Faculty Bibliography

The World Health Organization describes traumatic injuries as a "neglected epidemic" in developing countries, accounting for more deaths annually than HIV/AIDS, malaria, and tuberculosis combined. Low- and middle-income countries rely on volunteer assistance to address the growing surgical disease burden of traumatic injuries. Efforts to increase the availability of international electives for orthopaedic trainees can help with the short-term need for surgical personnel abroad and facilitate sustainability through capacity building, maximizing long-term benefits for all parties. The volunteer invariably benefits from this cross-cultural experience with many citing improved skills in communication, clinical diagnostics, appreciation of equality and diversity, and cost-consciousness. A consolidated discussion regarding barriers and implementation strategies can assist interested individuals and institutions plan for future volunteering endeavors.

STUDY DESIGN:This is a retrospective case review. OBJECTIVE:The objective of this study was to present an anatomic approach to transpsoas interbody fusion without psoas stimulated electromyography (sEMG) and to evaluate the rate of neurological and approach-related complications. BACKGROUND:The transpsoas approaches have become commonly utilized for lumbar interbody fusion and may have certain advantages compared with other methods of interbody stabilization. Traditionally, transpsoas approaches have been performed utilizing sEMG as it has been purported to reduce the risk of injury to the lumbar plexus; however, an anatomic approach to transpsoas surgery is also possible as cadaveric studies have demonstrated the anatomy of the psoas muscle and lumbar plexus. METHODS:Patients who underwent transpsoas interbody fusion using an anatomic approach without psoas sEMG between 2005 and 2018 were enrolled in this study. The preoperative and postoperative medical records for this cohort were carefully reviewed to identify any new or persistent radicular symptoms, neurological deficits or approach-related complications. RESULTS:A total of 133 patients (48 males, 85 females) underwent transpsoas interbody fusion at 222 levels in this cohort-which had a mean age of 63 (61, 65) years and body mass index of 28.8 (27.8, 29.9). New neurological complications were seen in 5 patients (3.8%) and 5 patients (3.8%) were found to have new postoperative radicular pain, up to 3 months postoperatively. The total number of perioperative, approach-related complications was 7 (5.3%) for the entire cohort. CONCLUSION:An anatomic transpsoas approach to the interbody space without psoas sEMG demonstrated a rate of neurological and approach-related complications that was comparable or superior to the rate of complications reported using the traditional transpsoas approach with sEMG.

OBJECTIVE:The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy. METHODS:The PearlDiver Patient Records Database (www.peardiverinc.com) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding. RESULTS:A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04). CONCLUSIONS:Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.

OBJECTIVE:To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease. METHODS:A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA> 2 years previously, and 3) patients with a history of LSF after having recent THA <2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use. RESULTS:Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P < 0.0001; hazard ratio, 1.69; P < 0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120). CONCLUSIONS:Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (<2 years).

Adult spinal deformity (ASD) is a challenging problem for spine surgeons given the high risk of complications, both medical and surgical.

STUDY DESIGN/METHODS:Retrospective Study. OBJECTIVE:This investigation examined matched cohorts of lumbar spinal fusion (LSF) patients undergoing robot-assisted and conventional LSF to compare risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization. SUMMARY OF BACKGROUND DATA/BACKGROUND:Patient outcomes and complication rates associated with robot-assisted LSF compared to conventional fusion techniques are incompletely understood. METHODS:The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary LSF between 2011 and 2017. Patients receiving robot-assisted or conventional LSF were matched using key demographic and comorbidity variables. Indication for revision was also studied. Risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization at 1 and 6 months was compared between the cohorts using multivariable logistic regression additionally controlling for age, sex, and Charlson Comorbidity Index. RESULTS:The percent of LSFs that were robot-assisted rose by 169% from 2011 to 2017, increasing linearly each year (p = 0.0007). Matching resulted in 2528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (adjusted odds ratio [aOR] = 2.35, P ≤ 0.0001), 30-day readmission (aOR = 1.39, P = 0.0002), and total 30-day complications (aOR = 1.50, P < 0.0001), specifically respiratory (aOR = 1.56, P = 0.0006), surgical site infection (aOR = 1.56, P = 0.0061), and implant-related complications (aOR = 1.74, P = 0.0038). The risk of revision due to infection after robot-assisted LSF was an estimated 4.5-fold higher (aOR = 4.46, 95% confidence interval [CI] 1.95-12.04, P = 0.0011). Furthermore, robot-assisted LSF had increased risk of revision due to instrument failure (aOR = 1.64, 95% CI 1.05-2.58, P = 0.0300), and pseudarthrosis (aOR = 2.24, 95%CI = 1.32-3.95, P = 0.0037). A higher percentage of revisions were due to infection in robot-assisted LSF (19.0%) than in conventional LSF (9.2%) (P = 0.0408). CONCLUSION/CONCLUSIONS:Robotic-assisted posterior LSF is independently associated with increased risk of revision surgery, infection, instrumentation complications, and postoperative opioid utilization compared to conventional fusion techniques. Further research is needed to investigate long-term postoperative outcomes following robot-assisted LSF. Spine surgeons should be cautious when considering immediate adoption of this emerging surgical technology. LEVEL OF EVIDENCE/METHODS:3.

BACKGROUND:Complication rates following occipitocervical and atlanto-axial fusion are high. While methods to fuse the upper cervical spine levels have evolved, complication rates and surgical survivorship of occipitocervical fusion versus atlanto-axial fusion are incompletely understood. METHODS:The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary occipitocervical or atlanto-axial fusion between 2007 and 2017. Incidence of each fusion procedure was studied across time. Multivariable logistic regression was used to compare 30-day readmission, 30-day medical complications, and post-operative opioid utilization at 1, 3, 6, and 12 months between cohorts, controlling for age, gender, Charlson Comorbidity Index (CCI), and indication for surgery. Risk of revision was compared through Cox-proportional hazards modeling, Kaplan-Meier survival, and log-rank test. RESULTS:< 0.0001). CONCLUSIONS:Rates of occipitocervical and atlanto-axial fusion are rising, while complication and revision surgery rates remain high, with occipiticervical fusion leading to higher rates even after controlling for patient characteristics and surgical indication. Spine surgeons should be cautious when considering fusion of the occipitocervical levels if atlanto-axial fusion could be performed safely and provide adequate stabilization to treat the same pathology.