All Publications

  • Correction: Mobile device-based 3D scanning is superior to scoliometer in assessment of adolescent idiopathic scoliosis. Spine deformity Oquendo, Y., Hollyer, I., Maschhoff, C., Calderon, C., DeBaun, M., Langner, J., Javier, N., Bryson, X., Richey, A., Naz, H., Tileston, K., Gardner, M., Vorhies, J. S. 2025

    View details for DOI 10.1007/s43390-025-01046-7

    View details for PubMedID 39847213

  • Mobile device-based 3D scanning is superior to scoliometer in assessment of adolescent idiopathic scoliosis. Spine deformity Oquendo, Y., Hollyer, I., Maschhoff, C., Calderon, C., DeBaun, M., Langner, J., Javier, N., Bryson, X., Richey, A., Naz, H., Tileston, K., Gardner, M., Vorhies, J. S. 2024

    Abstract

    Screening for adolescent idiopathic scoliosis (AIS) currently relies on clinical evaluations by trained practitioners, most commonly using a scoliometer. Modern structured light 3D scanning can generate high-quality 3D representations of surface anatomy using a mobile device. We hypothesized that a mobile-based 3D scanning system would provide accurate deformity assessments compared to a scoliometer.Between August 2020 and June 2022, patients 10-18 years being evaluated for AIS in our clinic with a scoliosis radiograph obtained within 30 days of clinic evaluation and no history of spinal surgery were enrolled. Patients had 3D scans taken in the upright and forward bend positions, and the largest angle of trunk rotation (ATR) was measured by a scoliometer. Image processing software was used to analyze trunk shift (TS), coronal balance (CB), and clavicle angle (CL) in the upright position and the largest ATR in the forward bend position. 3D and scoliometer measurements were correlated to major curve magnitude. Multiple logistic regression models were created based on 3D and scoliometer measurements, controlling for demographic covariates.Two hundred and fifty-eight patients were included in this study. Mean coronal major curve magnitude was 25.7° (range 0-100), and 59% had a thoracic major curve. There were good-to-excellent correlations between 3D and radiographic measures of TS, CB, and CL (r = 0.79, rs = 0.80, and r = 0.64, respectively, p < 0.001). Correlations between 3D and radiographic measures of largest lumbar and thoracic ATR also demonstrated good correlations (r = 0.64 for both, p < 0.001). Using Akaike's Information Criterion (AIC), a multivariable logistic regression model based on 3D scanning outperformed a scoliometer model.Mobile device-based 3D scanning of TS, CB, and TS identifies clinically relevant scoliotic deformity and is more predictive of radiographic curve magnitude than scoliometer in this population. This new modality may facilitate scoliosis screening by decreasing the need for trained personnel or dedicated equipment and clinical space to perform screening tests.II.

    View details for DOI 10.1007/s43390-024-01007-6

    View details for PubMedID 39663336

    View details for PubMedCentralID 3913566

  • Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents ORTHOPEDICS Kaur, J., Pham, N., Cahan, E., Halvorsen, K., Langner, J. L., Bryson, X. M., Chan, C. M., Vorhies, J. 2024; 47 (2): 83-88

    Abstract

    The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

    View details for DOI 10.3928/01477447-20230616-05

    View details for Web of Science ID 001190541800001

    View details for PubMedID 37341565

  • Cannabidiol Use Patterns and Efficacy for Children Who Have Cerebral Palsy ORTHOPEDICS Seltzer, R. A., Langner, J. L., Javier, N. M., Kaur, J., Shafau, A., Ezeonu, T., Bryson, X., Hastings, K., Tileston, K., Vorhies, J. S. 2024; 47 (1): 52-+

    Abstract

    Cannabidiol (CBD)-containing supplements are used by children with cerebral palsy (CP), but the prevalence and efficacy of their use have not been studied. We sought to describe CBD use patterns and perceived efficacy in the pediatric population with CP, evaluating any association between CBD use and health-related quality of life. Patients with CP were prospectively enrolled, and caregivers were offered the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) Questionnaire and a survey assessing CBD use. Of 119 participants, 20 (16.8%) endorsed CBD use (CBD+) and 99 (83.2%) denied it (CBD-). Participants in the CBD+ group had worse functional status (85% Gross Motor Function Classification System level IV-V for CBD+ vs 37.4% for CBD-, P<.001) and lower health-related quality of life (mean CPCHILD score of 49.3 for CBD+ vs 62.2 for CBD-, P=.001). Spasticity was the rationale most cited for CBD use (29%), followed by pain and anxiety (both 22.6%). CBD was perceived to be most effective for improving emotional health, spasticity, and pain. Fifty percent of the patients in the CBD+ group underwent surgery in the previous 2 years and most endorsed a general benefit in the postoperative setting. The most common side effects noted were fatigue and increased appetite (both 12%). Most participants endorsed no side effects (60%). CBD may serve as a useful adjunct for some children with CP, especially those with worse disease severity. Caregivers perceive CBD as offering some benefits, particularly in the domains of emotional health, spasticity, and pain. We found no evidence of severe adverse events in our small cohort. [Orthopedics. 2024;47(1):52-56.].

    View details for DOI 10.3928/01477447-20230517-06

    View details for Web of Science ID 001152481700018

    View details for PubMedID 37216564

  • Effectiveness of an early operating room start time in managing pediatric trauma. World journal of orthopedics Kym, D., Kaur, J., Pham, N. S., Klein, E., Langner, J. L., Wang, E., Vorhies, J. S. 2023; 14 (7): 516-525

    Abstract

    The timing of operative treatment for pediatric supracondylar humerus fractures (SCHF) and femoral shaft fractures (FSF) remains controversial. Many fractures previously considered to be surgical emergencies, such as SCHF and open fractures, are now commonly being treated the following day. When presented with an urgent fracture overnight needing operative treatment, the on-call surgeon must choose whether to mobilize resources for a late-night case or to add the case to an elective schedule of the following day.To describe the effect of a program allowing an early operating room (OR) start for uncomplicated trauma prior to an elective day of surgery to decrease wait times for surgery for urgent fractures admitted overnight.Starting in October 2017, patients were eligible for the early slot in the OR at the discretion of the surgeon if they were admitted after 21:00 the previous night and before 05:00. We compared demographics and timing of treatment of SCHF and FSF treated one year before and after implementation as well as the survey responses from the surgical team.Of the 44 SCHF meeting inclusion criteria, 16 received treatment before implementation while 28 were treated after. After implementation, the mean wait time for surgery decreased by 4.8 h or 35.4% (13.4 h vs 8.7 h; P = 0.001). There were no significant differences in the operative duration, time in the post anesthesia care unit, and wait time for discharge. Survey results demonstrated decreased popularity of the program among nurses and anesthesiologists relative to surgeons. Whereas 57% of the surgeons believed that the program was effective, only 9% of anesthesiologists and 16% of nurses agreed. The program was ultimately discontinued given the dissatisfaction.Our findings demonstrate significantly reduced wait times for surgery for uncomplicated SCHF presenting overnight while discussing the importance of shared decision-making with the stakeholders. Although the program produced promising results, it also created new conflicts within the OR staff that led to its discontinuation at our institution. Future implementations of such programs should involve stakeholders early in the planning process to better address the needs of the OR staff.

    View details for DOI 10.5312/wjo.v14.i7.516

    View details for PubMedID 37485431

    View details for PubMedCentralID PMC10359751

  • Spinal fusion is an aerosol generating procedure. World journal of orthopedics Langner, J. L., Pham, N. S., Richey, A., Oquendo, Y., Mehta, S., Vorhies, J. S. 2023; 14 (5): 340-347

    Abstract

    Transmission of severe acute respiratory syndrome coronavirus 2 can occur during aerosol generating procedures. Several steps in spinal fusion may aerosolize blood but little data exists to quantify the risk this may confer upon surgeons. Aerosolized particles containing infectious coronavirus are typically 0.5-8.0 μm.To measure the generation of aerosols during spinal fusion using a handheld optical particle sizer (OPS).We quantified airborne particle counts during five posterior spinal instrumentation and fusions (9/22/2020-10/15/2020) using an OPS near the surgical field. Data were analyzed by 3 particle size groups: 0.3-0.5 μm/m3, 1.0-5.0 μm/m3, and 10.0 μm/m3. We used hierarchical logistic regression to model the odds of a spike in aerosolized particle counts based on the step in progress. A spike was defined as a > 3 standard deviation increase from average baseline levels.Upon univariate analysis, bovie (P < 0.0001), high speed pneumatic burring (P = 0.009), and ultrasonic bone scalpel (P = 0.002) were associated with increased 0.3-0.5 μm/m3 particle counts relative to baseline. Bovie (P < 0.0001) and burring (P < 0.0001) were also associated with increased 1-5 μm/m3 and 10 μm/m3 particle counts. Pedicle drilling was not associated with increased particle counts in any of the size ranges measured. Our logistic regression model demonstrated that bovie (OR = 10.2, P < 0.001), burring (OR = 10.9, P < 0.001), and bone scalpel (OR = 5.9, P < 0.001) had higher odds of a spike in 0.3-0.5 μm/m3 particle counts. Bovie (OR = 2.6, P < 0.001), burring (OR = 5.8, P < 0.001), and bone scalpel (OR = 4.3, P = 0.005) had higher odds of a spike in 1-5 μm/m3 particle counts. Bovie (OR = 0.3, P < 0.001) and drilling (OR = 0.2, P = 0.011) had significantly lower odds of a spike in 10 μm/m3 particle counts relative to baseline.Several steps in spinal fusion are associated with increased airborne particle counts in the aerosol size range. Further research is warranted to determine if such particles have the potential to contain infectious viruses. Previous research has shown that electrocautery smoke may be an inhalation hazard for surgeons but here we show that usage of the bone scalpel and high-speed burr also have the potential to aerosolize blood.

    View details for DOI 10.5312/wjo.v14.i5.340

    View details for PubMedID 37304197

    View details for PubMedCentralID PMC10251270

  • Does spinal deformity affect adolescents' quality of life before we tell them it should? Spine deformity Langner, J. L., Kaur, J., Pham, N. S., Richey, A., Hastings, K., Mehta, S., Bryson, X., Vorhies, J. S. 2023

    Abstract

    PURPOSE: The Scoliosis Research Society 22r Questionnaire(SRS-22r) is the standard for assessing health-related quality of life(HRQoL) in patients with adolescent idiopathic scoliosis. Here we investigate whether patients' perceptions of their HRQoL are influenced by knowledge of scoliosis and counseling by an orthopedic surgeon.METHODS: Patients ages 10-18years referred for their first visit with an orthopaedic surgeon for scoliosis were enrolled from 9/30/19 to 10/22/20. Patients completed the SRS-22r pre- and post-visit. A Wilcoxon signed-rank test was used to analyze the SRS-22r scores.RESULTS: 52 patients participated in the study at a mean age of 14.3years (95% CI 13.8-14.8years) with an average major curve magnitude of 23.2 degrees (95% CI 19.4-27.0 degrees). SRS-22r scores were not correlated to curve magnitude pre- or post-visit. The SRS-22r Satisfaction with care domain exhibited a small increase from pre- to post-visit (pre: 3.3, post: 3.6). All other SRS-22r domains and total scores did not exhibit clinically significant differences.CONCLUSION: Among new adolescent referrals for scoliosis, it is unlikely that counseling by a surgeon influences perceptions of HRQoL as measured by the SRS-22r.LEVEL OF EVIDENCE: III.

    View details for DOI 10.1007/s43390-023-00691-0

    View details for PubMedID 37166749

  • Curve Characteristics and Surgical Outcomes in Scoliosis Associated With Childhood Sternotomy or Thoracotomy. Journal of pediatric orthopedics Langner, J. L., Ezeonu, T., Shafau, A., Javier, N., Bryson, X., Kaur, J., Poppino, K., Shivers, C., Chilakapati, S., Hall, K. E., Imrie, M. N., Rinsky, L., Riccio, A. I., Vorhies, J. S. 2022

    Abstract

    BACKGROUND: The purpose of this study is to describe curve characteristics and postoperative outcomes in patients undergoing spinal fusion (SF) to treat thoracogenic scoliosis related to sternotomy and/or thoracotomy as a growing child.METHODS: A retrospective review of electronic medical records of all patients with Post-Chest Incision scoliosis treated with SF was performed at 2 tertiary care pediatric institutions over a 19-year period. Curve characteristics, inpatient, and outpatient postoperative outcomes are reported.RESULTS: Thirty-nine patients (62% female) were identified. Eighteen had sternotomy alone, 14 had thoracotomy alone, and 7 had both. Mean age at the time of first chest wall surgery was 2.5 years (range: 1.0d to 14.2y). Eighty-five percent of patients had a main thoracic curve (mean major curve angle 72 degrees, range: 40 to 116 degrees) and 15% had a main lumbar curve (mean major curve angle 76 degrees, range: 59 to 83 degrees). Mean thoracic kyphosis was 40 degrees (range: 4 to 84 degrees). Mean age at the time of SF was 14 years (range: 8.2 to 19.9y). Thirty-six patients had posterior fusions and 3 had combined anterior/posterior. Mean coronal curve correction measured at the first postoperative encounter was 53% (range: 9% to 78%). There were 5 (13%) neuromonitoring alerts and 2 (5%) patients with transient neurological deficits. Mean length of hospital stay was 9±13 days. At an average follow-up time of 3.1±2.4 years, 17 complications (10 medical and 7 surgical) were noted in 9 patients for an overall complication rate of 23%. There was 1 spinal reoperation in the cohort. 2/17 (12%) complications were Clavien-Dindo-Sink class III and 5/17 (29%) were class IV.CONCLUSION: Kyphotic thoracic curves predominate in patients with Post-Chest Incision scoliosis undergoing SF. Although good coronal and sagittal plane deformity can be expected after a fusion procedure, postoperative complications are not uncommon in medically complex patients, often necessitating longer postoperative stays.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BPO.0000000000002229

    View details for PubMedID 36017932

  • 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

  • Current Prescribing Practices and Guideline Concordance for the Treatment of Uncomplicated Urinary Tract Infections in Women. American journal of obstetrics and gynecology Langner, J. L., Chiang, K. F., Stafford, R. S. 2021

    Abstract

    BACKGROUND: Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole and fosfomycin as first-line antibiotic treatments, and discourage the use of fluoroquinolone antibiotics. The United States Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade due to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.OBJECTIVE: To assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.STUDY DESIGN: A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, PA) National Disease and Therapeutic Index from 2015-2019. An estimated 44.9 million women with uncomplicated urinary tract infections ages 18-75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared to the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.RESULTS: Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 M visits/44.9 M visits) and increased from 48.2% (3.9 M visits/8.1 M visits) in 2015 to 64.6% (6.3 M visits/9.8 M visits) in 2019. The most commonly prescribed antibiotics were fluoroquinolones (36.4%, 16.3 M visits/44.9 M visits), nitrofurantoin (31.8%, 14.3 M visits/44.9 M visits) and trimethoprim-sulfamethoxazole (26.3%, 11.8 M visits/44.9 M visits). From 2015 to 2019 fluoroquinolone use decreased while nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients ages 18-29 years (OR 1.60, 95% CI 1.36-1.88, p<0.001) and 30-44 years (OR 1.21, 95% CI 1.03-1.42, p=0.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment compared to patients ages 45-75 years (reference group). Obstetricians/gynecologists (OR 3.56, 95% CI 2.91-4.37, p<0.001) and urologists (OR 3.51, 95% CI 2.45-5.13, p<0.001) had a statistically significantly higher likelihood of concordant treatment compared to all other specialties combined (reference group).CONCLUSION: Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotics. Although improving, continued misuse of antibiotics may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines, and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

    View details for DOI 10.1016/j.ajog.2021.04.218

    View details for PubMedID 33848538

  • The prevalence of femoroacetabular impingement anatomy in Division 1 aquatic athletes who tread water Journal of Hip Preservation Surgery Langner, J. L., Black, M. S., MacKay, J. W., Hall, K. E., Safran, M. R., Kogan, F., Gold, G. E. 2020; 0: 1-9

    Abstract

    Femoroacetabular impingement (FAI) is a disorder that causes hip pain and disability in young patients, particularly athletes. Increased stress on the hip during development has been associated with increased risk of cam morphology. The specific forces involved are unclear, but may be due to continued rotational motion, like the eggbeater kick. The goal of this prospective cohort study was to use magnetic resonance imaging (MRI) to identify the prevalence of FAI anatomy in athletes who tread water and compare it to the literature on other sports. With university IRB approval, 20 Division 1 water polo players and synchronized swimmers (15 female, 5 male), ages 18-23 years (mean age 20.7 ± 1.4), completed the 33-item International Hip Outcome Tool and underwent non-contrast MRI scans of both hips using a 3 Tesla scanner. Recruitment was based on sport, with both symptomatic and asymptomatic individuals included. Cam and pincer morphology were identified. The Wilcoxon Signed-Rank/Rank Sum tests were used to assess outcomes. Seventy per cent (14/20) of subjects reported pain in their hips yet only 15% (3/20) sought clinical evaluation. Cam morphology was present in 67.5% (27/40) of hips, while 22.5% (9/40) demonstrated pincer morphology. The prevalence of cam morphology in water polo players and synchronized swimmers is greater than that reported for the general population and at a similar level as some other sports. From a clinical perspective, acknowledgment of the high prevalence of cam morphology in water polo players and synchronized swimmers should be considered when these athletes present with hip pain.

    View details for DOI 10.1093/jhps/hnaa009

    View details for PubMedCentralID PMC7605769