Adult Deformity Research Articles

Role of Ilizarov external fixator in the treatment of long-standing knee flexion deformity in adults: A prospective cohort study

Background: One of the major disabilities of the lower limb is fixed knee flexion deformity. Post-polio residual paralysis is the main etiology, but there are others. This study evaluated the outcome of treatment of long-standing fixed knee flexion deformity with the Ilizarov external fixator without soft-tissue intervention or osteotomy in a certain age group. Methods: Thirty patients (33 knees) with knee flexion deformity were enrolled in this study. There were 11 women and 19 men. Three patients had bilateral lower limb affection. The etiology was post-polio residual paralysis in 11 patients (14 knees), four patients had brain insult, eight patients had post infectious etiology, and seven patients had failure of open reduction and internal fixation of tibial plateau fractures. An Ilizarov fixator was applied in all patients for deformity correction with no soft-tissue release or osteotomies. Results: The mean age of the patients was 28.7 yr (18-55 yr), the mean preoperative flexion knee angle was 77.87 degrees (50-130 degrees). The mean preoperative arc of motion was 17.1 degrees (0-50 degrees), the mean time since the deformity was well established was 9.4 yr (4-30 yr), the mean time needed for correction of the deformity was 49.2 days (27-120 days) at the end of the procedure. All patients achieved full correction of the deformity. Conclusions: The Ilizarov external fixator is an effective tool in the treatment of severe long-standing fixed knee flexion deformity in adults with minimal complications and good outcomes. Level of Evidence: Level II.

The Effect of Parity on Age-Related Degenerative Changes in Sagittal Balance.

Retrospective cohort study. Evaluate the effects of parity (number of births) on measures of sagittal posture in elderly women. The long-term objective of this study is to identify and mitigate factors contributing to age-related postural deformity in older adults. Adult spinal deformity is a prevalent condition that often requires costly surgical management. Females are disproportionately represented in spinal deformity surgical cases with up to 90% of patients being women. The potential contributions of pregnancy on postural degeneration have only begun to be acknowledged and require further study. Two hundred eight women with standing lateral radiographs were selected from the TwinsUK register. Parity information was extracted from questionnaires. Sagittal balance measurements (thoracic kyphosis, lumbar lordosis [LL], pelvic incidence [PI]) were collected and PI-LL mismatch was calculated. One-way analysis of variance tests were done between three separate age categories for measures of sagittal balance and parity and stepwise multivariate regression was done for PI-LL. Both age and PI-LL mismatch significantly differed between parity categories. PI-LL was on average 7.0° ± 2.5° greater in multiparous (3+ births) subjects than in nulliparous subjects (P < 0.01). Parity did not have an independent relationship with lumbar disc degeneration, lumbar bone mineral density, or any of the individual sagittal balance parameters (P > 0.05 for all), except for PI-LL. From a subanalysis of the effect of parity on sagittal alignment within twin pairs, we found that within pair differences in parity associate with within pair differences in thoracic kyphosis. This study established correlations between measures of spinal curvature in older women and parity for the first time. Longitudinal research is required to establish a causative relationship. 4.

Spine surgery is kyphosing to spine surgeon.

Spine surgery is a demanding surgical specialty which requires surgeons to operate for hours on end, often compromising good posture. Sustained poor posture in the operating room (OR) can be the source of many adverse health effects on spine surgeons. This study will analyze posture of a spine surgeon in different types of spine surgery cases. Posture of a surgeon was measured using the UPRIGHT Posture Training Device. The device was worn by the surgeon in the OR through a wide variety of spine surgery cases. The percent time spent slouched while performing cervical, adult deformity, and lumbar spine surgeries is 39.9, 58.9, and 38.6, respectively. For all surgeries recorded, the percent time slouched is 41.6. The average procedure time was 145.3min, with adult deformity cases on average being the longest (245.6min) followed by cervical (152.9min) and then lumbar (122.5min). Poor posture while operating is very likely to occur for many spine surgeons regardless of case type. This poor posture is maintained for long periods of time given the average spine surgery procedure recorded in the study was roughly 2.5h long. Spine surgeons should be aware of the tendency for poor posture while operating, and they should try using posture-improving techniques to maintain good spine health.

Advances in Spinal Fusion Strategies in Adult Deformity Surgery.

As the frequency of adult deformity surgery (ADS) continues to increase, our understanding of techniques that enhance fusion must continue to evolve because pseudarthrosis can be a serious and costly event. We sought to conduct a review of the literature investigating techniques that can enhance outcomes of ADS. Two databases were searched for keywords such as "advances in spinal fusion," "new technology in adult spinal deformity," "interbody devices for adult spinal deformity," "adult spinal deformity rods," and "screw design in adult spinal deformity" to examine recent literature and trends in ADS. We identified 45 articles for our review. Topics studied include the use of multiple rods, interbody fusion, distal fixation techniques, and bone morphogenetic protein or iliac crest bone graft. Many recent innovations in treatments to enhance fusion in ADS have been studied, some more controversial than others. Further research into the efficacy of these techniques may increase fusion rates in ADS.

Revision surgery for non-union in adult spinal deformity.

As adult spinal deformity surgery is performed more and more, the spine surgeon is faced with the challenge to treat pseudoarthrosis. The presentation may vary, from asymptomatic patients, who should be observed in most of the cases, to patients with acute episode of broken rods, and or chronic pain with often trunk imbalance. In some instances, patients will present with neurologic symptoms. The evaluation of such patients must start with a good understanding of why the surgery failed first place. Poor host, smoking, lack of anterior column support, poor sagittal balance, lack of fusion, poor construct. Often a combination of all of the above is encountered. The workup for such cases consists of imaging studies (with often a CT myelogram as the excessive metal artifact will render the MRI imaging useless), nutrition labs, DEXA scan, EOS films and internal medicine or cardiology consult for risk stratification as this may represent major surgery. Indication of surgery is mostly based on pain and imbalance and/or poor function. The surgeon planning a revision adult deformity surgery has many tasks to perform: Identify and avoid the reasons that lead to failure of the previous surgeries. Plan the anterior column reconstruction either through posterior or anterior interbody fusion. Restore the global alignment through anterior or posterior osteotomies to achieve sagittal and coronal balance. Obtain a solid fixation with sufficient levels above and below the osteotomies sites with in some cases the use of pelvic screws and four rods (Quad-Rod) techniques. The use of bone graft (either autologous, allograft, bone graft enhancers and inducer) agents. The requirement of decompression either through a virgin spine or a previous laminectomy bed. Despite the extent of these surgeries and the potential for immediate postoperative complications, the outcome is in most cases satisfactory if these goals are achieved. In this review, the authors explore different scenarios for pseudoarthrosis in the adult spine deformity patient and the preferred treatment method to obtain the best outcome for every individual patient. These slides can be retrieved under Electronic Supplementary Material.

Revision surgery in distal junctional kyphosis.

Opposed to proximal junctional kyphosis and proximal junctional failure, their distal equivalents, distal junctional kyphosis and failure (DJK/DJF) have received less attention in the literature. The aim of this article is to provide an overview of the problem of DJK-DJF in different clinical scenarios such as adolescent idiopathic scoliosis (AIS), Scheuermann's kyphosis (SK) and adult deformity surgery and to suggest a strategy for prevention and treatment. A narrative review of the literature was conducted to identify the best evidence on the risk factors of the problem. DJK/DJF have been described as a complication of AIS, SK and adult spine deformity (ASD). For AIS and SK, the choice of a lower instrumented vertebra more cranial than the sagittal stable vertebra has shown to increase the incidence of DJK and DJF. For ASD, constructs ending with S1 pedicle screws had a higher incidence of DJK/DJF than those ending distally with S1 pedicle plus iliac screws. The proposed strategy of treatment includes restoration of normal sagittal alignment, choice of a distal fixation point stable in the sagittal, coronal and transverse planes, balancing the fusion mass over the distal fixation point and providing solid fixation at the distal end of the construct. These slides can be retrieved under Electronic Supplementary Material.

Multiple Developmental Defects in sox11a Mutant Zebrafish with Features of Coffin-Siris Syndrome.

A previous study suggested that human Coffin-Siris syndrome is related to the mutation of SOX11. Since the homozygous SOX11 mutant mice died soon after birth, no suitable model was available for the study of the pathogenic mechanism of Coffin-Siris syndrome. To solve this problem, we generated two viable homozygous zebrafish mutants, sox11am/m and sox11bm/m. We found that the sox11am/m mutant possessed Coffin-Siris syndrome features. The sox11am/m mutants exhibited growth deficiency from 3.3 hpf embryos to adulthood. Furthermore, the sox11am/m mutant also displayed microcephaly, narrow pupillary distance, achondroplasia, and bone deformity in adults. Growth deficiency could be rescued by the injection of sox11a mRNA at the one-cell stage. In addition, the expression levels of genes related to cartilage and bone were downregulated in the sox11am/m mutant, indicating that sox11a mainly affected the growth and development of zebrafish by regulating the expression of genes related to skeletal development. Our results indicate that sox11am/m mutant zebrafish offered a potential model system to help with the search for pathogenic mechanisms of human Coffin-Siris syndrome.

Follow-up Comparison of the Effect of Eight-weeks Corrective Exercises With and Without Myofascial Release on Postural Kyphosis Deformity

Introduction: The present research aimed to compare and follow-up the effect of 8-week corrective exercises with and without the myofascial release on functional kyphosis deformity in young adults. Methods: It was a randomized controlled trial in the university laboratory. Forty-five male students suffering from abnormal hyperkyphosis deformity (kyphosis of more than 42°) were selected and randomly assigned to three groups: corrective exercises, combinational exercises (corrective and myofascial release), and control. The Mean±SD age, height, and weight of the study sample were 22.12±2.88 years, 175.44±6.80 cm, and 71.21±7.31 kg, respectively. The study groups did the exercises for 8 weeks, under the direct observation of the researchers. The kyphosis angle of the participants was measured using a flexible ruler, at the baseline, post-test, and follow-up (4 weeks after the end of the exercises) stages. The collected data were analyzed with repeated measures Analysis of Variance (ANOVA) and Analysis of Covariance (ANCOVA) tests. Results: After 8 weeks of exercises, the degree of kyphosis in the post-test and follow-up stages was significantly lower than that in the pre-test, in both training groups. The results of the ANCOVA test demonstrated that the thoracic kyphosis degree in the combinational exercises group was significantly lower than that of the corrective exercises group (P≤0.05), in the post-test and follow-up stages. Conclusion: According to the results, the corrective exercises program in combination with the myofascial release is more effective than the corrective exercises alone, in correcting the thoracic kyphosis deformity.

The Effect of Tobacco Smoking on Adverse Events Following Adult Complex Deformity Surgery: Analysis of 270 Patients From the Prospective, Multicenter Scoli-RISK-1 Study.

Post-hoc analysis of a prospective, multicenter cohort study. To analyze the impact of smoking on rates of postoperative adverse events (AEs) in patients undergoing high-risk adult spine deformity surgery. Smoking is a known predictor of medical complications after adult deformity surgery, but the effect on complications, implant failure and other AEs has not been adequately described in prospective studies. Twenty-six patients with a history of current smoking were identified out of the 272 patients enrolled in the SCOLI-RISK-1 study who underwent complex adult spinal deformity surgery at 15 centers, with 2-year follow-up. The outcomes and incidence of AEs in these patients were compared to the nonsmoking cohort (n = 244) using univariate analysis, with additional multivariate regression to adjust for the effect of patient demographics, complexity of surgery, and other confounders. The number of levels and complexity of surgery in both cohorts were comparable. In the univariate analysis, the rates of implant failure were almost double (odds ratio 2.28 [0.75-6.18]) in smoking group (n = 7; 26.9%)) that observed in the nonsmoking group (n = 34; 13.9%), but this was not statistically significant (P = 0.088). Surgery-related excessive bleeding (>4 L) was significantly higher in the smoking group (n = 5 vs. n = 9; 19.2% vs. 3.7%; OR 6.22[1.48 - 22.75]; P = 0.006). Wound infection rates and respiratory complications were similar in both groups. In the multivariate analysis, the smoking group demonstrated a higher incidence of any surgery-related AEs over 2 years (n = 13 vs. n = 95; 50.0% vs. 38.9%; OR 2.12 [0.88-5.09]) (P = 0.094). In this secondary analysis of patients from the SCOLI-RISK-1 study, a history of smoking significantly increased the risk of excessive intraoperative bleeding and nonsignificantly increased the rate of implant failure or surgery-related AEs over 2 years. The authors therefore advocate a smoking cessation program in patients undergoing complex adult spine deformity surgery. 2.

Halo-gravity traction for the treatment of pediatric cervical spine disorders.

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities. Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications. The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours. HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

Single-stage repair of secondary unilateral cleft lip-nose deformity in adults

Correction of cleft lip-nose deformity in adult patients is different from that in children. One-stage correction has proved to be a suitable technique for patients with cleft-lip nose deformity. This study aimed to explore a particular single-stage method and evaluate the effect of simultaneous reparation of secondary unilateral cleft lip-nose deformities.Cleft lip patients who had previously undergone nasolabial surgery with residual poor nasal/lip appearance were included. The alveolar bone defect was repaired with granular costal cortical bone. Lip revision and rhinoplasty were performed using diced costal cartilage. The lip, nose, and alveolar deformities were corrected in one stage.From 2011 to 2017, 53 cases were treated. The vermilion discrepancy was corrected in all cases. Fifty-one patients were successfully treated, with primary healing in the bony recipient area. Cancellous bone exposure occurred in two cases. The wounds were healed after debridement and drainage. Appearances were improved in all patients. The mean change in columella–labial angle ranged from 82.50 to 92.78° (p < 0.001).This one-stage correction appears to have led to a distinct improvement in the nasal tip projection and lip. The method is considered to be effective and reliable in patients with secondary unilateral cleft lip-nose deformities.

Complex Adult Deformity Surgery

Complex Adult Deformity Surgery

Incidence of spinal deformities and the relationship with physical status and back pain in ambulant adults with cerebral palsy and spastic diplegia.

The purpose of this study was to determine the incidence of spinal deformities in ambulant adults with cerebral palsy (CP) and spastic diplegia, more than 15years after orthopaedic interval surgery approach (ISA) treatment, and its relationship to contextual factors, level of pain and physical status. Spinal X-rays, pain (Oswestry Disability Index (ODI) and location/frequency) questionnaires and physical examination assessing lower extremity muscle strength (Medical Research Council scale), motor control (selectivity scale) and muscle tone (Ashworth score) were conducted in 30 adults with spastic diplegic CP. Mild scoliosis (curve 12-22°) was determined in eight (28%) participants. Hyperkyphosis (> 50°) was reported in two (7%) and lumbar hyperlordosis (> 60°) in five (17%) participants. Pain was most commonly reported at cervical (n = 19, 63%) and lumbosacral (n = 18, 60%) area, resulting in 'moderate disability' for six (20%) and 'severe disability' for one (3%) participant. Most apparent physical abnormalities determined were hip abduction weakness and increased rectus femoris muscle tone. Regarding correlations, no relations were found for scoliosis curvature, but kyphosis curvature was related to females, ODI scores (lifting and sitting) and increased muscle tone of ankle plantar flexor muscles, lordosis curvature to passive hip extension mobility, and hip flexors and ankle plantar flexors muscle tone. Adults with spastic diplegic CP who received their first orthopaedic intervention more than 15years ago (based on ISA) showed similar incidence of spinal deformities as reported in the younger CP population, suggesting stability of spinal curvature into adulthood. These slides can be retrieved under Electronic Supplementary Material.

Difficulties in Treating Postirradiation Kyphosis in Adults: A Series of Five Cases

Study DesignClinical case series. ObjectiveTo assess objective outcomes of surgical correction of post–external beam radiation therapy (ERBT) kyphosis in a series of five adults. Summary of Background DataEBRT is a well-established treatment for many cancers in children and adults. One complication associated with EBRT is postirradiation spine deformity. Scoliosis is the most common deformity, but kyphosis also occurs frequently. Differences in deformity patterns are likely related to the location and intensity of radiation. To our knowledge, no studies have addressed treatment of these deformities in adults, and the most recent case series (of children) was published in 2005. MethodsWe present a series of five adults who underwent surgery for postirradiation kyphosis, with a mean follow-up of 3.8 years (range, 2.5–6.2 years). ResultsSurgery improved the kyphotic deformity in all patients. Overall mean kyphotic deformity correction was 56° and was larger for cervical/cervicothoracic deformities (mean, 76°) than for lumbar deformities (mean, 42°) at midterm follow-up. Patients reported significant improvements in pain and self-image. Consistent with prior case series of children, we observed a high rate of complications (mean, 1.4 complications per patient) in adults. Three patients each underwent an unplanned surgical procedure because of a complication. ConclusionThe surgical treatment of postirradiation kyphotic spinal deformity is challenging, with common postoperative complications such as infection, instrumentation failure, and pseudarthrosis. However, with modern surgical techniques and spinal instrumentation, excellent deformity correction can be achieved and maintained. We recommend performing a two-stage procedure for cervicothoracic deformity, with anterior release followed by posterior fusion and instrumentation. In thoracolumbar deformities, correction can be achieved through single-stage posterior fusion. Rigid spinopelvic fixation with sacral-alar-iliac screws and second-stage anterior lumbar interbody fusion at L5–S1 is recommended to reduce nonunion risk. Cement augmentation of proximal and distal anchors can help prevent junctional failure. Level of EvidenceLevel IV.

Detection of the Tendon Properties in Posterior Tibial Tendinopathy in Three-Dimensional Space Using High Resolution Multiphoton and Second Harmonic Generation Imaging

Category:HindfootIntroduction/Purpose:Posterior tibial tendon dysfunction is the most common cause of acquired flat foot deformity in adults, and results in significant morbidity. The exact etiology of this condition is still unknown. Posterior tibial tendon is predominately made up of fibrillar collagens and we hypothesize that their structural properties such as the collagen fiber density, orientation properties and cross-linking density essentially control the biomechanical properties of posterior tibial tendons. In this study, our aim is to visualize and quantitate fibrillar collagen distributions, their organization, cross-link densities and the fiber orientation (using Fourier analysis) in three distinct regions of pathologic posterior tibial tendon human samples namely proximal, middle and distal regions.Methods:After an institutional IRB approval we obtained diseased posterior tibial tendon total excision samples from 10 patients that had reconstructive procedures for posterior tibial tendinopathy at our institution and two fresh non-frozen healthy posterior tibial tendon samples from cadavers were used as the control. This research mainly utilized well established multiphoton microscopy and harmonic generation methodologies which compared proximal, middle and distal 1/3 of the tendon samples; multiphoton microscopy provides a powerful imaging method for evaluation of remodeling of fibrillar collagen structures deep within tissues. Ultra-short IR laser pulses served as an excitation source to produce multiphoton excitation fluorescence (MPEF) from endogenously fluorescent macromolecular systems and to induce highly specific second harmonic generation (SHG) signals from fibrillar collagens. Since MPEF and SHG involve different principles and contrast mechanisms, they were captured simultaneously to provide spectrally and spatially resolved, quantitative imaging of complex structures.Results:We systematically examined the nature of fibrillar collagen remodeling in relatively thick posterior tibial tendon tissues. Representative 3D forward SHG (FSHG), backward SHG (BSHG) and auto-fluorescence (MPEF) images originating from fibrillar collagen matrix from relatively thick (˜50 microns) posterior tibial tendon sections of three different regions namely proximal, middle and distal regions are shown in Figure 1. Computed Orientation Index values obtained from Fourier analysis show statistically significant differences particularly between proximal and middle regions (decreased orientation of collagen fibers in the middle region, p<0.0001). The cross-linking densities determined from the ratio of auto-fluorescence (MPEF) to BSHG again show differences particularly between proximal and middle regions (increased cross-linking in the middle region, p<0.01).Conclusion:The multiphoton and harmonic generation microscopy can be a powerful high resolution imaging method requiring minimal sample preparation that can provide structural information about spatially and spectrally resolved fibrillar collagens in three different posterior tibial tendon tendon regions. We found that middle third of the pathologic tendons show increased cross-linking and decreased orientation ratio of the collagen fibers which can provide insight into the regional based collagen remodeling and improved understanding of earliest stages of tendon destruction that could lead to improvements in the treatment of this condition.

Transpedicular-Transdiscal Cement Augmentation Treatment of Thoracolumbar Fusion Proximal Junctional Failure.

Long instrumented fusions for adult deformity have a proximal junction kyphosis rate between 20% and 40%. When symptomatic, proximal junctional failure (PJF) often requires revision surgery and is associated with significant morbidity. Vertebral cement augmentation (VCA) has been used for prophylaxis against PJF but has not been previously described as treatment after onset of PJF has occurred. We describe a series of patients with PJF of long posterior spinal fusions that were treated at our institution using a novel VCA technique. Three patients with PJF above thoracolumbopelvic fusions were retrospectively reviewed following treatment with transpedicular-transdiscal VCA. The medical record was reviewed for demographic data, outcomes scores, and radiographic images. Mean age was 69.3 years. Mean follow-up was 13.3 months. Mean preprocedure visual analog scale score was 8.67, and postprocedure visual analog scale score was 4.00. Mean preprocedure sagittal balance was 9.7 cm, and postprocedure sagittal balance was 5.8 cm. No patients required revision surgery for PJF in the follow-up period. Transpedicular-transdiscal VCA treatment for PJF is safe and may have the potential to prevent the need for revision surgery. 4.

The “AdductoValgus” Foot: Description of Deformity and Technique for Surgical Reconstruction

Category:Midfoot/ForefootIntroduction/Purpose:The literature is replete with descriptions of metatarsus adductus (pediatric patients) and metatarsus primus varus (adult patients) deformities along with recommendations for treatment. For adult deformities isolated to the first ray, a technique involving a cuneiform-metatarsal arthrodesis (e.g. Lapidus procedure) is often employed. There is a paucity of literature describing adult manifestations of adduction deformities involving multiple metatarsals. The senior author has treated a number of adult patients with these types of deformities. This case series is presented here with a description of the deformity and a technique for surgical reconstruction.Methods:Five patients having undergone surgical reconstruction for symptomatic midfoot/forefoot deformities involving adduction of multiple metatarsals (and valgus metatarsophalangeal joints) were retrospectively reviewed. The first ray deformities were treated with arthrodesis of the first metatarsal to the medial cuneiform, along with a distal soft tissue release and medial eminence resection as appropriate. Lesser ray deformities were corrected with oblique osteotomies of the metatarsal shafts (and metatarsophalangeal joint capsulorraphies and/or pinning as appropriate).Results:All patients went on to radiographic union of their arthrodeses and osteotomies. The midfoot (metatarsus adductus) deformities, and hallux valgus deformities, maintained correction compared to preoperative alignment. There were some lesser metatarsophalangeal joint valgus recurrences. There were no severe complications of deep infection or revision surgery. Conclusion: The “AdductoValgus” foot deformity presents in adult patients with adduction of multiple metatarsals and corresponding metatarsophalangeal joint valgus. The deformity can result in pain with mobility and difficulty with shoewear. Surgical reconstruction including first ray tarsometatarsal arthrodesis and osteotomies of the involved lesser metatarsals appears a viable option for deformity correction and symptomatic relief.

Inhibitory effect of Zingiberaceae essential oils against Conopomorpha cramerella (Snellen) Lepidoptera: Gracillariidae

Zingiberaceae (Order: Zingiberales) is recognized as the essential herbaceous species in the tropics. Several species of Zingiberaceae have shown potential in managing some Lepidopteran and Dipteran pests. Currently, there is no report in Malaysia explores the potential use of Zingiberaceae in managing cocoa pests, particularly the Cocoa pod borer (CPB), Conopomorpha cramerella. The study was conducted to evaluate the potential of Zingiberaceae as an adult emergence inhibition of C. cramerella using three locally grown species in Malaysia; Alpinia galanga (galanga), Curcuma longa (turmeric), and Zingiber officinale (ginger). Different ages of the CPB pupa (Days 1, 2, 3, 4, and 5) were selected and were sprayed with Zingiberaceae essential oils (EOs). Pupa was sprayed with EOs at four different concentrations; 100, 200, 400, and 800 ppm. Observations were carried out after 5 to 7 days, where the percentage of the unhatched pupa and healthy adult was recorded. The percentage of the deformed adults were examined based on the abdomen, the antenna, the wings, and overall deformities. The study was repeated four times for each EOs. Results denoted that the percentage of the unhatched pupa was the highest at C. longa (49.75 % a) and significantly different (p&lt;0.05) with A. galanga (48.00 % b), Z. officinale (40.97 % c) and control treatment (13.59 % d). The highest healthy adult emergence was recorded under the control treatment (75.77 % a), and significantly different with all Zingiberaceae EOs. The overall results denoted that most of the deformities occurred after pupa were treated with the Zingiberaceae EOs at high concentrations (400 and 800 ppm), and engaged with the body and wing deformities. The symptom of adult deformities after treating with EOs may indicate the potential of Zingiberaceae as an adult emergence inhibitor of C. cramerella, and can be possibly used for the development of Zingiberaceae based botanical pesticide in the future.&#x0D; J Bangladesh Agril Univ 17(3): 349–354, 2019

Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction.

Retrospective cohort study. To determine whether type of intraoperative blood transfusion used is associated with increased incidence of postoperative delirium after complex spine fusion involving five levels or greater. Postoperative delirium after spine surgery has been associated with age, cognitive status, and several comorbidities. Intraoperative allogenic blood transfusions have previously been linked to greater complication risks and length of hospital stay. However, whether type of intraoperative blood transfusion used increases the risk for postoperative delirium after complex spinal fusion remains relatively unknown. The medical records of 130 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (more than or equal to five levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 104 patients who encountered an intraoperative blood transfusion. Of the 104, 15 (11.5%) had Allogenic-only, 23 (17.7%) had Autologous-only, and 66 (50.8%) had Combined transfusions. The primary outcome investigated was the rate of postoperative delirium. There were significant differences in estimated blood loss (Combined: 2155.5 ± 1900.7 mL vs. Autologous: 1396.5 ± 790.0 mL vs. Allogenic: 1071.3 ± 577.8 mL vs. None: 506.9 ± 427.3 mL, P < 0.0001) and amount transfused (Combined: 1739.7 ± 1127.6 mL vs. Autologous: 465.7 ± 289.7 mL vs. Allogenic: 986.9 ± 512.9 mL, P < 0.0001). The Allogenic cohort had a significantly higher proportion of patients experiencing delirium (Combined: 7.6% vs. Autologous: 17.4% vs. Allogenic: 46.7% vs. None: 11.5%, P = 0.002). In multivariate nominal-logistic regression analysis, Allogenic (odds ratio [OR]: 24.81, 95% confidence interval [CI] [3.930, 156.702], P = 0.0002) and Autologous (OR: 6.43, 95% CI [1.156, 35.772], P = 0.0335) transfusions were independently associated with postoperative delirium. Our study suggests that there may be an independent association between intraoperative autologous and allogenic blood transfusions and postoperative delirium after complex spinal fusion. Further studies are necessary to identify the physiological effect of blood transfusions to better overall patient care and reduce healthcare expenditures. 3.

274. Opioid prescribing practice among adult spinal deformity surgeons: where are we in 2018?

BACKGROUND CONTEXT The opioid crisis in the US has created a backlash from the government and third- party payors with headlines appearing daily in the media. We sought to understand the current opioid prescribing practices of adult spinal deformity surgeons in this difficult environment. PURPOSE We wanted to investigate the opioid prescribing practices of surgeons from neurosurgical and orthopedic disciplines treating adult spinal deformity STUDY DESIGN/SETTING Survey of the prescribing practices of surgeons treating adult spinal deformity. PATIENT SAMPLE A total of 33 surgeons: 20 orthopedist and 13 neurosurgeons. OUTCOME MEASURES Survey of opioid prescribing practices. METHODS A questionnaire was given to adult deformity surgeons with varied years of practice. Years in practice and residency specialty (ortho vs neuro) were noted. Various questions regarding prescribing practice were asked. Descriptive statistics were performed to show the prevalence of the different prescribing practices among the cohort. RESULTS A total of 33 surgeons (20 ortho, 13 neuro) returned the survey. Years in practice were as follows: 20yrs, 4 (12.1%). The following questions were asked: Do you actively wean patients off narcotic medications before surgery? {Yes=18 (54.5%) [Neuro=4 (31%) and Ortho=14 (70%) (p=0.0270)]; No=15 (45.5%)}; Do you require them to be completely off of the narcotics? {Yes=0 No=33 (100%)}; Do you prescribe opioids to your patients postoperatively? {Yes=30 (90.9%) No=3 (9.1%)}; If no, who does? {Pain Management=2; Fellows=1 (Japan)}; If yes, do you have a cut-off time point postoperatively after which you no longer primarily prescribe narcotics? {Yes=28 (84.8%), No=2 (6.1%), N/A=3 (9.1%)}; If yes, how long do you prescribe? {6 weeks=5 (15.2%), 2 months=1 (3.0%), 3 months=19 (57.6%), 6 months=3 (9.1%), 1 year= None, indefinitely=2 (6.1%), N/A=3 (9.1%)}; Do you actively attempt to wean your patients off of opioids postoperatively? {Yes=30 (90.9%) [Neuro=10 (77%) and Ortho=20 (100%) (p=0.0242)], No=3 (9.1%)}. Differences between the group of surgeons in their training background of neurosurgery vs orthopedics was significantly different in actively weaning patients off narcotics either before or after surgery. CONCLUSIONS Surgeons operating on adult deformity patients in 2018 are limiting the amount of narcotics given to surgical patients preoperatively and postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.