Faculty Bibliography

All-suture anchors (ASAs) are a relatively new alternative to traditional suture anchors, comprised of sutures, suture tapes, or ribbons woven through a soft sleeve. These novel anchors are typically smaller than traditional anchors, allowing for more anchors to be used in the same amount of space or for use when bone stock is limited, for example, in revision settings. They can be inserted through curved guides to reach more challenging locations, and they have thus far had similar loads to failure during biomechanical testing as traditional anchors. However, these benefits must be weighed against new challenges. When using ASAs, care must be taken to fully deploy and seat the anchor against cortical bone for optimal fixation and to prevent gap formation. Furthermore, decortication, often performed to enhance the biologic environment for soft-tissue healing, may weaken the cortical bone on which ASA fixation depends on. The purpose of this article is to provide insight on the designs, advantages, and potential disadvantages associated with ASAs, as well as review the available biomechanical and clinical data.

BACKGROUND:value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). METHODS:We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. RESULTS: = .000012). CONCLUSIONS:This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. LEVEL OF EVIDENCE/METHODS:Level I; Systematic Review.

INTRODUCTION:The purpose of this study was to determine the most common orthopedic diagnoses and procedures among patients who experience domestic violence (DV) and to determine whether these were more common in patients who experienced DV compared with those who did not. METHODS:We performed a retrospective cohort study of all patients identified in the National Trauma Data Bank. Patients were divided into two cohorts for comparison: victims of DV and all other patients. The main outcome measurements were a diagnosis of an orthopedic injury and/or a procedure performed for an orthopedic diagnosis. RESULTS:In total, 1,204,596 patients were included in the analysis, of whom 3191 (0.26%) were victims of DV. Adult trauma patients with DV were more likely to have a diagnosis of neck and back sprain (odds ratio 1.98, 95% confidence interval 1.60 to 2.44, P < 0.0001) and more likely to undergo surgical repair of the flexor tendon of the hand (odds ratio 2.76, 95% confidence interval 1.75 to 4.35, P < 0.0001) than patients without a diagnosis of DV. DISCUSSION:Patients who experience DV were more likely to have back and neck sprain and more likely to undergo repair of flexor tendon of the hand than those who do not experience DV.

OBJECTIVE:Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population. METHODS:Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records. RESULTS:From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery. CONCLUSIONS:Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.

OBJECTIVE:Significant investigation in the adult population has generated a body of research regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following long fusions to the sacrum and pelvis. However, much less is known regarding early complications, including PJK and PJF, in the ambulatory pediatric patient. As such, the objective of this study was to address the minimal literature on early complications after ambulatory pediatric patients underwent fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac (S2AI) instrumentation. METHODS:The authors performed a retrospective review of pediatric patients with nonidiopathic spinal deformity < 18 years of age with ambulatory capacity who underwent fusion to the pelvis at a multisurgeon pediatric academic spine practice from 2016 to 2018. All surgeries were posterior-only approaches with S2AI screws as the primary technique for sacropelvic fixation. Descriptive, outcome, and radiographic data were obtained. The definition of PJF included symptomatic PJK presenting as fracture, screw pullout, or disruption of the posterior osseoligamentous complex. RESULTS:Twenty-five patients were included in this study. Nine patients (36.0%) had 15 complications for an overall complication rate of 60.0%. Unplanned return to the operating room occurred 8 times in 6 patients (24.0%). Four patients (16.0%) had wound issues (3 with deep wound infection and 1 with wound breakdown) requiring reoperation. Three patients (12.0%) had PJF, all requiring reoperation. A 16-year-old female patient with syndromic scoliosis underwent extension of fusion due to posterior tension band failure at 6 months. A 17-year-old male patient with neuromuscular scoliosis underwent extension of fusion due to proximal screw pullout at 5 months. A 10-year-old female patient with congenital scoliosis underwent extension for PJF at 5 months following posterior tension band failure. One patient had pseudarthrosis requiring reoperation 20 months postoperatively. CONCLUSIONS:Fixation to the pelvis enables significant deformity correction, but with rather high rates of complications and unexpected returns to the operating room. Considerations of sagittal plane dynamics for PJK and PJF should be strongly analyzed when performing fixation to the pelvis in ambulatory pediatric patients.

BACKGROUND:Glenohumeral instability is a common condition of the shoulder. Glenoid bone loss and humeral head bone loss are well recognized as risk factors for recurrent instability. There are few studies in the literature that examine the role of coracoacromial arch anatomy in the pathogenesis of glenohumeral instability. Previous reports found an association between posterior acromial coverage (PAC) and posterior instability. We hypothesize that coracoacromial arch anatomy is related to anterior shoulder instability. METHODS:In this retrospective cohort study, 50 patients with unidirectional anterior shoulder instability were matched to a control group of 50 glenohumeral arthritis patients without any history of shoulder instability. Radiographic measurements of the coracoacromial arch anatomy were made: shoulder arch angle, scapular Y angle, anterior coracoid tilt (ACT), posterior acromial tilt, anterior acromial coverage angle, PAC angle, coracoid height, posterior acromial height, and critical shoulder angle were determined using standard lateral scapular and anteroposterior radiographs. RESULTS: = .001). CONCLUSIONS:Shoulder coracoacromial arch morphology may play a role in the stability of the shoulder joint and development of recurrent anterior instability. Shoulders with a decreased shoulder arch angle, a less contained and flatter coracoacromial arch and larger ACT, were associated with anterior instability. This study identifies the shoulder coracoacromial arch angle and anterior coracoid tile angles as risk factors for anterior shoulder instability. Our findings suggest that measuring these angles may help orthopedic surgeons understand the risk of anterior instability and analyze risk factors to improve clinical decision making.

BACKGROUND:Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications. METHODS:The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis. RESULTS:< .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts. CONCLUSIONS:Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.

Large chondral lesions of the humeral head are often treated with total shoulder arthroplasty, but this may not be an ideal option for young, active patients. Humeral head resurfacing is another option, which better preserves the native biomechanics. This article and the accompanying video present the surgical technique of partial humeral head resurfacing, which further preserves the remaining healthy cartilage. It is described for a chondral lesion due to avascular necrosis, but the method has been successfully used to treat chondral lesions from a broad range of causes.

Formation of woven and lamellar bone in the adult skeleton can be induced through mechanical loading. Although much is known about the morphological appearance and structural properties of the newly formed bone, the molecular responses to loading are still not well understood. The objective of our study was to use a microarray to distinguish the molecular responses between woven and lamellar bone formation induced through mechanical loading. Rat forelimb loading was completed in a single bout to induce the formation of woven bone (WBF loading) or lamellar bone (LBF loading). A set of normal (non-loaded) rats were used as controls. Microarrays were performed at three timepoints after loading: 1 hr, 1 day and 3 days. Confirmation of microarray results was done for a select group of genes using quantitative real-time PCR (qRT-PCR). The micorarray identified numerous genes and pathways that were differentially regulated for woven, but not lamellar bone formation. Few changes in gene expression were evident comparing lamellar bone formation to normal controls. A total of 395 genes were differentially expressed between formation of woven and lamellar bone 1 hr after loading, while 5883 and 5974 genes were differentially expressed on days 1 and 3, respectively. Results suggest that not only are the levels of expression different for each type of bone formation, but that distinct pathways are activated only for woven bone formation. A strong early inflammatory response preceded an increase in angiogenic and osteogenic gene expression for woven bone formation. Furthermore, at later timepoints there was evidence of bone resorption after WBF loading. In summary, the vast coverage of the microarray offers a comprehensive characterization of the early differences in expression between woven and lamellar bone formation.