP-WB and CT (Pearson's=0.29, p=0.08).MP-WB imaging proved to be correlated more strongly with AAFD than CT by revealing greater hindfoot valgus. This confirmed that CT scans are useful in predicting AAFD, but cannot be used as a surrogate for MP-WB scans.

  View details for DOI 10.1016/j.fas.2017.05.010

  View details for Web of Science ID 000451098700006

  View details for PubMedID 29409191

• Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Koltsov, J. B., Marx, R. G., Bachner, E., McLawhorn, A. S., Lyman, S. 2018; 100 (14): 1203–8

  Abstract

  Studies of volume-outcome relationships typically subdivide volume via non-evidence-based methods, producing categories that vary widely among studies, preclude the comparison of results, and possibly obscure the true volume-outcome relationships. The goal of the current study was to use quantitative methods to derive meaningful, risk-based categories for hospital and surgeon total hip arthroplasty (THA) volume based on relationships with mortality, complications, and revision.Using New York statewide patient data (1997 to 2014; n = 187,557), we derived risk-based hospital and surgeon-volume categories for primary THA based on relationships with 90-day complications and mortality and 2-year revision.The following categories, based on relationships with complications, mortality, and revision, were derived for surgeon volume: 0 to 12, 13 to 25, 26 to 72, 73 to 165, 166 to 279, and ≥280 THA/year. For hospital volume, the categories derived were 0 to 11, 12 to 54, 55 to 157, 158 to 526, and ≥527 THA/year. More than 35% of THA cases in New York State were conducted by surgeons performing ≤1 THA/month (0 to 12 THA/year), and these were associated with a 2 to 2.5-fold increase in the risk for complications, mortality, and revision relative to higher-volume surgeons. Similarly, 15% of THA cases in New York State were conducted in hospitals performing ≤1 THA/week (0 to 11 or 12 to 54 THA/year), and these were associated with a nearly 1.5-fold increase in complications and between a 4 and 6-fold increase in mortality. Traditional non-evidence-based quartile categories were concentrated at lower volumes, did not capture the full magnitude of the volume-related differences, and were a poorer representation of the outcome data, as assessed by several model metrics. Thus, quartiles showed only a <2-fold increase in complications, mortality, and revision for the lowest versus the highest surgeon-volume quartile and failed to show the increased risk for lower versus higher hospital volumes.The volume-outcome relationships in THA are more pronounced than previously apparent through standard statistical techniques. Volume-based strategies for improving outcomes in THA should use benchmarks that are evidence-based to achieve optimal results.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.17.00967

  View details for Web of Science ID 000441550500012

  View details for PubMedID 30020125

• The Root-Ely Modified Test of Rectus Femoris Spasticity Has Reliability in Individuals with Cerebral Palsy. HSS journal : the musculoskeletal journal of Hospital for Special Surgery Drefus, L. C., Clarke, S., Resnik, K., Koltsov, J., Dodwell, E. R., Scher, D. M. 2018; 14 (2): 143–47

  Abstract

  Background: Stiff-knee gait is a common gaitdeviation in individuals with cerebral palsy (CP) due to rectus femoris (RF) muscle spasticity. The Duncan-Ely test is a velocity-dependent measurement of spasticity that is recorded as positive or negative. At our institution, we use a modification of the Duncan-Ely test, a 5-point ordinal rating scale, which delineates where the catch occurs within the rapid arc of knee flexion. It has been named the Root-Ely test.Questions/Purposes: We sought to determine the intra- and inter-rater reliability of the Duncan-Ely and Root-Ely tests in pediatric patients with CP.Methods: A convenience sample of 20 ambulatory subjects was recruited; mean age was 10.5±4.5years, and the Gross Motor Function Classification System (GMFCS) levels were I-III. Five clinicians measured each individual's RF spasticity using the Root-Ely protocol during a single visit. Simple kappa statistics with 95% confidence intervals (CI) were utilized for intra-rater reliability and weighted kappa statistics with 95% CI for inter-rater reliability.Results: The Root-Ely scale intra-rater reliability was 0.77 to 0.90 and inter-rater reliability was 0.32 to 0.87. Inter-rater reliability was good to excellent among experienced clinicians and fair to moderate in new clinicians.Conclusion: The Root-Ely 5-point scale has acceptable intra- and inter-rater reliability in pediatric individuals with CP among experienced clinicians. The Root-Ely test allows experienced clinicians to reliably quantify severity of RF spasticity and may give orthopaedic surgeons a clinical tool to betterpredict ideal candidates for RF transfers in individuals with CP in order to improve stiff-knee gait.

  View details for DOI 10.1007/s11420-018-9609-5

  View details for PubMedID 29983655

• Lumbar Epidural Steroid Injections for Herniation and Stenosis: Incidence and Risk Factors of Subsequent Surgery. The spine journal : official journal of the North American Spine Society Koltsov, J. C., Smuck, M. W., Zagel, A., Alamin, T. F., Wood, K. B., Cheng, I., Hu, S. S. 2018

  Abstract

  BACKGROUND CONTEXT: Lumbosacral ESIs have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI.PURPOSE: The purpose of this research was to determine the proportion of patients having surgery after lumbar epidural steroid injection (ESI) for disc herniation or stenosis and to identify the timing and factors associated with this progression STUDY DESIGN/SETTING: This study was a retrospective review of nationally-representative administrative claims data from the Truven Health MarketScan databases from 2007 - 2014.PATIENT SAMPLE: The study cohort was comprised of 179,025 patients (54±15 years, 48% female) having lumbar epidural steroid injections (ESIs) for diagnoses of stenosis and/or herniation.OUTCOME MEASURES: The primary outcome measure was the time from ESI to surgery.METHODS: Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year prior to ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.RESULTS: Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to 5 to 7 fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, CHF, obesity, COPD, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates.CONCLUSIONS: In the long-term, more than 1 out of every 4 patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly 1 of 6 had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision making process.

  View details for PubMedID 29959098

• Feasibility, Validity, and Reliability of the 10-item Patient Reported Outcomes Measurement Information System Global Health Short Form in Outpatients with Systemic Lupus Erythematosus JOURNAL OF RHEUMATOLOGY Kasturi, S., Szymonifka, J., Burket, J. C., Berman, J. R., Kirou, K. A., Levine, A. B., Sammaritano, L. R., Mandl, L. A. 2018; 45 (3): 397–404

  Abstract

  To assess the feasibility, validity, and reliability of the Patient Reported Outcomes Measurement Information System Global Health Short Form (PROMIS10) in outpatients with systemic lupus erythematosus (SLE).SLE outpatients completed PROMIS10, Medical Outcomes Study Short Form-36 (SF-36), LupusQoL-US, and selected PROMIS computerized adaptive tests (CAT) at routine visits at an SLE Center of Excellence. Construct validity was evaluated by correlating PROMIS10 physical and mental health scores with PROMIS CAT, legacy instruments, and physician-derived measures of disease activity and damage. Test-retest reliability was determined among subjects reporting stable SLE activity at 2 assessments 1 week apart using intraclass correlation coefficients (ICC).A diverse cohort of 204 out of 238 patients with SLE (86%) completed survey instruments. PROMIS10 physical health scores strongly correlated with physical function, pain, and social health domains in PROMIS CAT, SF-36, and LupusQoL, while mental health scores strongly correlated with PROMIS depression CAT, SF-36, and LupusQoL mental health domains (Spearman correlations ≥ 0.70). Active arthritis, comorbid fibromyalgia (FM), and anxiety were associated with worse PROMIS10 scores, but sociodemographic factors and physician-assessed flare status were not. Test-retest reliability for PROMIS10 physical and mental health scores was high (ICC ≥ 0.85). PROMIS10 required < 2 minutes to complete.PROMIS10 is valid and reliable, and can efficiently screen for impaired physical function, pain, and emotional distress in outpatients with SLE. With strong correlations to LupusQoL and SF-36 but significantly reduced responder burden, PROMIS10 is a promising tool for measuring patient-reported outcomes in routine SLE clinical care and value-based healthcare initiatives.

  View details for DOI 10.3899/jrheum.170590

  View details for Web of Science ID 000426368000016

  View details for PubMedID 29419473

  View details for PubMedCentralID PMC5873576

• Men and Women Differ in the Biochemical Composition of Platelet-Rich Plasma AMERICAN JOURNAL OF SPORTS MEDICINE Xiong, G., Lingampalli, N., Koltsov, J. B., Leung, L. L., Bhutani, N., Robinson, W. H., Chu, C. R. 2018; 46 (2): 409–19

  Abstract

  Autologous platelet-rich plasma (PRP) is widely used for a variety of clinical applications. However, clinical outcome studies have not consistently shown positive effects. The composition of PRP differs based on many factors. An improved understanding of factors influencing the composition of PRP is important for the optimization of PRP use.Age and sex influence the PRP composition in healthy patients.Controlled laboratory study.Blood from 39 healthy patients was collected at a standardized time and processed into leukocyte-poor PRP within 1 hour of collection using the same laboratory centrifuge protocol and frozen for later analysis. Eleven female and 10 male patients were "young" (aged 18-30 years), while 8 male and 10 female patients were "older" (aged 45-60 years). Thawed PRP samples were assessed for cytokine and growth factor levels using a multiplex assay and enzyme-linked immunosorbent assay. The platelet count and high-sensitivity C-reactive protein levels were measured. Two-way analysis of variance determined age- and sex-based differences.Platelet and high-sensitivity C-reactive protein concentrations were similar in PRP between the groups ( P = .234). Male patients had higher cytokine and growth factor levels in PRP compared with female patients for inflammatory cytokines such as interleukin-1 beta (IL-1β) (9.83 vs 7.71 pg/mL, respectively; P = .008) and tumor necrosis factor-alpha (TNF-α) (131.6 vs 110.5 pg/mL, respectively; P = .048); the anti-inflammatory IL-1 receptor antagonist protein (IRAP) (298.0 vs 218.0 pg/mL, respectively; P < .001); and growth factors such as fibroblast growth factor-basic (FGF-basic) (237.9 vs 194.0 pg/mL, respectively; P = .01), platelet-derived growth factor (PDGF-BB) (3296.2 vs 2579.3 pg/mL, respectively; P = .087), and transforming growth factor-beta 1 (TGF-β1) (118.8 vs 92.8 ng/mL, respectively; P = .002). Age- but not sex-related differences were observed for insulin-like growth factor-1 (IGF-1) ( P < .001). Age and sex interaction terms were not significant. While mean differences were significant, there was also substantial intragroup variability.This study in healthy patients shows differences in the composition of PRP between men and women, with sex being a greater factor than age. There was also proteomic variability within the groups. These data support a personalized approach to PRP treatment and highlight the need for a greater understanding of the relationships between proteomic factors in PRP and clinical outcomes.Variability in the proteomic profile of PRP may affect tissue and clinical responses to treatment. These data suggest that clinical studies should account for the composition of PRP used.

  View details for PubMedID 29211968

• Tarsometatarsal joint communication during fluoroscopy-guided therapeutic joint injections and relationship with patient age and degree of osteoarthritis SKELETAL RADIOLOGY Endo, Y., Nwawka, O., Smith, S., Burket, J. C. 2018; 47 (2): 271–77

  Abstract

  Although the tarsometatarsal joints are separated into three distinct synovial compartments, communications between adjacent compartments are often noted during image-guided injections. This study aims to determine whether abnormal inter-compartment tarsometatarsal joint communication is associated with patient age or degree of tarsometatarsal osteoarthritis.One hundred forty tarsometatarsal injections were retrospectively reviewed by two radiologists. Extent of inter-compartment communication and degree of osteoarthritis were independently scored. Univariate and multivariable analyses were performed to assess whether the presence of and number of abnormal joint communications were related to age and degree of osteoarthritis.Forty out of 140 tarsometatarsal joints showed abnormal communication with a separate synovial compartment, and 3 of the 40 showed abnormal communication with two separate compartments. On univariate analysis, higher grade osteoarthritis (p < 0.001) and older age (p = 0.014) were associated with an increased likelihood of abnormal inter-compartment tarsometatarsal communication and a greater number of these abnormal communications. On multivariate analysis, the degree of osteoarthritis remained a significant predictor of the presence of (p < 0.001) and number of (p < 0.001) abnormal communications, while the association of age was not statistically significant. There was significant correlation between age and degree of osteoarthritis (p < 0.001).Higher grade osteoarthritis increases the likelihood of abnormal inter-compartment tarsometatarsal joint communication and is associated with a greater number of abnormal communications. Diagnostic injection to localize a symptomatic tarsometatarsal joint may be less reliable in the setting of advanced osteoarthritis.

  View details for DOI 10.1007/s00256-017-2806-3

  View details for Web of Science ID 000418808200016

  View details for PubMedID 29116343

• Influence of Diagnosis and Other Factors on Patients' Expectations of Foot and Ankle Surgery. Foot & ankle international Cody, E. A., Do, H. T., Koltsov, J. C., Mancuso, C. A., Ellis, S. J. 2018; 39 (6): 641–48

  Abstract

  Many patient factors have been associated with higher or lower expectations of orthopedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients' preoperative expectations of elective foot and ankle surgery.Two hundred seventy-eight patients undergoing elective foot or ankle surgery for 1 of 7 common diagnoses were enrolled in a prospective cohort study. Preoperative expectations were assessed with the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed the Foot & Ankle Outcome Score, Short Form 12, pain visual analog scale, and questionnaires for depressive and anxiety symptoms. Demographic and clinical data were collected. Patient factors and diagnosis were analyzed using multivariate regression analysis to identify independent predictors of higher expectations and determine the effect of diagnosis relative to other patient factors on expectations.The multivariate regression analysis adjusting for demographics and other clinical characteristics showed that diagnosis contributed the most to the model, accounting for 10.5% of the variation in expectations survey scores. Patients with mid- or hindfoot arthritis ( P < .001), hallux valgus ( P = .001), or hallux rigidus ( P = .005) had lower scores (lower expectations) than those with ankle instability or osteochondral lesion. In the model, female sex ( P = .001), non-Caucasian race ( P = .031), and lower scores on the Foot & Ankle Outcome Score daily activities subscale ( P = .024) were associated with higher scores.Diagnosis of ankle instability or osteochondral lesion, female sex, non-Caucasian race, and lower Foot & Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively.Level II, cross-sectional study.

  View details for PubMedID 29448824

• Preoperative Physical Therapy Education Reduces Time to Meet Functional Milestones After Total Joint Arthroplasty CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Soeters, R., White, P. B., Murray-Weir, M., Koltsov, J. B., Alexiades, M. M., Ranawat, A. S., Hip Knee Surgeons Writing Comm 2018; 476 (1): 40–48

  Abstract

  As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty.Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery?Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively).The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups.Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS.Level II, therapeutic study.

  View details for DOI 10.1007/s11999.0000000000000010

  View details for Web of Science ID 000431409000011

  View details for PubMedID 29529614

  View details for PubMedCentralID PMC5919221

• Neurologic adverse event avoidance in lateral lumbar interbody fusion: technical considerations using muscle relaxants. Journal of spine surgery (Hong Kong) Fogel, G. R., Rosen, L. n., Koltsov, J. C., Cheng, I. n. 2018; 4 (2): 247–53

  Abstract

  The retroperitoneal trans-psoas extreme lateral interbody fusion (XLIF) technique has improved over the last decade with increased efficiency and an emphasis on complication avoidance. After all known procedural safeguards are enacted, the most common failure of neuro-monitoring precision may be the use of non-depolarizing muscle relaxants (MR) for induction that is standard of care for anesthesia. Even when non-depolarizing MRs are minimized there is often a small dose given to decrease risk of vocal cord injury with intubation. The most common neurological adverse events (AE) attendant to the lateral approach are thigh dysesthetic pain and hip flexor weakness. The purpose of this study is to present a consecutive series of L3-4 and L4-5 XLIF patients treated by a single surgeon using all procedural safeguards with and without the use of a low dose of non-depolarizing MRs prior to intubation.A retrospective review of 74 consecutive patients treated at 150 levels with XLIF and no muscle relaxants (NMR) were compared to a group of 124 consecutive XLIF patients treated at 238 levels with MR. The surgeon upon discovering a small dose of rocuronium was used for intubation, questioned the effect on the neuromonitoring and NMR group was begun. All procedural technique details remained the same. All patients had XLIF at L3-4, L4-5, or both levels. Perioperative variables were collected, including evoked and free-run EMG readings and postoperative neural and muscular side effects. Hospital records including progress notes describing postoperative symptoms and anesthesia records describing the drugs, dosages, and timing were studied. Clinical records were reviewed at 1, 3 and 6 months for complaints of neurologic AE.NMR patients had a perfect twitch test (>99%) immediately. MR patients had slower arrival of the twitch and often settled at a lower level (80-92%). No surgery was attempted until the twitch test was at least 80%. NMR had 8/74 (10.8%) and MR 36/125 (28.8%) thigh AE (thigh dysthetic pain) at 1 month (P<0.005). No lower extremity weaknesses (femoral nerve injury) were observed in the NMR group and three in the MR group. All NMR thigh AEs resolved by the third month postoperative visit compared with 17/125 at 3 months (P=0.001) and 6/125 at 6 months (P=0.176) with persistent thigh AEs in the MR group.Eliminating MRs altogether appears to have allowed the evoked and free running EMG to be more reliable and accurate in predicting the proximity of the neurologic structures. Thigh AEs related to neural and muscular integrity in NMR patients were limited and eliminated by the 3rd month. The MR group was significantly more likely to have a thigh AE at 1 month and persistent at 3 months. Neurologic AEs may be limited or eliminated when MRs are avoided in lateral lumbar fusion surgery.

  View details for PubMedID 30069514

  View details for PubMedCentralID PMC6046327

• Total hip arthroplasty in young patients with post-traumatic arthritis of the hip HIP INTERNATIONAL Swarup, I., Sutherland, R., Burket, J. C., Figgie, M. P. 2017; 27 (6): 546–50

  Abstract

  Post-traumatic arthritis of the hip is a degenerative condition that commonly affects young patients. In this study, we evaluate long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients aged 35 or younger with post-traumatic arthritis of the hip.We conducted a retrospective study with follow-up. A chart review was performed to identify young patients with post-traumatic arthritis of the hip treated with primary THA. Follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Implant survival was assessed using Kaplan-Meier survival analysis, and patient outcomes were determined using the hip disability and osteoarthritis outcome score (HOOS).We studied 42 patients (44 THAs) with a mean time to follow-up of 14 years. The 10-year implant survival rate was 87% and 20-year implant survival rate was 41%. Implant survival did not differ based on patient age, gender, implant type, bearing surface, or use of cement for implant fixation (p>0.05). The mean HOOS scores at follow-up were 87 for pain, 85 for symptoms, 89 for ADLs, and 76 for sports. HOOS scores were significantly worse in patients that had undergone revision THA (p<0.05).Young patients with post-traumatic arthritis of the hip have good long-term outcomes after THA. However, revision THA is predictive of worse long-term outcomes.

  View details for DOI 10.5301/hipint.5000499

  View details for Web of Science ID 000416143400007

  View details for PubMedID 28574124

• Validity and Reliability of Patient Reported Outcomes Measurement Information System Computerized Adaptive Tests in Systemic Lupus Erythematosus JOURNAL OF RHEUMATOLOGY Kasturi, S., Szymonifka, J., Burket, J. C., Berman, J. R., Kirou, K. A., Levine, A. B., Sammaritano, L. R., Mandl, L. A. 2017; 44 (7): 1024–31

  Abstract

  The aims of this study were to assess the construct validity and the test-retest reliability of Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests (CAT) in patients with systemic lupus erythematosus (SLE).Adults with SLE completed the Medical Outcomes Study Short Form-36, LupusQoL-US version ("legacy instruments"), and 14 selected PROMIS CAT. Using Spearman correlations, PROMIS CAT were compared with similar domains measured with legacy instruments. CAT were also correlated with the Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) disease activity and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) scores. Test-retest reliability was evaluated using ICC.There were 204 outpatients with SLE enrolled in the study and 162 completed a retest. PROMIS CAT showed good performance characteristics and moderate to strong correlations with similar domains in the 2 legacy instruments (r = -0.49 to 0.86, p < 0.001). However, correlations between PROMIS CAT and the SELENA-SLEDAI disease activity and SDI were generally weak and statistically insignificant. PROMIS CAT test-retest ICC were good to excellent, ranging from 0.72 to 0.88.To our knowledge, these data are the first to show that PROMIS CAT are valid and reliable for many SLE-relevant domains. Importantly, PROMIS scores did not correlate well with physician-derived measures. This disconnect between objective signs and symptoms and the subjective patient disease experience underscores the crucial need to integrate patient-reported outcomes into clinical care to ensure optimal disease management.

  View details for DOI 10.3899/jrheum.161202

  View details for Web of Science ID 000405601900011

  View details for PubMedID 28412708

• Retrieval Analysis of Neck-Stem Coupling in Modular Hip Prostheses JOURNAL OF ARTHROPLASTY Su, S. L., Koch, C. N., Nguyen, T. M., Burket, J. C., Wright, T. M., Westrich, G. H. 2017; 32 (7): 2301–6

  Abstract

  Dual-taper modular stems have suffered from high revision rates caused by adverse local tissue reactions secondary to fretting and corrosion. We compared the fretting and corrosion behavior of a group of modular neck designs to that of a design that had been recalled for risks associated with fretting and corrosion at the modular neck junction.We previously analyzed fretting and corrosion on 60 retrieved Rejuvenate modular neck-stem implants. Here we compare those results to results from 26 retrieved implants from 7 other modular neck designs. For the 26 additional cases, histology slides of tissue collected at revision were reviewed and graded for aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). Multivariate analyses were performed to assess differences in fretting and corrosion, adjusting for confounding factors (eg, length of implantation).The Rejuvenate design had higher damage and corrosion scores than the other 7 designs (P < .01). Histologic samples from the recalled design were 20 times more likely to show ALVAL than samples from the other designs (P < .01). Mixed metal couples had higher fretting (P < .01) and corrosion (P = .02) scores than non-mixed metal couples.Fretting and corrosion occurred on all modular neck-stem retrievals regardless of design. However, mixed metal couples suffered more corrosion than homogenous couples. This may be due to the lower modulus of the titanium alloy used for the stem, allowing for increased metal transfer and surface damage when loaded against a cobalt alloy modular neck, which in turn could account for the higher ALVAL and corrosion scores. Due to increased corrosion risk with mixed metals and increased neck fracture risk with non-mixed metal stem and necks, we suggest that clinicians avoid implantation of modular neck-stem systems.

  View details for DOI 10.1016/j.arth.2017.02.016

  View details for Web of Science ID 000406487700049

  View details for PubMedID 28262451

• Outcomes after total hip arthroplasty in young patients with osteonecrosis of the hip HIP INTERNATIONAL Swarup, I., Shields, M., Mayer, E. N., Hendow, C. J., Burket, J. C., Figgie, M. P. 2017; 27 (3): 286–92

  Abstract

  Osteonecrosis of the hip is a clinical, radiographic, and pathologic entity that commonly affects young patients. This study evaluates long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients with osteonecrosis aged 35 or younger.A retrospective study with prospective follow-up was conducted at a major academic medical center. Chart review was performed to identify young THA patients with osteonecrosis, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes.The study included 135 patients (204 THAs) with a mean time to follow-up of 14 years. In this group, 10-year implant survival was 86% and 20-year implant survival was 66%. Implant survival was longer in male patients (p = 0.02) and patients that were over the age of 25 at the time of surgery (p = 0.03). The mean HOOS scores at follow-up were 87 for pain, symptoms, and ADLs, and 77 for sports. All HOOS measures were lower in patients that underwent a revision THA, and HOOS-Pain and HOOS-Sport scores were lower in patients that were over the age of 25 at the time of surgery (p<0.05).Young patients with osteonecrosis have good implant survival and long-term outcomes after THA. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with osteonecrosis.

  View details for DOI 10.5301/hipint.5000457

  View details for Web of Science ID 000401634100014

  View details for PubMedID 28165595

• Single-Level Lateral Lumbar Interbody Fusion for the Treatment of Adjacent Segment Disease SPINE Aichmair, A., Alimi, M., Hughes, A. P., Sama, A. A., Du, J. Y., Hartl, R., Burket, J. C., Lampe, L. P., Cammisa, F. P., Girardi, F. P. 2017; 42 (9): E515–E522

  Abstract

  A retrospective case series.The aim of this study was to assess the postoperative outcome after single-level lateral lumbar interbody fusion (LLIF) for adjacent segment disease (ASD).Although there is a plethora of literature on ASD following traditional arthrodesis techniques, literature on ASD following LLIF is limited. Vice versa, the surgical outcome after LLIF for the treatment of ASD remains to be elucidated.Patients who underwent single-level LLIF for ASD at two institutions (March 2006-April 2012) were included, and the medical records, operative reports, radiographic imaging studies, and office records reviewed.Out of 523 LLIF patients, 52 met the inclusion criteria, and were postoperatively followed for 16.1 ± 9.8 months (range: 5-44). When comparing the pre-operative data with both the first and most recent follow-up postoperatively, LLIF resulted in a reduction in back pain (P < 0.001, and P < 0.001, respectively) and leg pain (P < 0.001, and P < 0.001, respectively), increase in segmental lordosis (P = 0.003, and P = 0.014, respectively), decrease in segmental coronal angulation (P < 0.001, and P = 0.003, respectively), and increase in intervertebral height (P < 0.001, and P < 0.001, respectively) at the surgical level. The reoperation rate related to the LLIF procedure was 21.2% (11/52), which was performed after an average of 14.6 ± 10.1 months (range: 3.3-31.0). Eight out of 11 patients (72.7%) in the reoperation subgroup underwent standalone LLIF, whereas only 23 out of 41 patients (56.1%) without a reoperation underwent standalone LLIF (P = 0.491). There was a trend toward a higher fusion rate in patients who underwent circumferential fusion than the standalone subgroup (87.5% vs. 53.8%; P = 0.173).LLIF may be an effective surgical treatment option for ASD with regard to both the clinical and radiographic outcome in a large proportion of cases. Although standalone LLIF is associated with a narrower spectrum of adverse effects than circumferential fusion, posterior instrumentation may be necessary to increase segmental stability.4.

  View details for DOI 10.1097/BRS.0000000000001871

  View details for Web of Science ID 000401015100003

  View details for PubMedID 28128791

• Patient Factors Associated With Higher Expectations From Foot and Ankle Surgery FOOT & ANKLE INTERNATIONAL Cody, E. A., Mancuso, C. A., Burket, J. C., Marinescu, A., MacMahon, A., Ellis, S. J., HSS Orthopaedic Foot Ankle Surg 2017; 38 (5): 472–78

  Abstract

  Few authors have investigated patients' expectations from foot and ankle surgery. In this study, we aimed to examine relationships between patients' preoperative expectations and their demographic and clinical characteristics. We hypothesized that patients with more disability and those with anxiety or depressive symptoms would have greater expectations.All adult patients scheduled for elective foot or ankle surgery by 1 of 6 orthopaedic foot and ankle surgeons were screened for inclusion over 8 months. Preoperatively, all patients completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey in addition to the Foot & Ankle Outcome Score (FAOS), Short Form (SF)-12, Patient Health Questionnaire (PHQ)-8, Generalized Anxiety Disorder 7-item scale (GAD-7), and pain visual analog scale (VAS). The expectations survey contained 23 expectations categories, each with 5 answer choices ranging from "I do not have this expectation" to "complete improvement" expected. It was scored from 0 to 100, with higher scores indicating more expectations. Differences in expectations relating to numerous patient demographic and clinical variables were assessed. In total, 352 patients with an average age of 55 ± 15 (range, 18-86) years were enrolled.Expectations scores were not related to age ( P = .36). On average, women expected to achieve complete improvement more often than men ( P = .011). Variables that were significantly associated with higher expectations scores ( P < .05) included nonwhite race, use of a cane or other assistive device, and greater medical comorbidity. Worse function and quality of life (as assessed by all FAOS subscales and the SF-12 physical and mental components), more depressive and anxiety symptoms, and higher pain VAS scores were associated with higher expectations scores and more expectations ( P < .01 for all).The results of this study may help inform surgeons' preoperative discussions with their patients regarding realistic expectations from surgery. Generally, patients with worse function and more disability had higher expectations from surgery. Addressing these patients' expectations preoperatively may help improve their ultimate satisfaction with surgery.Level II, cross sectional study.

  View details for DOI 10.1177/1071100717690807

  View details for Web of Science ID 000400486000002

  View details for PubMedID 28196438

• Fretting and Corrosion at the Backside of Modular Cobalt Chromium Acetabular Inserts: A Retrieval Analysis JOURNAL OF ARTHROPLASTY Tarity, T., Koch, C. N., Burket, J. C., Wright, T. M., Westrich, G. H. 2017; 32 (3): 1033–39

  Abstract

  Adverse local tissue reaction formation has been suggested to occur with the Modular Dual Mobility (MDM) acetabular design. Few reports in the literature have evaluated fretting and corrosion damage between the acetabular shell and modular metal inserts in this modular system. We evaluated a series of 18 retrieved cobalt chromium MDM inserts for evidence of fretting and corrosion.We assessed the backsides of 18 MDM components for evidence of fretting and corrosion in polar and taper regions based on previously established methods. We collected and assessed 30 similarly designed modular inserts retrieved from metal-on-metal (MoM) total hip arthroplasties as a control.No specific pattern of fretting or corrosion was identified on the MDM inserts. Both fretting and corrosion were significantly greater in the MoM cohort than the MDM cohort, driven by higher fretting and corrosion scores in the engaged taper region of the MoM inserts.MoM components demonstrated more fretting and corrosion than MDM designs, specifically at the taper region, likely driven by differences in the taper engagement mechanism and geometry among the insert designs. The lack of significant fretting and corrosion observed in the MDM inserts are inconsistent with recent claims that this interface may produce clinically significant metallosis and adverse local tissue reactions.

  View details for DOI 10.1016/j.arth.2016.09.038

  View details for Web of Science ID 000401119900058

  View details for PubMedID 28341314

• Validation of Patient-Reported Outcomes Measurement Information System Computerized Adaptive Tests Against the Foot and Ankle Outcome Score for 6 Common Foot and Ankle Pathologies. Foot & ankle international Koltsov, J. C., Greenfield, S. T., Soukup, D. n., Do, H. T., Ellis, S. J. 2017; 38 (8): 870–78

  Abstract

  The field of foot and ankle surgery lacks a widely accepted gold-standard patient-reported outcome instrument. With the changing infrastructure of the medical profession, more efficient patient-reported outcome tools are needed to reduce respondent burden and increase participation while providing consistent and reliable measurement across multiple pathologies and disciplines. The primary purpose of the present study was to validate 3 Patient-Reported Outcomes Measurement Information System computer adaptive tests (CATs) most relevant to the foot and ankle discipline against the Foot and Ankle Outcome Score (FAOS) and the Short Form 12 general health status survey in patients with 6 common foot and ankle pathologies.Patients (n = 240) indicated for operative treatment for 1 of 6 common foot and ankle pathologies completed the CATs, FAOS, and Short Form 12 at their preoperative surgical visits, 1 week subsequently (before surgery), and at 6 months postoperatively. The psychometric properties of the instruments were assessed and compared.The Patient-Reported Outcomes Measurement Information System CATs each took less than 1 minute to complete, whereas the FAOS took 6.5 minutes, and the Short Form 12 took 3 minutes. CAT scores were more normally distributed and had fewer floor and ceiling effects than those on the FAOS, which reached as high as 24%. The CATs were more precise than the FAOS and had similar responsiveness and test-retest reliability. The physical function and mobility CATs correlated strongly with the activities subscale of the FAOS, and the pain interference CAT correlated strongly with the pain subscale of the FAOS. The CATs and FAOS were responsive to changes with operative treatment for 6 common foot and ankle pathologies.The CATs performed as well as or better than the FAOS in all aspects of psychometric validity. The Patient-Reported Outcomes Measurement Information System CATs show tremendous potential for improving the study of patient outcomes in foot and ankle research through improved precision and reduced respondent burden.Level II, prospective comparative study.

  View details for PubMedID 28602138

• Crosslink Density Is Reduced and Oxidation Is Increased in Retrieved Highly Crosslinked Polyethylene TKA Tibial Inserts Liu, T., Esposito, C. I., Burket, J. C., Wright, T. M. LIPPINCOTT WILLIAMS & WILKINS. 2017: 128–36

  Abstract

  The wear resistance of highly crosslinked polyethylene depends on crosslink density, which may decrease with in vivo loading, leading to more wear and increased oxidation. The relationship among large and complex in vivo mechanical stresses, breakdown of the polyethylene crosslinks, and oxidative degradation is not fully understood in total knee arthroplasty (TKA). We wished to determine whether crosslink density is reduced at the articular surfaces of retrieved tibial inserts in contact areas exposed to in vivo mechanical stress.(1) Does polyethylene crosslink density decrease preferentially in regions of the articular surface of thermally stabilized crosslinked polyethylene tibial components exposed to mechanical stress in vivo; and (2) what is the ramification of decreased crosslink density in TKA in terms of accompanying oxidation of the polyethylene?From May 2011 to January 2014, 90 crosslinked polyethylene tibial components were retrieved during revision surgery as a part of a long-standing implant retrieval program. Forty highly crosslinked polyethylene tibial inserts (27 posterior-stabilized designs and 13 cruciate-retaining designs) retrieved for instability (15 cases), stiffness (11), infection (six), aseptic loosening (four), pain (two), and malposition (two) after a mean time of 18 months were inspected microscopically to identify loaded (burnished) and unloaded (unburnished) regions on the articular surfaces. Swell ratio testing was done according to ASTM F2214 to calculate crosslink density and infrared spectroscopy was used according to ASTM F2102 to measure oxidation.The region of the tibial insert influenced crosslink density. Loaded surface regions had a mean crosslink density of 0.19 (95% confidence interval [CI], 0.18-0.19) mol/dm3, lower than the other three regions (loaded subsurface, unloaded surface, and unloaded subsurface), which had crosslink densities of 0.21 (95% CI, 0.21-0.22; p < 0.01) mol/dm3. Peak oxidation levels were higher in loaded regions with a mean oxidation index (OI) of 0.67 (95% CI, 0.56-0.78) versus unloaded regions with a mean OI of 0.36 (95% CI, 0.27-0.45; p < 0.01). Peak oxidation levels were higher in annealed samples with a mean OI of 0.66 (95% CI, 0.52-0.81) versus remelted samples with a mean OI of 0.40 (95% CI, 0.34-0.47; p < 0.01).The results suggest that the crosslink density decreases and accompanying oxidation is driven predominantly by contact stress conditions. If crosslink density continues to decrease with continued loading over time, crosslinked polyethylene may not provide a clinical advantage over conventional polyethylene in the long term for TKA. Therefore, we will continue to collect longer term retrievals to evaluate mechanical property changes in crosslinked polyethylenes.Although we found a decrease in crosslink density and increase in oxidation in the tibial inserts, the degree of oxidation does not suggest, for now, a reason for concern in these early retrievals. The OI values of the tibial inserts in this study were lower than the critical oxidation level (OI > 3) reported in the literature where polyethylene may lose mechanical properties and have the compromised ability to withstand mechanical loading.

  View details for DOI 10.1007/s11999-016-4820-5

  View details for Web of Science ID 000391386700024

  View details for PubMedID 27084716

  View details for PubMedCentralID PMC5174027

• Development of an Expectations Survey for Patients Undergoing Foot and Ankle Surgery FOOT & ANKLE INTERNATIONAL Cody, E. A., Mancuso, C. A., MacMahon, A., Marinescu, A., Burket, J. C., Drakos, M. C., Roberts, M. M., Ellis, S. J. 2016; 37 (12): 1277–84

  Abstract

  Many authors have reported on patient satisfaction from foot and ankle surgery, but rarely on expectations, which may vary widely between patients and strongly affect satisfaction. In this study, we aimed to develop a patient-derived survey on expectations from foot and ankle surgery.We developed and tested our survey using a 3-phase process. Patients with a wide spectrum of foot and ankle diagnoses were enrolled. In phase 1, patients were interviewed preoperatively with open-ended questions about their expectations from surgery. Major concepts were grouped into categories that were used to form a draft survey. In phase 2, the survey was administered to preoperative patients on 2 occasions to establish test-retest reliability. In phase 3, the final survey items were selected based on weighted kappa values for response concordance and clinical relevance.In phase 1, 94 preoperative patients volunteered 655 expectations. Twenty-nine representative categories were discerned by qualitative analysis and became the draft survey. In phase 2, another 60 patients completed the draft survey twice preoperatively. In phase 3, 23 items were retained for the final survey. For retained items, the average weighted kappa value was 0.54. An overall score was calculated based on the amount of improvement expected for each item on the survey and ranged from zero to 100, with higher scores indicating more expectations. For patients in phase 2, mean scores for both administrations were 65 and 66 and approximated normal distributions. The intraclass correlation coefficient between scores was 0.78.We developed a patient-derived survey specific to foot and ankle surgery that is valid, reliable, applicable to diverse diagnoses, and includes physical and psychological expectations. The survey generates an overall score that is easy to calculate and interpret, and thus offers a practical and comprehensive way to record patients' expectations. We believe this survey may be used preoperatively by surgeons to help guide patients' expectations and facilitate shared decision making.Level II, cross-sectional study.

  View details for DOI 10.1177/1071100716666260

  View details for Web of Science ID 000389716000002

  View details for PubMedID 27654045

• Microbiologic profile of infections in presumed aseptic revision spine surgery EUROPEAN SPINE JOURNAL Shifflett, G. D., Bjerke-Kroll, B. T., Nwachukwu, B. U., Kueper, J., Burket, J., Sama, A. A., Girardi, F. P., Cammisa, F. P., Hughes, A. P. 2016; 25 (12): 3902–7

  Abstract

  Intra-operative cultures may be obtained in revision spine surgery despite the absence of pre-operative clinical markers of infection. The microbiologic profile of culture positive cases in which there is no clear evidence of infection preoperatively has not been described. The aim of this investigation is to report on the microbiologic profile of unexpected culture positive revision spine surgery cases.We retrospectively reviewed 595 consecutive revision spine surgeries performed between 2008 and 2013. Five hundred and seventy-eight revision surgeries were performed for diagnoses other than infection and were included in the study.Operative cultures were obtained in 112 cases (19.4 %). Cultures were positive in 45 cases. Pseudarthrosis was not only the most common diagnosis overall (49.1 %) in which intra-operative cultures were obtained, it was also the most common revision surgical diagnosis where cultures were positive (55.6 %). Propionibacterium acnes was cultured in 54.2 % of cases with the primary diagnosis of pseudarthrosis, but only in 40.9 % of cases with other diagnoses (P = 0.554). Overall, staphylococcal species were found most commonly (57.8 % of cases), but P. acnes was at least one of the isolates in 48.9 % of cases and was three times more common than any other organism.Nearly one in five patients with the diagnosis of pseudarthrosis were culture positive. More specifically, pseudarthrosis was the most common culture positive diagnosis and P. acnes species predominated in this patient population. Propionibacterium acnes was overwhelmingly the most common single organism cultured in revision spine surgery. Given this, we recommend all cultures be held for P. acnes, particularly in the setting of pseudarthrosis.

  View details for DOI 10.1007/s00586-016-4539-8

  View details for Web of Science ID 000389265000007

  View details for PubMedID 27026016

• The Quality of Open-Access Video-Based Orthopaedic Instructional Content for the Shoulder Physical Exam is Inconsistent. HSS journal : the musculoskeletal journal of Hospital for Special Surgery Urch, E., Taylor, S. A., Cody, E., Fabricant, P. D., Burket, J. C., O'Brien, S. J., Dines, D. M., Dines, J. S. 2016; 12 (3): 209–15

  Abstract

  BACKGROUND: The internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open-access video content designed for provider use.QUESTIONS/PURPOSES: The primary goal of the study was to determine the accuracy of internet-based instructional videos featuring the shoulder physical examination.METHODS: An assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a surrogate for the "best-case scenario" due to its widely accepted components that are stable over time. Three search terms ("shoulder," "examination," and "shoulder exam") were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopaedic surgeons. Quality and accuracy were assessed in accordance with previously published standards.RESULTS: Of the 39 video tutorials reviewed, 61% were rated as fair or poor. Specific maneuvers such as the Hawkins test, O'Brien sign, and Neer impingement test were accurately demonstrated in 50, 36, and 27% of videos, respectively. Inter-rater reliability was excellent (mean kappa 0.80, range 0.79-0.81).CONCLUSION: Our results suggest that information presented in open-access video tutorials featuring the physical examination of the shoulder is inconsistent. Trainee exposure to such potentially inaccurate information may have a significant impact on trainee education.

  View details for PubMedID 27703413

• Effects on the Tarsal Tunnel Following Malerba Z-type Osteotomy Compared to Standard Lateralizing Calcaneal Osteotomy FOOT & ANKLE INTERNATIONAL Cody, E. A., Greditzer, H. G., MacMahon, A., Burket, J. C., Sofka, C. M., Ellis, S. J. 2016; 37 (9): 1017–22

  Abstract

  Tarsal tunnel syndrome is a known complication of lateralizing calcaneal osteotomy. A Malerba Z-type osteotomy may preserve more tarsal tunnel volume (TTV) and decrease risk of neurovascular injury. We investigated 2 effects on the tarsal tunnel of the Malerba osteotomy compared to a standard lateralizing osteotomy using a cadaveric model: (1) the effect on TTV as measured by magnetic resonance imaging (MRI) and (2) the proximity of the osteotomy saw cuts to the tibial nerve.Ten above-knee paired cadaveric specimens underwent MRI of the ankle to obtain a baseline measurement of TTV. One foot in each pair received a standard lateralizing calcaneal osteotomy, with the other foot receiving a Malerba osteotomy. MRIs were performed after each of 3 increasing amounts of lateral displacement, which were accompanied by increasing amounts of wedge resection in the Malerba osteotomy group. TTV was measured on MRI using previously described and validated parameters. Differences in TTV with osteotomy type, displacement, and their interaction were assessed with generalized estimating equations. After all MRIs were completed, each specimen was dissected and the nearest distance of tibial nerve branches to the osteotomy site was measured.Baseline TTV averaged 13 229 ± 2354 mm(3) and did not differ between groups (P = .386). TTV decreased on average by 7% after the first translation, 14% after the second, and 27% after the third (P < .005 for each). The magnitude of the decrease in TTV did not differ between those specimens with standard osteotomies versus those with Malerba osteotomies (P = .578). At least one of the major branches of the tibial nerve crossed the osteotomy site in 5 of 5 specimens that received the Malerba osteotomy versus 2 of 5 that received a standard osteotomy.Regardless of osteotomy type, lateralizing calcaneal osteotomy decreased TTV. In all specimens, the osteotomy was at the level of branches of the tibial nerve.Our results demonstrate that lateralizing calcaneal osteotomies must be performed with care to avoid excessive lateral translation as well as direct nerve injury on the nonvisualized medial side of the calcaneus.

  View details for DOI 10.1177/1071100716651966

  View details for Web of Science ID 000382971600016

  View details for PubMedID 27283154

• Correlation of Talar Anatomy and Subtalar Joint Alignment on Weightbearing Computed Tomography With Radiographic Flatfoot Parameters FOOT & ANKLE INTERNATIONAL Cody, E. A., Williamson, E. R., Burket, J. C., Deland, J. T., Ellis, S. J. 2016; 37 (8): 874–81

  Abstract

  Underlying bony deformity may be related to development of adult-acquired flatfoot deformity (AAFD). Multiplanar weightbearing (MP-WB) computed tomography can be used to identify subtalar deformity which may contribute to valgus hindfoot alignment. On coronal MP-WB images, 2 angles reliably evaluate the subtalar joint axis: the angle between the inferior facet of the talus and the horizontal (inftal-hor) and the angle between the inferior and superior facets of the talus (inftal-suptal). Although these angles have been shown to differ significantly between flatfoot patients and controls, no study has investigated their relationships with other components of AAFD. We hypothesized that these angles would correlate strongly with commonly used radiographic measures of AAFD.Forty-five patients with stage II AAFD and 17 control patients underwent MP-WB imaging and standard weightbearing radiographs. MP-WB measurements were correlated with standard radiographic measurements of AAFD. Differences between AAFD and control patients were assessed using independent samples t tests and Mann-Whitney U tests. To assess correlations between each MP-WB measurement and radiographic measurement, factorial generalized linear models (GLMs) were constructed.Patients with AAFD differed from the controls in all measured angles (P ≤ .001 for each). After accounting for differences between flatfoot and control patients, inftal-hor was not significantly correlated with any of the radiographic angles. Inftal-suptal, however, correlated with the AP coverage angle, AP talar-first metatarsal angle, calcaneal pitch, Meary's angle, medial column height, and hindfoot alignment after accounting for differences between flatfoot patients and controls. Meary's angle alone explained 48% of the variation in inftal-suptal angles.As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. It is possible that this information could be used to identify patients likely to have progression of deformity and may ultimately guide the approach to operative reconstruction.Level III, case-control study.

  View details for DOI 10.1177/1071100716646629

  View details for Web of Science ID 000382214900012

  View details for PubMedID 27137795

• Return to Sports and Physical Activities After Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients FOOT & ANKLE INTERNATIONAL MacMahon, A., Kim, P., Levine, D. S., Burket, J., Roberts, M. M., Drakos, M. C., Deland, J. T., Elliott, A. J., Ellis, S. J. 2016; 37 (4): 355–62

  Abstract

  Research regarding outcomes in sports and physical activities after primary partial arthrodesis for Lisfranc injuries has been sparse. The purposes of this study were to assess various sports and physical activities in young patients following primary partial arthrodesis for Lisfranc injuries and to compare these with clinical outcomes.Patients who underwent primary partial arthrodesis for a Lisfranc injury were identified by a retrospective registry review. Thirty-eight of 46 eligible patients (83%) responded for follow-up at a mean of 5.2 (range, 1.0 to 9.3) years with a mean age at surgery of 31.8 (range, 16.8 to 50.3) years. Physical activity participation was assessed with a new sports-specific, patient-administered questionnaire. Clinical outcomes were assessed with the Foot and Ankle Outcome Score (FAOS).Patients participated in 29 different and 155 total physical activities preoperatively, and 27 different and 145 total physical activities postoperatively. Preoperatively, 47.1% were high impact, and postoperatively, 44.8% were high impact. The most common activities were walking, bicycling, running, and weightlifting. Compared to preoperatively, difficulty was the same in 66% and increased in 34% of physical activities. Participation levels were improved in 11%, the same in 64%, and impaired in 25% of physical activities. Patients spent on average 4.2 (range, 0.0 to 19.8) hours per week exercising postoperatively. In regard to return to physical activity, 97% of respondents were satisfied with their operative outcome. Mean postoperative FAOS subscores were significantly worse for patients who had increased physical activity difficulty.Most patients were able to return to their previous physical activities following primary partial arthrodesis for a Lisfranc injury, many of which were high-impact. However, the decreased participation or increase in difficulty of some activities suggests that some patients experienced postoperative limitations in exercise. Future studies could compare sports outcomes between primary partial arthrodesis and open reduction internal fixation for Lisfranc injuries.Level IV, retrospective case series.

  View details for DOI 10.1177/1071100715617743

  View details for Web of Science ID 000373668700002

  View details for PubMedID 26596795

• Return to Sports and Physical Activities After the Modified Lapidus Procedure for Hallux Valgus in Young Patients FOOT & ANKLE INTERNATIONAL MacMahon, A., Karbassi, J., Burket, J. C., Elliott, A. J., Levine, D. S., Roberts, M. M., Deland, J. T., O'Malley, M. J., Yu, J., Mancuso, C. A., Ellis, S. J. 2016; 37 (4): 378–85

  Abstract

  The modified Lapidus procedure has successfully relieved pain and corrected deformity in patients with hallux valgus, but its effect on participation in specific sports and physical activities remains unclear. Our goals were to assess sports and physical activities in young patients following the modified Lapidus procedure and to compare these with clinical outcomes.Fifty-eight eligible patients were identified from a retrospective registry review. Of these, 48 (83%) were reached for follow-up at a mean of 2.8 (range, 1.0 to 6.1) years and had a mean age at surgery of 37.3 (range, 14.1 to 49.3) years. Physical activity participation was evaluated with a new sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS) and compared to sports outcomes.Patients participated in 26 different physical activities, consisting of 212 total physical activities preoperatively and 209 total postoperatively. The most common were walking, running, bicycling, and swimming. Compared to preoperatively, patients rated 29% of activities as less difficult, 52% as the same, and 19% as more difficult and rated participation levels as improved in 40%, the same in 41%, and impaired in 19%. Eighty-one percent of patients were satisfied with their operative outcome in regard to return to physical activity. Changes in the FAOS Pain subscore were significantly associated with improvements in physical activity difficulty (P < .05), and changes in the Pain, Sports, and QOL subscores were significantly associated with changes in physical activity participation levels (P < .05).Four in 5 patients were able to participate in previous sports and physical activities, including high-impact activities, at their preoperative participation level or better after the modified Lapidus procedure, and were satisfied with surgery in regard to return to previous activity. However, several patients had increased difficulty and impaired participation in physical activity postoperatively. Altogether, this suggests that the procedure is a viable treatment option for hallux valgus in young, active patients.Level IV, retrospective case series.

  View details for DOI 10.1177/1071100715617750

  View details for Web of Science ID 000373668700005

  View details for PubMedID 26578481

• Evaluation of Physical Examination Tests for Thumb Basal Joint Osteoarthritis. Hand (New York, N.Y.) Model, Z., Liu, A. Y., Kang, L., Wolfe, S. W., Burket, J. C., Lee, S. K. 2016; 11 (1): 108–12

  Abstract

  BACKGROUND: We compare the ability of 3 diagnostic tests to reproduce the pain of basilar joint arthritis (BJA): the grind test, the lever test (grasping the first metacarpal just distal to the basal joint and shucking back and forth in radial and ulnar directions), and the metacarpophalangeal extension test.METHODS: Sixty-two patients with thumb BJA were enrolled. The 3 tests were performed in a random order on both hands of each patient. Prior to testing, patients reported their typical pain level and subsequently rated their pain after each test on a 0 to 10 scale, also specifying the extent to which the test reproduced their thumb pain (fully, partially, not at all). All patients had radiographs that displayed basal joint arthritis. A test was defined as positive for BJA if pain produced was greater than 0. Sensitivity and specificity for each test were calculated using the patients' history of pain localized to the basal joint and BJA diagnosis on radiographs as the gold standard.RESULTS: The lever test produced the greatest level of pain and best reproduced the presenting pain. The lever test also had the highest sensitivity, high specificity, and the lowest false-negative rate. The grind test had the lowest sensitivity, highest specificity, and highest false-negative rate.CONCLUSIONS: The lever test was the diagnostic test that best reproduced the pain caused by thumb basal joint osteoarthritis. We recommend using the lever physical examination test when evaluating the patient with suspected basal joint osteoarthritis. The often-quoted grind test is of limited diagnostic value.

  View details for DOI 10.1177/1558944715616951

  View details for PubMedID 27418899

• Altered distributions of bone tissue mineral and collagen properties in women with fragility fractures BONE Wang, Z., Lloyd, A. A., Burket, J. C., Gourion-Arsiquaud, S., Donnelly, E. 2016; 84: 237–44

  Abstract

  Heterogeneity of bone tissue properties is emerging as a potential indicator of altered bone quality in pathologic tissue. The objective of this study was to compare the distributions of tissue properties in women with and without histories of fragility fractures using Fourier transform infrared (FTIR) imaging. We extended a prior study that examined the relationship of the mean FTIR properties to fracture risk by analyzing in detail the widths and the tails of the distributions of FTIR properties in biopsies from fracture and non-fracture cohorts. The mineral and matrix properties of cortical and trabecular iliac crest tissue were compared in biopsies from women with a history of fragility fracture (+Fx; n=21, age: mean 54±SD 15y) and with no history of fragility fracture (-Fx; n=12, age: 57±5y). A subset of the patients included in the -Fx group were taking estrogen-plus-progestin hormone replacement therapy (HRT) (-Fx+HRT n=8, age: 58±5y) and were analyzed separately from patients with no history of HRT (-Fx-HRT n=4, age: 56±7y). When the FTIR parameter mean values were examined by treatment group, the trabecular tissue of -Fx-HRT patients had a lower mineral:matrix ratio (M:M) and collagen maturity (XLR) than that of -Fx+HRT patients (-22% M:M, -18% XLR) and +Fx patients (-17% M:M, -18% XLR). Across multiple FTIR parameters, tissue from the -Fx-HRT group had smaller low-tail (5th percentile) values than that from the -Fx+HRT or +Fx groups. In trabecular collagen maturity and crystallinity (XST), the -Fx-HRT group had smaller low-tail values than those in the -Fx+HRT group (-16% XLR, -5% XST) and the +Fx group (-17% XLR, -7% XST). The relatively low values of trabecular mineral:matrix ratio and collagen maturity and smaller low-tail values of collagen maturity and crystallinity observed in the -Fx-HRT group are characteristic of younger tissue. Taken together, our data suggest that the presence of newly formed tissue that includes small/imperfect crystals and immature crosslinks, as well as moderately mature tissue, is an important characteristic of healthy, fracture-resistant bone. Finally, the larger mean and low-tail values of mineral:matrix ratio and collagen maturity noted in our -Fx+HRT vs. -Fx-HRT biopsies are consistent with greater tissue age and greater BMD arising from decreased osteoclastic resorption in HRT-treated patients.

  View details for DOI 10.1016/j.bone.2016.01.012

  View details for Web of Science ID 000370914600028

  View details for PubMedID 26780445

• Effect of Obesity on Clinical and Radiographic Outcomes Following Reconstruction of Stage II Adult Acquired Flatfoot Deformity FOOT & ANKLE INTERNATIONAL Soukup, D. S., MacMahon, A., Burket, J. C., Yu, J. M., Ellis, S. J., Deland, J. T. 2016; 37 (3): 245–54

  Abstract

  Obesity is a known risk factor for the development of adult acquired flatfoot deformity (AAFD), but obesity's effects on outcomes following AAFD reconstruction are unknown. We hypothesized that obesity would negatively impact outcomes following joint-preserving stage II AAFD reconstruction.This retrospective study compared the outcomes of normal-weight (18.5 kg/m(2) ≤ BMI < 25 kg/m(2)), overweight (25 kg/m(2) ≤ BMI < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)) patients after AAFD reconstruction. Clinical outcome measures included the Foot and Ankle Outcome Score (FAOS), Short-Form 12 (SF-12), and Numeric Rating Scale of Pain (NRS Pain) administered preoperatively and at least 1 year postoperatively. Anteroposterior and lateral radiographs were taken preoperatively and at least 6 months postoperatively. Pre- to postoperative changes in outcome measures were assessed within BMI classes. Preoperative, postoperative, and pre- to postoperative changes in outcomes were compared among BMI classes. There were 41 normal-weight patients, 39 overweight patients, and 44 obese patients with a mean age of 56 years, FAOS follow-up of 2.9 years, and radiographic follow-up of 2.1 years. Demographics and reconstructive procedures were comparable among the 3 BMI classes.All outcomes significantly increased pre- to postoperatively in the 3 groups with the exception of the FAOS Symptoms subscale for normal-weight patients (P = .340) and SF-12 Mental Component score for all 3 BMI classes (P > .999). Preoperatively, obese patients had more symptoms than normal-weight patients, scoring 12 points lower on the FAOS Symptoms subscore (P = .008). Obese patients also scored 11 points lower preoperatively on the SF-12 Overall score (P = .028) and had 31% greater pain than normal-weight patients (P = .003). There were no differences among the 3 BMI classes in any postoperative outcomes assessed.Although obese patients had significantly worse symptoms, overall health, and NRS pain scores preoperatively, the short-term clinical and radiographic outcomes of stage II AAFD reconstruction were similar for normal-weight, overweight, and obese patients. We suggest that joint-preserving reconstruction remains a viable alternative to fusion of the triple joint complex for the treatment of overweight and obese stage II AAFD patients.Level III, retrospective cohort study.

  View details for DOI 10.1177/1071100715614841

  View details for Web of Science ID 000371314500001

  View details for PubMedID 26542162

• Otto Aufranc Award: Large Heads Do Not Increase Damage at the Head-neck Taper of Metal-on-polyethylene Total Hip Arthroplasties CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Triantafyllopoulos, G. K., Elpers, M. E., Burket, J. C., Esposito, C. I., Padgett, D. E., Wright, T. M. 2016; 474 (2): 330–38

  Abstract

  Fretting and corrosion at head-neck junctions of total hip arthroplasties (THAs) have been associated with adverse local tissue reactions in patients with both metal-on-polyethylene (MoP) and metal-on-metal (MoM) prostheses. Femoral head size contributes to the severity of fretting and corrosion in large-diameter MoM THAs, but its impact on such damage in MoP THAs remains unknown.(1) Is femoral head size associated with increased fretting or corrosion at the head-neck junction in MoP total hips? (2) Is duration of implantation associated with increased fretting or corrosion?The severity of fretting/corrosion on surfaces of head tapers and stem trunnions was visually examined in 154 MoP THAs retrieved as part of 3282 revision surgeries performed at our institution between January 1, 2007, and December 31, 2013. Fretting and corrosion damage were subjectively graded by two independent observers on a 1 to 4 scale, and their relations to head size, alloy combinations, taper/trunnion design, length of implantation (LOI), and location were investigated. Differences in scores never exceeded one grade, and this occurred in only 17% of examined implants. With the available implants, the study provided 88% power to detect differences of 0.5 in fretting or corrosion scores in these analyses.Fretting and corrosion of the tapers and the trunnions were not affected by head size (p = 0.247, p = 0.471, p = 0.837, and p = 0.868, respectively), although taper/trunnion design affected taper fretting (p = 0.005) and corrosion (p = 0.0031) and trunnion fretting (p = 0.0028). Head taper fretting (observed in 73% of heads) increased with LOI, but head taper corrosion (noted in 93% of heads) was not affected. Trunnion fretting (observed in 86% of stems) was more severe in mixed-alloy combinations and with increased LOI and was more severe proximally. Trunnion corrosion (noted in 72% of stems) was also location-dependent with greater corrosion distally.Fretting and corrosion are regular occurrences in MoP THAs, but neither damage type was related to femoral head size. Conversely, taper design, LOI, and alloy combination affected the severity of both fretting and corrosion.Although it has been suggested that trunnion corrosion seen in MoP bearings is a function of larger diameter heads, our data suggest that larger femoral heads may be used for increased damage at the modular junction of MoP THAs.

  View details for DOI 10.1007/s11999-015-4468-6

  View details for Web of Science ID 000368021900011

  View details for PubMedID 26208607

  View details for PubMedCentralID PMC4709304

• The value of intraoperative Gram stain in revision spine surgery SPINE JOURNAL Shifflett, G. D., Nwachukwu, B. U., Bjerke-Kroll, B. T., Kueper, J., Koltsov, J. B., Sama, A. A., Girardi, F. P., Cammisa, F. P., Hughes, A. P. 2015; 15 (10): 2198–2205

  Abstract

  Intraoperative cultures and Gram stains are often obtained in cases of revision spine surgery even when clinical signs of infection are not present. The clinical utility and cost-effectiveness of this behavior remain unproven.The aim was to evaluate the clinical utility and cost-effectiveness of routine intraoperative Gram stains in revision spine surgery.This was a retrospective clinical review performed at an academic center in an urban setting.One hundred twenty-nine consecutive adult revision spine surgeries were performed.The outcome measures included intraoperative Gram stains.We retrospectively reviewed the records of 594 consecutive revision spine surgeries performed by four senior surgeons between 2008 and 2013 to identify patients who had operative cultures and Gram stains performed. All revision cases including cervical, thoracic, and lumbar fusion and non-fusion, with and without instrumentation were reviewed. One hundred twenty-nine (21.7%) patients had operative cultures obtained and were included in the study.The most common primary diagnosis code at the time of revision surgery was pseudarthrosis, which was present in 41.9% of cases (54 of 129). Infection was the primary diagnosis in 10.1% (13 of 129) of cases. Operative cultures were obtained in 129 of 595 (21.7%) cases, and 47.3% (61 of 129) were positive. Gram stains were performed in 98 of 129 (76.0%) cases and were positive in 5 of 98 (5.1%) cases. Overall, there was no correlation between revision diagnosis and whether or not a Gram stain was obtained (p=.697). Patients with a history of prior instrumentation were more likely to have a positive Gram stain (p<.0444). Intraoperative Gram staining was found to have a sensitivity of 10.9% (confidence interval [CI] 3.9%-23.6%) and specificity of 100% (CI 93.1%-100%). The positive and negative predictive values were 100% (CI 48.0%-100%) and 57.3% (CI 45.2%-66.2%), respectively. Kappa coefficient was calculated to be 0.1172 (CI 0.0194-0.2151). The cost per discrepant diagnosis (total cost/number discrepant) was $172.10.This study demonstrates that while very specific for infection, the sensitivity of intraoperative Gram staining is low, and agreement between positive cultures and Gram stains is very poor. Gram staining demonstrated limited cost-effectiveness because of the low prevalence of findings that altered patient management.

  View details for DOI 10.1016/j.spinee.2015.06.001

  View details for Web of Science ID 000361967700040

  View details for PubMedID 26070285

• Intermittent Parathyroid Hormone Enhances Cancellous Osseointegration of a Novel Murine Tibial Implant JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Yang, X., Ricciardi, B. F., Dvorzhinskiy, A., Brial, C., Lane, Z., Bhimani, S., Burket, J. C., Hu, B., Sarkisian, A. M., Ross, F., van der Meulen, M. H., Bostrom, M. G. 2015; 97A (13): 1074–83

  Abstract

  Long-term fixation of uncemented joint implants requires early mechanical stability and implant osseointegration. To date, osseointegration has been unreliable and remains a major challenge in cementless total knee arthroplasty. We developed a murine model in which an intra-articular proximal tibial titanium implant with a roughened stem can be loaded through the knee joint. Using this model, we tested the hypothesis that intermittent injection of parathyroid hormone (iPTH) would increase proximal tibial cancellous osseointegration.Ten-week-old female C57BL/6 mice received a subcutaneous injection of PTH (40 μg/kg/day) or a vehicle (n = 45 per treatment group) five days per week for six weeks, at which time the baseline group was killed (n = 6 per treatment group) and an implant was inserted into the proximal part of the tibiae of the remaining mice. Injections were continued until the animals were killed at one week (n = 7 per treatment group), two weeks (n = 14 per treatment group), or four weeks (n = 17 per treatment group) after implantation. Outcomes included peri-implant bone morphology as analyzed with micro-computed tomography (microCT), osseointegration percentage and bone area fraction as shown with backscattered electron microscopy, cellular composition as demonstrated by immunohistochemical analysis, and pullout strength as measured with mechanical testing.Preimplantation iPTH increased the epiphyseal bone volume fraction by 31.6%. When the data at post-implantation weeks 1, 2, and 4 were averaged for the iPTH-treated mice, the bone volume fraction was 74.5% higher in the peri-implant region and 168% higher distal to the implant compared with the bone volume fractions in the same regions in the vehicle-treated mice. Additionally, the trabecular number was 84.8% greater in the peri-implant region and 74.3% greater distal to the implant. Metaphyseal osseointegration and bone area fraction were 28.1% and 70.1% higher, respectively, in the iPTH-treated mice than in the vehicle-treated mice, and the maximum implant pullout strength was 30.9% greater. iPTH also increased osteoblast and osteoclast density by 65.2% and 47.0%, respectively, relative to the values in the vehicle group, when the data at post-implantation weeks 1 and 2 were averaged.iPTH increased osseointegration, cancellous mass, and the strength of the bone-implant interface.Our murine model is an excellent platform on which to study biological enhancement of cancellous osseointegration.

  View details for DOI 10.2106/JBJS.N.01052

  View details for Web of Science ID 000366395700006

  View details for PubMedID 26135074

  View details for PubMedCentralID PMC4574908

• Risk for Complication after Total Joint Arthroplasty at a Center of Excellence: The Impact of Patient Travel Distance JOURNAL OF ARTHROPLASTY Nwachukwu, B. U., Dy, C. J., Burket, J. C., Padgett, D. E., Lyman, S. 2015; 30 (6): 1058–61

  Abstract

  Healthcare reorganization and bundled payment schemes have resulted in increased patient travel distances in orthopedics. Travel distance has been previously associated with increased complication risk but has yet to be studied in orthopedics. We analyzed the impact of patient travel distance on short-term complications. We reviewed 38,887 TJAs performed between 2008 and 2011 and identified 1606 complications in 1110 procedures. There was no significant association between complication risk and patient travel distance. Complication risk was associated with age, ASA class, Medicare and Medicaid status (P<0.0001 for all). Regional centers of excellence appear to be a viable model in healthcare reorganization however continued attention should be paid to attenuating the individual patient factors associated with complication at these institutions.

  View details for DOI 10.1016/j.arth.2015.01.015

  View details for Web of Science ID 000356183500031

  View details for PubMedID 25639857

• New Radiographic Parameter Assessing Hindfoot Alignment in Stage II Adult-Acquired Flatfoot Deformity FOOT & ANKLE INTERNATIONAL Williamson, E. R., Chan, J. Y., Burket, J. C., Deland, J. T., Ellis, S. J. 2015; 36 (4): 417-423

  Abstract

  The hindfoot moment arm is a reliable measurement of hindfoot valgus deformity in stage II adult-acquired flatfoot deformity (AAFD) and can be used to guide intraoperative correction of the hindfoot. There is currently little understanding of how the hindfoot moment arm relates to angular measurements of hindfoot alignment. The purpose of this study was to develop a new hindfoot alignment angle that can reliably quantify hindfoot valgus in patients with AAFD and to establish the relationship of this angle with the hindfoot moment arm.Preoperative hindfoot alignment radiographs were reviewed for 10 consecutive patients (10 feet) who were indicated for reconstruction for stage II AAFD. A second group of 10 patients (10 feet) without flatfoot were identified to serve as normal controls. The hindfoot moment arm and the new hindfoot alignment angle were measured in blinded fashion by 2 readers. Reliability was assessed using intraclass correlation coefficients (ICCs). The difference in angle between normal and flatfoot patients was assessed with a Mann-Whitney U test. A linear regression model was used to assess the relationship between hindfoot moment arm and the new hindfoot alignment angle.Intra- and interrater reliability for the hindfoot alignment angle was excellent (ICC = 0.979 and 0.965, respectively). Flatfoot patients had greater mean angles than did normal patients (22.5 ± 4.9 vs 5.6 ± 5.4 degrees, P < .001). The hindfoot moment arm was correlated significantly with the hindfoot alignment angle (P < .001), increasing by 0.81 mm for every degree increase in angle (adjusted R (2) = 0.9046).These results indicate that the new hindfoot alignment angle is a reliable measure of hindfoot valgus and can differentiate between flatfoot and normal patients. In addition, the strong linear relationship between the hindfoot alignment angle and moment arm may allow for the use of this angle in the intraoperative correction of hindfoot valgus.Level III, retrospective case control study.

  View details for DOI 10.1177/1071100714558846

  View details for Web of Science ID 000352643500010

  View details for PubMedID 25380772

• Ankle Fracture Spur Sign Is Pathognomonic for a Variant Ankle Fracture FOOT & ANKLE INTERNATIONAL Hinds, R. M., Garner, M. R., Lazaro, L. E., Warner, S. J., Loftus, M. L., Birnbaum, J. F., Burket, J. C., Lorich, D. G. 2015; 36 (2): 159–64

  Abstract

  The hyperplantarflexion variant ankle fracture is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. This infrequently reported injury pattern often includes an associated "spur sign" or double cortical density at the inferomedial tibial metaphysis. The objective of this study was to quantitatively establish the association of the ankle fracture spur sign with the hyperplantarflexion variant ankle fracture.Our clinical database of operative ankle fractures was retrospectively reviewed for the incidence of hyperplantarflexion variant and nonvariant ankle fractures as determined by assessment of injury radiographs, preoperative advanced imaging, and intraoperative observation. Injury radiographs were then evaluated for the presence of the spur sign, and association between the spur sign and variant fractures was analyzed.The incidence of the hyperplantarflexion variant fracture among all ankle fractures was 6.7% (43/640). The spur sign was present in 79% (34/43) of variant fractures and absent in all nonvariant fractures, conferring a specificity of 100% in identifying variant fractures. Positive predictive value and negative predictive value were 100% and 99%, respectively.The ankle fracture spur sign was pathognomonic for the hyperplantarflexion variant ankle fracture. It is important to identify variant fractures preoperatively as patient positioning, operative approach, and fixation construct of variant fractures often differ from those employed for osteosynthesis of nonvariant fractures. Identification of the spur sign should prompt acquisition of advanced imaging to formulate an appropriate operative plan to address the variant fracture pattern.Level III, retrospective comparative study.

  View details for DOI 10.1177/1071100714553470

  View details for Web of Science ID 000351245900005

  View details for PubMedID 25278340

• Psoriatic Arthritis is Associated with Heterotopic Ossification after Total Hip Arthroplasty. Cedillo, M., Fein, A., Goodman, S. M., Zhu, R., Figgie, M. P., Alexiades, M., Burket, J. C., Mandl, L. A. WILEY-BLACKWELL. 2014: S1298

  View details for Web of Science ID 000344384906204

• Revision Arthroplasty in Rheumatoid and Osteoarthritis: Does Methotrexate Decrease Radiographic Lucency in RA Patients? Wei, M., Mintz, D. N., Mandl, L. A., Fein, A., Burket, J. C., Lee, Y., Huang, W., Bykerk, V. P., Figgie, M. P., DiCarlo, E. F., Cronstein, B. N., Goodman, S. M. WILEY-BLACKWELL. 2014: S79

  View details for Web of Science ID 000344384900188

• Microdiscectomy for the treatment of lumbar disc herniation: an evaluation of reoperations and long-term outcomes. Evidence-based spine-care journal Aichmair, A., Du, J. Y., Shue, J., Evangelisti, G., Sama, A. A., Hughes, A. P., Lebl, D. R., Burket, J. C., Cammisa, F. P., Girardi, F. P. 2014; 5 (2): 77–86

  Abstract

  DesignRetrospective case series. ObjectiveThe objective of this study was to assess the reoperation rate after microdiscectomy for the treatment of lumbar disc herniation (LDH) in patients with≥5-year follow-up and identify demographic, perioperative, and outcome-related differences between patients with and without a reoperation. MethodsThe medical records, operative reports, and office notes of patients who had undergone microdiscectomy at a single institution between March 1994 and December 2007 were reviewed and long-term follow-up was assessed via a telephone questionnaire. ResultsForty patients (M:24, F:16) with an average age at surgery of 39.9±12.5 years (range: 18-80) underwent microdiscectomy at the levels L5-S1 (n=28, 70%), L4-L5 (n=9, 22.5%), L3-L4 (n=2, 5.0%), and L1-L2 (n=1, 2.5%). After an average of 40.4±40.1 months (range: 1-128), 25% of patients (10/40) required further spine surgery related to the initial microdiscectomy. At an average postoperative follow-up of 11.1±4.0 years (range: 5-19), additional symptoms apart from back and leg pain were reported more frequently by patients who underwent a reoperation (p=0.005). Patient satisfaction was significantly higher in patients who did not undergo a reoperation (p=0.041). For the Oswestry disability index, pain intensity (p=0.036), and pain-related sleep disturbances (p=0.006) were reported to be more severe in the reoperation group. ConclusionsMicrodiscectomy for the treatment of LDH results in a favorable long-term outcome in the majority of cases. The reoperation rate was higher in our series than reported in previous investigations with shorter follow-up. Although there were no statistically significant pre-/perioperative differences between patients with and without reoperation, our findings suggest a difference in self-reported long-term outcome measures.

  View details for DOI 10.1055/s-0034-1386750

  View details for PubMedID 25278881

• Risk Factors for Posttraumatic Synostosis and Outcomes Following Operative Treatment of Ankle Fractures FOOT & ANKLE INTERNATIONAL Hinds, R. M., Lazaro, L. E., Burket, J. C., Lorich, D. G. 2014; 35 (2): 141–47

  Abstract

  Distal tibiofibular synostosis is a known but poorly described complication of ankle fractures. The objective of this study was to evaluate the relationship between ankle fracture fixation method and other risk factors in the development of synostosis in posttraumatic operative ankle fractures. Outcomes of patients with no synostosis, incomplete bony bridging, or complete synostosis also were compared.All operative ankle fractures from a single surgeon's prospectively collected clinical database were evaluated for the presence of distal tibiofibular synostosis not earlier than 3 months postoperatively. All fractures were treated in a fracture-specific and ligament-specific fashion. Syndesmotic screws, when used, were routinely removed no sooner than 4 months after operation. Patient demographic and medical history data as well as injury and fixation profile were evaluated. Incidence of complications was also reviewed. Foot and Ankle Outcome Score (FAOS) and range of motion (ROM) were compared between the groups.Of the 564 ankle fractures included in the study, 91 demonstrated complete synostosis and 46 demonstrated incomplete bony bridging. Multivariate analysis revealed male sex (odds ratio [OR] = 2.82, P < .001), syndesmotic screw fixation (OR = 2.46, P < .001), and tibiotalar dislocation (OR = 1.74, P = .032) to remain significant independent risk factors for the development of incomplete bony bridging or complete synostosis while adjusting for confounding risk factors. Ankles with synostosis also demonstrated significant reduction in dorsiflexion (P = .017), plantarflexion (P = .024), and inversion (P < .001), though patient-reported outcome measures were equivalent with patients without synostosis.Syndesmotic screw fixation, male sex, and tibiotalar dislocation were significant risk factors in the formation of postoperative distal tibiofibular synostosis, though patient-reported outcome measures seemed equivalent among patients with and without synostosis.Level III, case control study of prospectively collected registry data.

  View details for DOI 10.1177/1071100713510913

  View details for Web of Science ID 000339327300007

  View details for PubMedID 24165573

• Variations in nanomechanical properties and tissue composition within trabeculae from an ovine model of osteoporosis and treatment BONE Burket, J. C., Brooks, D. J., MacLeay, J. M., Baker, S. P., Boskey, A. L., van der Meulen, M. H. 2013; 52 (1): 326–36

  Abstract

  Osteoporosis and treatment may affect both composition and nanomechanical properties and their spatial distributions within the individual trabeculae of cancellous bone at length scales that cannot be captured by bulk measurements. This study utilized 25 mature adult ewes divided into 5 treatment groups. Four treatment groups were given a dietary model for human high-turnover osteoporosis, and two of these were treated with antiresorptive drugs, either zoledronate (ZOL) or raloxifene (RAL), to examine their effects on bulk tissue properties and nanoscale tissue composition and mechanical properties within trabeculae. Treatment effects were most pronounced at the nanoscale, where RAL increased indentation modulus and hardness throughout trabeculae by 10% relative to the osteoporosis model. In comparison, ZOL increased these properties exclusively at the surfaces of trabeculae (indentation modulus +12%, hardness +16%). Nanomechanical alterations correlated with changes in tissue mineralization, carbonate substitution, crystallinity, and aligned collagen. Despite only minimal changes in bulk tissue tBMD, the nanomechanical improvements within trabeculae with both treatments greatly improved the predicted theoretical bending stiffness of individual trabeculae when idealized as cylindrical struts. Hence, small tissue-level alterations in critical locations for resisting trabecular failure could account for some of the discrepancy between the large reductions in fracture risk and the only modest changes in BMD with antiresorptive treatments.

  View details for DOI 10.1016/j.bone.2012.10.018

  View details for Web of Science ID 000312750700038

  View details for PubMedID 23092698

  View details for PubMedCentralID PMC3612543

• Microstructure and nanomechanical properties in osteons relate to tissue and animal age JOURNAL OF BIOMECHANICS Burket, J., Gourion-Arsiquaud, S., Havill, L. M., Baker, S. P., Boskey, A. L., van der Meulen, M. H. 2011; 44 (2): 277–84

  Abstract

  Material property changes in bone tissue with ageing are a crucial missing component in our ability to understand and predict age-related fracture. Cortical bone osteons contain a natural gradient in tissue age, providing an ideal location to examine these effects. This study utilized osteons from baboons aged 0-32 years (n=12 females), representing the baboon lifespan, to examine effects of tissue and animal age on mechanical properties and composition of the material. Tissue mechanical properties (indentation modulus and hardness), composition (mineral-to-matrix ratio, carbonate substitution, and crystallinity), and aligned collagen content (aligned collagen peak height ratio) were sampled along three radial lines in three osteons per sample by nanoindentation, Raman spectroscopy, and second harmonic generation microscopy, respectively. Indentation modulus, hardness, mineral-to-matrix ratio, carbonate substitution, and aligned collagen peak height ratio followed biphasic relationships with animal age, increasing sharply during rapid growth before leveling off at sexual maturity. Mineral-to-matrix ratio and carbonate substitution increased 12% and 6.7%, respectively, per year across young animals during growth, corresponding with a nearly 7% increase in stiffness and hardness. Carbonate substitution and aligned collagen peak height ratio both increased with tissue age, increasing 6-12% across the osteon radii. Indentation modulus most strongly correlated with mineral-to-matrix ratio, which explained 78% of the variation in indentation modulus. Overall, the measured compositional and mechanical parameters were the lowest in tissue of the youngest animals. These results demonstrate that composition and mechanical function are closely related and influenced by tissue and animal age.

  View details for DOI 10.1016/j.jbiomech.2010.10.018

  View details for Web of Science ID 000287466300011

  View details for PubMedID 21074774

  View details for PubMedCentralID PMC3128908

• Spatial Variation in Osteonal Bone Properties Relative to Tissue and Animal Age JOURNAL OF BONE AND MINERAL RESEARCH Gourion-Arsiquaud, S., Burket, J. C., Havill, L. M., DiCarlo, E., Doty, S. B., Mendelsohn, R., van der Meulen, M. H., Boskey, A. L. 2009; 24 (7): 1271–81

  Abstract

  Little is known about osteonal bone mineral and matrix properties, although these properties are of major importance for the understanding of bone alterations related to age and bone diseases such as osteoporosis. During aging, bone undergoes modifications that compromise their structural integrity as shown clinically by the increase of fracture incidence with age. Based on Fourier transform infrared (FTIR) analysis from baboons between 0 and 32 yr of age, consistent systematic variations in bone properties as a function of tissue age are reported within osteons. The patterns observed were independent of animal age and positively correlated with bone tissue elastic behavior measured by nano-indentation. As long as tissue age is expressed as a percentage of the entire osteon radius, osteonal analyses can be used to characterize disease changes independent of the size of the osteon. These mineral and matrix analyses can be used to explain bone fragility. The mineral content (mineral-to-matrix ratio) was correlated with the animal age in both old (interstitial) and newly formed bone tissue, showing for the first time that age-related changes in BMC can be explain by an alteration in the mineralization process itself and not only by an imbalance in the remodeling process.

  View details for DOI 10.1359/JBMR.090201

  View details for Web of Science ID 000267234400015

  View details for PubMedID 19210217

  View details for PubMedCentralID PMC2697626