Study Design.Retrospective controlled cohort.Objective.To evaluate the effect of intraoperative liposomal bupivacaine (LB) through erector spinae plane block (ESPB) on patients with postoperative adolescent idiopathic scoliosis (AIS) with and without patient-controlled analgesia (PCA).Background.Pain control after posterior spinal fusion (PSF) for AIS includes opioids and other modalities. The goal of these modalities is to reduce pain and opioid consumption. Two new modalities for pain control include LB and ESPB. There are scant studies on these modalities tested in concert on patients undergoing PSF for AIS.Patients and Methods.Seventy-two consecutive patients with AIS who underwent PSF were separated into patients who had a PCA (group A) as part of their postoperative pain management and those who did not (group B). Opioid consumption was measured through morphine milligram equivalents. Pain scores were measured through the visual acuity score (Visual Analog Scale). Patient mobility was measured by steps taken. These were measured by the function of postoperative days from surgery.Results.Group B had significantly lower morphine milligram equivalents at every point after surgery, most notably throughout the entire hospital stay (99.8 vs. 200.7). Postoperative pain scores in group B were the same if not better than group A. There was no difference in mobility between the cohorts. Group B had lower LOS (3.7 vs. 4.1).Conclusion.In postoperative PSF for patients with AIS receiving LB through ESPB, those who did not receive a PCA had lower opioid consumption without worse pain scores or mobility and had a lower LOS. Adding LB through ESPB to postoperative pain regimens effectively replaces a PCA by providing the same pain control and reducing overall opioid consumption and LOS.

INTRODUCTION: Medical education imposes a financial burden on trainees. Given that cost-of-living varies across geographical regions, understanding its relationship with resident compensation can inform about the finances of residents. We investigated: (1) How does compensation for orthopaedic surgery residents vary across regions? (2) How does compensation for orthopaedic surgery residents vary with respect to cost of living? (3) What is the extent of surplus income for residents after accounting for hours worked? (4) What are the predictors of annual income for orthopaedic residents? MATERIAL AND METHODS: Using the American Medical Association FREIDA database, we collected weekly work hours, location, program type, moonlight allowance, and geographic region for 190 nonmilitary orthopaedic programs. We used institutional websites to collect compensation information. We utilized SmartAsset to estimate take-home pay. We collected reputation ranking from Doximity. Lastly, we collected the Required Annual Income (RAI), a proxy for cost of living, and living hourly wage from the MIT Living Wage database for each program. We estimated Surplus Income (SI) and Hourly Surplus Income (HSI). RESULTS: Compensation and take-home pay varied significantly across regions (p < 0.001). Additionally, we found a weak positive correlation between RAI and PGY-1 compensation (R-2 = 0.34). Pretax SI ranged from $24,600 to $35,200, while HSI hours ranged from $0.27 to $2.86 per hour across PGY levels. Standardized to an 80-hour work week, the HSI ranged from- $2.55 to - $0.37 per hour. Doximity reputation ranking, RAI, and region were significant predictors (<0.001). CONCLUSIONS: Despite significant variations across geographic regions, a weak correlation between RAI and compensation indicates that residents in high- cost areas face challenges in offsetting relatively higher expenses. Additionally, our research reveals that orthopaedic residents may be financially strained.

Unplanned hospital readmissions remain one of the largest causes for increased episode of care and adverse events. These readmissions are especially significant in posterior spinal fusion (PSF) for idiopathic adolescent scoliosis (AIS). Therefore, this study aimed to 1) determine the overall 90-day PSF readmission rate; 2) report the timing of readmission post-discharge; and 3) identify the most frequent causes of 90-day readmissions (i.e., medical- or orthopedic-related). A cohort of 657 consecutive patients undergoing PSF for AIS between January 1, 2010 and February 28, 2021 were selected. Readmissions were examined manually for determination of primary cause and verification. Two-tailed t tests and chi-squared/Fisher tests were utilized with logistic regressions for individual variables. The 90-day readmission rate was 6.24

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:Assess the influence of graft type on the development of pseudoarthrosis in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). BACKGROUND:Long-term bony fusion after PSF for AIS is crucial to preserve deformity correction, whereas pseudoarthrosis represents a concerning potential complication. Debate continues over the necessity of allograft bone grafting to achieve cost-effective spinal arthrodesis. METHODS:A retrospective comparative cohort study was performed in patients who underwent a primary PSF for treatment of AIS between 2010 and 2021 at a single tertiary institution. Exclusion criteria were age younger than 10 years, non-idiopathic scoliosis, non-posterior fusion approaches, or <2 years follow-up. Pseudoarthrosis was defined as radiographic loss of correction >10 degrees, or direct visualization of nonunion during reoperation. Patients were grouped according to whether allograft (AL) plus local autograft or local autograft only (AT) was used. The cost of 30 mL of allograft bone at the completion of this study was $404.00 per case. RESULTS:A total of 657 patients (80.2% female) with a mean follow-up of 32.5 months were included. Overall, 415 were treated with AL and 242 with AT. There were no differences in the rate of pseudoarthrosis between groups [AL: 1.2% (n=5) vs. AT: 2% (n=5), P=0.384]. The percentage of patients not developing pseudoarthrosis was 93.1% and 95% at 105 months for AL and AT, respectively (P=0.596). The development of pseudoarthrosis was not affected by the type of graft used (HZ: 3.04; 95% CI: 0.65-14.12). CONCLUSIONS:PSF for AIS achieves high fusion rates exceeding 90% survivorship free of pseudoarthrosis at 9 years postoperatively, regardless of whether local AT or AL are utilized. Importantly, the use of AT alone showed no inferiority compared with AL suggesting that may be sufficient for achieving successful fusion. LEVEL OF EVIDENCE:Level III.

Retrospective cohort study. Assess the influence of graft type on the development of pseudoarthrosis in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Long-term bony fusion after PSF for AIS is crucial to preserve deformity correction, whereas pseudoarthrosis represents a concerning potential complication. Debate continues over the necessity of allograft bone grafting to achieve cost-effective spinal arthrodesis. A retrospective comparative cohort study was performed in patients who underwent a primary PSF for treatment of AIS between 2010 and 2021 at a single tertiary institution. Exclusion criteria were age younger than 10 years, non-idiopathic scoliosis, non-posterior fusion approaches, or <2 years follow-up. Pseudoarthrosis was defined as radiographic loss of correction >10 degrees, or direct visualization of nonunion during reoperation. Patients were grouped according to whether allograft (AL) plus local autograft or local autograft only (AT) was used. The cost of 30 mL of allograft bone at the completion of this study was $404.00 per case. A total of 657 patients (80.2% female) with a mean follow-up of 32.5 months were included. Overall, 415 were treated with AL and 242 with AT. There were no differences in the rate of pseudoarthrosis between groups [AL: 1.2% (n=5) vs. AT: 2% (n=5), P =0.384]. The percentage of patients not developing pseudoarthrosis was 93.1% and 95% at 105 months for AL and AT, respectively ( P =0.596). The development of pseudoarthrosis was not affected by the type of graft used (HZ: 3.04; 95% CI: 0.65–14.12). PSF for AIS achieves high fusion rates exceeding 90% survivorship free of pseudoarthrosis at 9 years postoperatively, regardless of whether local AT or AL are utilized. Importantly, the use of AT alone showed no inferiority compared with AL suggesting that may be sufficient for achieving successful fusion. Level III.

STUDY DESIGN:Retrospective controlled cohort. OBJECTIVE:To evaluate the effect of intraoperative liposomal bupivacaine (LB) through erector spinae plane block (ESPB) on patients with postoperative adolescent idiopathic scoliosis (AIS) with and without patient-controlled analgesia (PCA). BACKGROUND:Pain control after posterior spinal fusion (PSF) for AIS includes opioids and other modalities. The goal of these modalities is to reduce pain and opioid consumption. Two new modalities for pain control include LB and ESPB. There are scant studies on these modalities tested in concert on patients undergoing PSF for AIS. PATIENTS AND METHODS:Seventy-two consecutive patients with AIS who underwent PSF were separated into patients who had a PCA (group A) as part of their postoperative pain management and those who did not (group B). Opioid consumption was measured through morphine milligram equivalents. Pain scores were measured through the visual acuity score (Visual Analog Scale). Patient mobility was measured by steps taken. These were measured by the function of postoperative days from surgery. RESULTS:Group B had significantly lower morphine milligram equivalents at every point after surgery, most notably throughout the entire hospital stay (99.8 vs . 200.7). Postoperative pain scores in group B were the same if not better than group A. There was no difference in mobility between the cohorts. Group B had lower LOS (3.7 vs . 4.1). CONCLUSION:In postoperative PSF for patients with AIS receiving LB through ESPB, those who did not receive a PCA had lower opioid consumption without worse pain scores or mobility and had a lower LOS. Adding LB through ESPB to postoperative pain regimens effectively replaces a PCA by providing the same pain control and reducing overall opioid consumption and LOS.

Study Design: Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. Objective: The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. Summary of Background Data: AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. Materials and Methods: A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. Results: The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). Conclusions: Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.

The devastating COVID-19 pandemic has caused abrupt worldwide changes to healthcare infrastructure. The goals of these changes are to curb the pandemic, appropriately care for patients and prevent spread of this highly contagious pathogen (1). In the United States (US), the US Coronavirus Task Force has called on all hospital systems to delay or cancel nonessential elective procedures. The reasons for this are multiple, including but not limited to: (I) conserve personal protective equipment (PPE) such as gloves, gowns, eye shields, etc.; (II) decrease the risk of unnecessary iatrogenic transmission; (III) reallocate the health care work force to meet the overwhelming demands and challenges of increased patient volume and risk to healthcare providers that this pandemic brings; and (IV) free up beds and equipment such as ventilators, which effectively increases capacities and resources for care of COVID-19 patients (1). From an orthopaedic surgical training perspective, the implications of these transitory changes on residency and fellowship training are very complex, dynamic, and overall, monumental. Our institution, which is a tertiary academic, multi-hospital enterprise with an orthopaedic surgery residency program and seven orthopaedic fellowship training programs has undergone daily changes to protocols, schedules, clinical rotations, and roles of residents, fellows, and staff since we began preparations in early March of 2020. In addition to residents, fellows in the specialties of Adult Reconstruction, Spine, Hand and Upper Extremity, Shoulder and Elbow, Foot and Ankle, Pediatric Orthopaedics, as well as Sports Medicine have been redeployed to serve the shared purpose of preparing for the COVID pandemic in multiple capacities. Therefore, the purpose of this editorial is to discuss the potential implications of the COVID-19 outbreak on orthopaedic surgical residency and fellowship training.

BACKGROUND:Telemedicine platforms have been developed to support the convenient delivery of health care services to their patients while maintaining appropriate quality of care. However, it is unclear whether they can be utilized effectively in patients with pediatric spinal deformity (PSD). Therefore, this study aimed to evaluate the feasibility and patient satisfaction associated with virtual visit (VV) utilization in PSD patients in comparison to general pediatric orthopaedic indications.METHODS:Of the 482 VVs offered to pediatric orthopaedic patients at a large academic health care system between January 1, 2017, and December 31, 2018, a total of 189 VVs conducted by board-certified orthopaedic surgeons were included in the final analysis. Patient satisfaction scores were collected at the end of each VV by patient and parent rankings of the surgeon and the telemedicine service. Data on patients, visits, and connectivity sessions characteristics were collected and statistically compared between PSD visits (n=33) versus those conducted for general pediatric orthopaedic indications (n=156).RESULTS:Although PSD patients were older (15±3.7 vs. 12±4.7 y; P<0.01), mostly female (76% vs. 47%, P=0.003), and had longer VVs (8±4.6 vs. 5±3.6 min; P=0.003) versus their general pediatric orthopaedic counterparts, they demonstrated similarly high satisfaction scores for surgeon performance (5±0 vs. 4.8±0.1 points; P=0.08) and overall satisfaction (3±2.4 vs. 3.5±2.1; P=0.23). Approximately 80% of all VVs were conducted over mobile devices. Wait time was substantially less for PSD VVs relative to subsequent office visits (13±10 vs. 41±30 min; P<0.001).CONCLUSIONS:Our analysis found that telemedicine VVs provided a convenient alternative to traditional in-office visits for PSD patients. Specifically, we found that PSD patients received faster care with comparable satisfaction. The findings of our present analysis should encourage health care systems to continually evaluate and implement telehealth platforms to improve both the accessibility and appropriate quality of care.LEVEL OF EVIDENCE:Level IV.

Study Design: Retrospective comparative cohort study. Objective: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. Summary of Background Data: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. Materials and Methods: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). Conclusions: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery.

The original version of this article unfortunately contained a mistake. The spelling of Erin Ohliger's name was incorrect.

Background Intraoperative neuromonitoring (IONM) is used to detect impending neurologic damage during complex spinal surgeries. Although IONM is increasingly used during pediatric scoliosis surgeries in the United States, the effect of IONM on the outcomes of such surgeries at a national level is unclear. Methods Using National Inpatient Sample (NIS) from 2009 to 2012, 32,305 spinal fusions performed in children 18 years old or younger of age with scoliosis were identified using ICD-9 procedure and diagnosis codes. IONM was identified using the ICD-9 procedure code 00.94. The effects of IONM use on length of stay (LOS), discharge disposition, hospital charges, and in-hospital complications were assessed using multivariate regression analysis adjusting for patient and hospital characteristics. Results IONM was used in 5,706 (18%) of the surgeries. IONM was associated with increased home discharge (adjusted odds ratio [AOR] = 1.25 [95% confidence interval 1.10-1.40], p = .001). There was no difference in LOS (p = .096) and hospital charges (p = .750). Neurologic complications were noted in 52 (0.9%) surgeries using IONM and 368 (1.4%) surgeries without IONM (p = .005). Although IONM use trended toward lower risk of neurologic complications in multivariate analysis, it failed to achieve statistical significance (AOR = 0.77 [0.57-1.04], p = .084). Conclusions Reported use of IONM in this database was significantly less compared with other databases, suggesting that IONM might be underreported in the NIS database. Nevertheless, in this database, IONM was significantly associated with increased home discharge. Hospital charges and LOS were not affected by IONM. There was a trend toward lower risk of neurologic complications with IONM use, though this finding was not statistically significant.

Background Clinical decision making, preoperative planning, and surgical correction for adolescent idiopathic scoliosis (AIS) has traditionally focused on obtaining the maximum coronal plane correction to improve cosmesis and function. More recently, restoring sagittal alignment has also received increasing attention in AIS patients, correlating with positive health-related quality of life (HRQOL) outcomes in multiple studies. In this realm, cervical sagittal alignment (CSA) has also emerged as one of the variables that may correlate with clinical and functional outcomes in AIS patients undergoing surgical correction. Several studies have focused on studying the cervical sagittal plane parameters in patients with spinal deformity, while few have investigated the impact of surgical correction on CSA. In this study, we aimed to capture the baseline cervical sagittal characteristics and evaluate the changes in CSA in a cohort of AIS patients with Lenke type I curves following posterior spinal instrumented fusion (PSIF). Methods We evaluated our longitudinal database of patients who had surgical correction for AIS between January 1, 2015 and September 1, 2017. The initial search yielded 270 patients. Next, the following inclusion criteria were applied to identify the study cohort: (I) patients who had Lenke type 1 curves, (II) patients with adequate pre-operative and post-operative radiographs (posterior-anterior and lateral), (III) patients who had a minimum radiographic follow-up of 6 months, and (IV) patients who were treated with the same standard rod instrumentation system. In addition, the following exclusion criteria were applied: (I) patients with neuromuscular disorders, (II) patients with prior spine surgery, and (III) those who received greater than Schwab-2 osteotomies. A total of 30 patients were included in our final analysis. The C2-C7 angle, C0-C2 angle, C2-C7 sagittal vertical axis (SVA), McGregor slope (McGS), and the T1 slope angle were measured preoperatively and at 6 months. A kyphotic measurement was assigned a negative value while positive values were used to describe lordotic measurements. Descriptive statistics and paired sample t-test were used to compare pre-and post-operative data with a cutoff P value of 0.05 to determine statistical significance. Results Overall, CSA improved in most patients post-operatively, with 19/30 (63%) resulting in improved lordosis. Pre-operatively, mean C2-C7 cervical lordosis was -4.3°, which improved to -0.5° postoperatively (P=0.075), with a mean difference of 3.7°. Simultaneously, mean C0-C2, C2-C7 SVA, McGS, and T1 slope changed from 17° (range, -18° to 41°), 26.5 mm (range, 10 to 45 mm), 4° (range, -7.5° to 25°), and 17.4° (range, 1° to 42°) to 16° (range, 0° to 34.4°, mean difference =1.01°, and P=0.548), 28.2 mm (range, 9 to 57 mm, mean difference =2 mm, and P=0.244), 4.03°, (range, -7.8° to 25°, mean difference =0.16, and P=0.916), and 18° (range, 5.4° to 42°, mean difference =0.37, and P=0.761) (mean change of C2-C7 angle of 3.76°). Conclusions This study demonstrated baseline cervical kyphosis and a trend towards cervical lordosis restoration in patients with AIS and a Lenke type 1 curve who underwent PSIF. This study adds to emerging evidence and, together with further studies, will help estimate the impact of PSIF on the cervical sagittal profile, the effect of CSA on patient reported outcomes, and ways to address cervical sagittal malalignment when undertaking the surgical correction for specific curve types in AIS.

Study Design. Retrospective cohort study. Objective. The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). Summary of Background Data. Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. Methods. A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. Results. Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ± 2 vs. 7 ± 2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ± 548 vs. 488 ± 341 cm3, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ± 2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. Conclusion. Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. Level of Evidence: 3

Background: As the indications for total hip arthroplasty (THA) have expanded, this procedure is being increasingly performed in young patients. Oftentimes, this population has undergone one or more salvage procedures in an attempt to delay or forestall a THA. However, it is unclear whether patients with prior salvage procedure have higher risk of adverse events. Methods: From 2004 to 2014, 215 THAs performed in patients less than 30 years at a single institution were identified. These patients were screened to identify 37 THAs in which one or more salvage procedures were performed prior to the THA (salvage group). The prior salvage procedures were open in 30 (pelvic osteotomy = 5, femoral osteotomy = 15, combined osteotomy = 2, core decompression = 7, bone graft = 1) and arthroscopic in 7. Medical and surgical complications within 90 days and overall survivorship at a minimum follow-up of 2 years were recorded. Nonparametric tests and Kaplan-Meier survival curves were used to compare the groups. Results: Salvage group had a higher rate of wound complications (P = .037), superficial infections (P = .005), and reoperations (P = .015). The 5-year survivorships in the salvage and nonsalvage groups were 97.1% and 96.7%, respectively (P = .787). Conclusion: Patients less than 30 years who undergo THA after a previous salvage procedure have a higher risk of wound complications, superficial infections, and reoperations, but similar survivorship, compared to those who did not have any prior salvage procedures. This information is helpful in counseling young patients while offering various surgical options for the management of various hip pathologies. (c) 2017 Elsevier Inc. All rights reserved.

Background: Vertebral compression fractures are a common result of osteoporosis and osteopenia secondary to steroid use and chemotherapy treatment. Balloon kyphoplasty is a treatment option with good to excellent results well described in adults. Although a few recent studies have been published regarding the use of kyphoplasty in children, no formal indication exists for the pediatric population. The purpose of this study is to describe the outcomes of 3 chronically ill children with intractable pain from vertebral compression fractures, managed with kyphoplasty. Methods: We retrospectively reviewed 3 pediatric patients who underwent balloon kyphoplasty for vertebral compression fractures secondary to chronic illness. Patient variables included age, sex, primary diagnosis and treatments, levels of vertebral fracture, and time elapsed from initial therapy to fracture. A numeric rating scale of 0 to 10 was used for patient-reported pain, before and after kyphoplasty. Preoperative and postoperative analgesic use and physical function were also described. Surgical variables included levels of kyphoplasty, operative time, and procedure-related complications. Results: The primary diagnoses were relapsed rhabdomyosarcoma, abdominal desmoplastic small round cell tumor, and IPEX-like (immune dysregulation, polyendrocrinopathy, enteropathy, X-linked) syndrome. All 3 patients were males, aged 12, 12, and 13, respectively, at the time of kyphoplasty. Pain scores were 8 to 9 preoperatively in 2 patients, severely affecting their physical function including independent walking. Excruciating back pain was a contributing factor to the respiratory distress of the third patient, who required elective intubation. All of the patients reported significant pain relief (range, 0 to 2) and improved physical function with kyphoplasty. The third patient was successfully extubated 1 week postoperatively and eventually returned to baseline activity. There were no complications related to kyphoplasty. Conclusions: Balloon kyphoplasty seems to be safe in terminally ill children and may be a useful tool for managing intractable pain due to vertebral compression fractures. Level of Evidence: Level IV—retrospective case series.

Learn how three training programs used personality assessment - and shared the results with the participants - to assess and facilitate leadership development in orthopedic surgery.

Background: The aim of surgical treatment of scoliosis is to obtain fusion of the spinal column, balanced in the coronal and sagittal planes. Great success has been attained with coronal correction; however, the sagittal profile has received less attention, resulting in little correction of sagittal plane alignment. The purpose of this study was to compare uniplanar and fixed pedicle screws in the correction of the thoracic sagittal alignment in the treatment of adolescent idiopathic scoliosis (AIS). Methods: The sagittal profile of 2 groups of patients undergoing posterior spinal fusion (PSF) for AIS was compared. One group had uniplanar screws (n=16) as bone anchors, and the second group had fixed screws (n=20). Consecutive patients with AIS treated by PSF during 2004 to 2006 with fixed screws; and those treated in 2008 with uniplanar screws were included in the study. Data included: patient demographics, medical conditions, curve type, Risser stage, coronal and sagittal curve magnitude, curve flexibility, osteotomies, fusion levels, type and location of instrumentation, curve magnitude at the initial postoperative visit and at final follow-up. ANOVA and χ2 testing was completed. A P<0.05 was considered significant. Results: Both groups were comparable demographically, medically, in relation to the curve characteristics and the surgical treatment. Immediate postcorrection sagittal curvature measurements were greater using the uniplanar than fixed screws, 36 versus 26 degrees and was also statistically significant at final follow-up (P=0.006). There was no difference between groups with respect to coronal thoracic deformity. In the Lenke 1 and Lenke 2 curve population, similar results were found. Conclusions: In patients undergoing PSF for AIS, uniplanar screws achieved superior correction of the sagittal thoracic alignment than fixed screws. This advantage was maintained in the postoperative follow-up period. The ability of the uniplanar screws to adapt to variable sagittal orientation appears to contribute to better radiographic outcomes. Level of Evidence: This is a level III respective review study conducted at a single center from a single, pediatric spine surgeon.

BACKGROUND:Spinal fusion surgery for the treatment of adolescent idiopathic scoliosis (AIS) is increasing. Health systems and surgeons are decreasing hospital length of stay (LOS) to decrease costs. The purpose of this study was to review the contribution of an accelerated discharge protocol on the total cost of a single episode of care related to the surgical treatment of AIS at a single institution.METHODS:A retrospective cost analysis was performed over an 18-month period, from January 2014 through June 2015, before and after the institution of an accelerated discharge program. Patients treated surgically with ICD-9 code 737.30 (Idiopathic Scoliosis) were reviewed. Itemized costs and LOS were analyzed collectively and by surgeon before and after the accelerated discharge protocol.RESULTS:Eighty AIS patients were treated surgically. The accelerated discharge program significantly reduced average LOS from 4.2 days in 2014 to 3.3 days during the first 6 months of 2015 (P≤0.05). There were no increases in complications. There was a 9% decrease in the total average costs per episode of care. A weighted average, a relative average change in costs, and an average cost savings per case were calculated for 12 different categories. Average Surgical Services and Nursing costs decreased during the study period while all other costs increased. The accelerated discharge program did not directly contribute significantly to this decrease in costs. Greatest cost reduction was associated with average bone graft and pedicle screw cost, with an overall 8.5% reduction in pedicle screw use and a 58% reduction in bone graft costs.CONCLUSIONS:Intraoperative variables under the direct control of the surgeon contribute much more to cost reduction than an accelerated discharge program for surgically treated AIS patients.