Senior Orthopaedic Surgeons Research Articles

Coronal magnetic resonance imaging of three-dimensional fast-field echo with water-selective excitation improves the sensitivity and reliability of identification of extraforaminal lumbar disc herniation

ObjectiveThe complete view of the nerve root, including the extraforaminal zone, can be displayed by coronal magnetic resonance imaging (MRI) of three-dimensional (3D) fast-field echo with water-selective excitation (CMRI). However, its sensitivity, specificity, and reliability for the diagnosis of extraforaminal lumbar disc herniation are unclear. We compared the sensitivity, specificity, and reliability of conventional MRI, CMRI, and 3D MRI for the identification of extraforaminal lumbar disc herniation.MethodsThis study involved 140 patients (68 with extraforaminal lumbar disc herniation and 72 with paramedian disc herniation). Their mean age was 44.57 ± 14.59 years. Conventional MRI, CMRI, and 3D MRI of all patients were evaluated by five experts. The reliability, sensitivity, and specificity of the three imaging techniques for identification of extraforaminal lumbar disc herniation were compared using kappa statistics and the chi-squared test.ResultsCMRI showed higher agreement (0.843) than conventional MRI (0.671) and 3D MRI (0.771) for the identification of extraforaminal lumbar disc herniation. CMRI demonstrated higher sensitivity (95.6% vs. 91.2%) than conventional MRI (85.3% vs. 70.6%) and 3D MRI (92.6% vs. 86.7%) regardless of whether performed by junior or senior surgeons.ConclusionsCMRI is helpful for identification of extraforaminal disc herniation by junior and senior orthopedic surgeons.

The incidence of occult and missed surgical neck fractures in patients with isolated greater tuberosity fracture of the proximal humerus

BackgroundOccult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period. The purpose of this study was to retrospectively assess the incidence rate of occult and missed surgical neck fractures in those initially diagnosed with isolated GT fracture.MethodsRecords of patients diagnosed as having an isolated GT fracture were retrieved from a database in a medical center. Two senior orthopedic surgeons blindly reviewed all images of these patients three times to classify GT fracture types (split, avulsion and depression types), and recorded any surgical neck fractures found. Then a meeting was help to confirm the fracture types and presence of surgical neck fracture.ResultsOccult surgical neck fractures were found in 5 out of 68 (7.4%) patients, whereas missed surgical neck fractures were found in 3 out of 68 (4.4%) patients. In total, 32 patients had split type GT fracture, 32 had avulsion type and 4 had depression type. For those with occult surgical neck fractures, 7 had the split type GT fracture, while the remaining one had the avulsion type. Although the proportion of occult surgical neck fracture was higher in the split-type GT fracture (21.9%) than in the avulsion-type GT fracture (3.1%), the difference was not statistically significant (p = 0.056).ConclusionOccult humeral surgical neck fractures occurred in 7.4% of isolated greater tuberosity fractures after re-evaluation, while missed humeral surgical neck fractures occurred in 4.4%.

Efficacy and Safety of Tranexamic Acid in Intertrochanteric Fractures: A Single-Blind Randomized Controlled Trial.

ObjectiveTo investigate the efficacy and safety of tranexamic acid (TXA) in the reduction of bleeding and the need for transfusion in elderly intertrochanteric fracture patients.MethodsA total of 100 patients with intertrochanteric fractures undergoing surgery were enrolled and randomly allocated to the TXA group in which patients (75.10 ± 8.27 years old) were treated with 1 g of TXA, or the control group (77.82 ± 6.42 years old) treated with a placebo. Surgery was performed by two senior orthopaedic surgeons from two institutions. The proximal femoral nail antirotation (PFNA) was conducted using the standard procedure. Three outcome measures, including blood loss, transfusion, and complications, were recorded. Blood loss and transfusion were investigated to assess TXA's effectiveness, while complications were investigated to assess TXA's safety. Statistical indicators for blood loss included total, intraoperative, postoperative, and hidden blood loss volumes, calculated by hemoglobin levels, hematocrit levels, and drainage volume. The number and amount of blood transfusions were recorded. Complications associated with surgery, including deep vein thrombosis, pulmonary embolism, wound hematoma, wound infection, cardiovascular and cerebrovascular accidents, and respiratory infections, were also recorded.ResultsAll patients were followed up for 1 month after surgery. There were no significant differences in demographic and clinical characteristics between the two groups. The TXA group suffered significantly less total blood loss (563.37 ± 197.51 vs 819.25 ± 273.96 mL, 95% CI: −349.49 to −162.27, P < 0.01), intraoperative blood loss (140.3 ± 80.64 vs 230.5 ± 130.56 mL, 95% CI −132.74 to −47.66, P < 0.01), and hidden blood loss (410.42 ± 178.23 vs 571.19 ± 218.13 mL, 95% CI: −238.85 to −82.69, P < 0.01) than the control group. However, postoperative total blood loss was not significantly different (97.5 ± 20.93 vs 94.7 ± 35.78 mL; P = 0.63). A total of 5 patients from the TXA group and 27 from the control group received packed RBC for postoperative transfusion, but the mean number of transfusion units was not significantly different between groups. Complications including deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic cerebral infarction, hematoma, and infection were observed in both groups, but no significant differences were found.ConclusionsIn intertrochanteric fracture surgery performed using PFNA, intravenous administration of TXA significantly reduced the risk of intraoperative, total and hidden blood loss, in addition to the need for allogeneic transfusion, without increasing the rate of complications.

Surgical Trends in the Treatment of Lisfranc Injuries Using the American Board of Orthopaedic Surgery (ABOS) Certification Examination Database.

Background: Lisfranc joint complex injury may be managed surgically by either an open reduction internal fixation (ORIF) or primary arthrodesis (PA). Published literature advocates PA for purely ligamentous injuries, but many surgeons in actuality refrain from performing PA. The purpose of the study is to assess surgeon practices and behavior in managing Lisfranc injuries due to the influence of peer reviewed literature with the help of the American Board of Orthopaedic Surgery (ABOS) database. Methods: Data were requested from the ABOS database of cases on Lisfranc joint injury requiring either an ORIF or PA from examination year 2004 to 2017 for both part II and maintenance of certification (MOC) examinees. Cases with ICD-9 code 838.03 only were considered as primarily ligamentous and all fracture codes classified under 825 with 838.03 were considered as fracture dislocation. The number of PA and ORIF were recorded for both types of examinees and specific type of Lisfranc joint injury (primarily ligamentous and fracture dislocation). Results: A total of 2010 cases of Lisfranc joint injuries managed surgically by 1230 board-eligible orthopaedic surgeons. Open fractures (93) and non-/malunion fractures were excluded. A total of 1016 primarily ligamentous and 474 fracture dislocation cases were performed by part II examinees. Overall, 288 primarily ligamentous and 139 fracture dislocation cases were performed by MOC examinees. A total of 27 PA were performed in the primarily ligamentous and 17 were performed on fracture dislocation cases. Conclusion: ORIF is commonly performed by newly trained and senior orthopaedic surgeons. There was no change in the number of PA performed on primarily ligamentous injuries in spite of the published literature.Levels of Evidence: Not applicable.

Diagnostic Accuracy of Lever Sign Test in Acute, Chronic, and Postreconstructive ACL Injuries.

Background The aim of this study is to determine the diagnostic accuracy of lever sign test in acute, chronic, and postreconstructive ACL injuries. Methods In total, 78 patients (69 male, 9 female) were subjected to clinical instability tests including Lachman, anterior drawer, pivot shift, and lever sign when an injury of the ACL was suspected. All tests were performed bilaterally in all patients in acute, chronic period and patients who underwent surgery after the anaesthesia and after the reconstruction at the last follow-up by two senior orthopaedic surgeons. MRI was taken from all patients and MRI image was taken as the reference test when evaluating the accuracy of the tests. Results The mean age of patients was 26.2±6.4 years (range, 17-44 years). Sensitivity and accuracy values of the Lachman, anterior drawer, pivot shift, and lever tests in the acute phase were calculated as 80.6%, 77.4%, 51.6%, 91.9% and 76.9%, 75.6%, 60.3%, 92.3%, respectively, and in the chronic (preanaesthesia) phase were calculated as 83.9%, 79.0%, 56.5%, 91.9% and 80.8%, 78.2%, 64.1%, 92.3%, respectively. Lachman, anterior drawer, pivot shift, and lever sign Acute's significant [AUC: 0.716, 0.731, 0.727, 0.928, respectively] activity were observed in the prediction of ACL rupture in MRI. Conclusion An ideal test to diagnose the integrity of the ACL should be easy to perform and reproducible with high sensitivity and specificity. From this perspective, the lever test seems to be a good test for clinicians in acute, chronic and postreconstructive ACL injuries.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

Summary:There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Ultrasound Is an Alternative to X-ray for Diagnosing Developmental Dysplasia of the Hips in 6-Month-Old Children.

Infants previously treated for developmental dysplasia of the hips (DDH) are routinely imaged with ultrasound initially and reimaged with an anteroposterior (AP) pelvis X-ray at 6months of age to assess for dysplasia. It has become convention to transition from ultrasound to AP X-ray at 6months of age, but no study has demonstrated that ultrasound is inadequate at this age. The purpose of this study was to confirm that ultrasound for the 6-month DDH evaluation is a feasible alternative to the standard X-ray. Thirty-one 5- to 7-month-old infants undergoing AP pelvis X-ray related to previous Pavlik harness treatment for DDH or to a history of breech presentation were prospectively enrolled. All patients were imaged with an AP pelvis X-ray and bilateral hip ultrasounds. Three senior orthopedic surgeons unfamiliar with the patient histories evaluated both types of imaging for standard measures of hip dysplasia, including acetabular index (AI), alpha angle, and bony rim percent coverage of the femoral head. Pearson correlation coefficients were calculated for the X-ray and ultrasound measures. Good quality ultrasound images were obtained in all patients, despite the presence of the ossific nucleus in 66% of the hips. All three reviewers correctly diagnosed the one dislocated hip via both X-ray and ultrasound. There were no false negatives on ultrasound, and none of the patients with negative ultrasounds required treatment during the mean 26months of follow up. An increased AI on X-ray was correlated with lower percent coverage of the femoral head on ultrasound. Ultrasound is a technically feasible DDH imaging modality that can be used as an alternative to X-ray for 6-month-olds.

Education and repetition improve success rate and quantitative measures of the pivot shift test.

Clinicians have different techniques and varying levels of experience with the pivot shift test, introducing variability into its performance. The purpose of this study was to evaluate the influence of teaching and repetition on the success rate and anterior translation of the lateral knee compartment during the pivot shift test in a cadaveric ACL injury model. Twenty-five participants (five each of medical students, orthopaedic surgery residents, physical therapists, athletic trainers, sports medicine fellows) were recruited and a senior orthopaedic surgeon served as gold standard examiner. Each participant performed 20 pivot shift tests on lower extremity cadaveric specimens with ACL deficiency and lateral meniscectomy: 5 prior to education (baseline), 10 after watching an instructional video (passive teaching), and 5 after an interactive education session (active teaching). The anterior translation of the lateral knee compartment was recorded during each pivot shift test using electromagnetic tracking system. For medical students and orthopaedic surgery residents, significant improvement in success rate was found when compared to baseline (12% and 24%, respectively) after both passive (36% and 60%, respectively) and active teaching (52% and 72%, respectively) (p < 0.5). Medical students and residents were the only participants that independently achieved significant increases in anterior translation of the lateral knee compartment, each tripling the respective baseline value (p < 0.5). In the entire study population, significant increases in anterior translation of the lateral knee compartment and success rate of the pivot shift test were seen with continuous repetition (p < 0.5). However, the standard deviation of anterior translation of the lateral knee compartment was more than twice the gold standard examiner's standard deviation, indicating a high degree of variability. Teaching of the pivot shift test plays a major role in the development of a proper technique. However, variability persisted despite teaching and repetition. New methods may be needed to improve the teaching of the pivot shift test.

Evaluation of intra- and interobserver reliability of the AO classification for wrist fractures

ObjectiveThis study evaluated the intraobserver and interobserver reliability of the AO classification for standard radiographs of wrist fractures. MethodsThirty observers, divided into three groups (orthopedic surgery senior residents, orthopedic surgeons, and hand surgeons) classified 52 wrist fractures, using only simple radiographs. After a period of four weeks, the same observers evaluated the initial 52 radiographs, in a randomized order. The agreement among the observers, the groups, and intraobserver was obtained using the Kappa index. Kappa-values were interpreted as proposed by Landis and Koch. ResultsThe global interobserver agreement level of the AO classification was considered fair (0.30). The three groups presented fair global interobserver agreement (residents, 0.27; orthopedic surgeons, 0.30; hand surgeons, 0.33). The global intraobserver agreement level was moderated. The hand surgeon group obtained the higher intraobserver agreement level, although only moderate (0.50). The residents group obtained fair levels (0.30), as did the orthopedics surgeon group (0.33). ConclusionThe data obtained suggests fair levels of interobserver agreement and moderate levels of intraobserver agreement for the AO classification for wrist fractures.

AO international consensus panel for metrics on a closed reduction and fixation of a 31A2 pertrochanteric fracture

BackgroundThe foundations of an effective and evidence-based training program are the metrics, which characterize optimal performance. PurposesTo develop, operationally define, and seek consensus from procedure experts on the metrics that best characterize a reference approach to the performance of a closed reduction and internal fixation of a 31A2 unstable pertrochanteric fracture with a cephalomedullary nail with distal locking through the proximal guide. MethodsA Metrics Group consisting of 3 senior orthopaedic surgeons, a surgeon/medical scientist, an education expert and a behavioural scientist deconstructed the performance of the selected fixation procedure and defined performance metrics. At a modified Delphi meeting, 32 senior orthopaedic and trauma surgeons from 18 countries critiqued these metrics and their operational definitions before reaching consensus. ResultsInitially performance metrics consisting of 14 Phases with 62 Steps, 84 errors and 20 Sentinel errors were identified that characterize the safe and effective performance of the procedure. During the Delphi panel meeting these were modified and consensus was reached on 15 Phases (1 added, p = 0.967)) with 75 Steps (14 added and 1 deleted; p = 0.028), 88 errors (10 added and 6 deleted; p = 0.47), and 28 Sentinel errors (8 added; p = 0.107). Pre and Post Delphi characterizations were highly correlated (r = 0.81–0.94). ConclusionsSurgical procedures can be broken down into constituent, essential, and elemental tasks necessary for the safe and effective completion of a reference approach to a specified procedure. Procedure experts from 18 countries reached consensus on performance metrics for the fixation procedure. This metric-based characterization should form the basis of more quantitative validation studies to guide the construction of a proficiency-based progression training curriculum.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 215. Patients presenting with a lumbar far-lateral herniated nucleus pulposus can expect similar postoperative outcomes to those presenting with a central or paracentral herniation

BACKGROUND CONTEXT A far lateral herniated nucleus pulposus (HNP) consists of 7%-12% of all disc herniations. 'Far lateral' is often used to describe a lumbar disc herniation that compresses the exiting nerve root at the same level, lateral to the neural foramen. The far lateral disc herniations have been described to elicit radicular leg pain that is more severe than a central or paracentral lumbar disc herniation due to direct compression of dorsal root ganglion, and are said to have a more acute onset in their clinical symptoms. However, literature does not provide much description of the comparative postoperative outcomes between those presenting with a far lateral HNP and those with a central or paracentral herniation. PURPOSE The goal of this study is to examine the pre- and postoperative outcomes between patients presenting with a central or paracentral versus a far lateral HNP. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar microdiscectomy between 2009 and 2015 by one of two senior orthopaedic spine surgeons for lumbar spinal stenosis. Patients were excluded from analysis if they had any previous lumbar surgery, an unstable spondylolisthesis, were under 18 years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into two groups based on the location of the HNP (central or paracentral versus far-lateral). OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 191 patients who presented with a central or paracentral HNP, while 21 patients presented with a far-lateral HNP. There were no significant differences in the demographic variables between these two groups. Patients with a far lateral disc herniation presented with a trend towards a shorter duration of symptoms prior to surgery (24.5 vs. 31.5 months; p=.052). On multivariate analysis, patients with a far lateral disc herniation presented with significantly lower SF-12 mental (52.14±13.49 vs. 55.1±6.55; p=.034) and physical scores (24.76±7.5 vs. 36.9±11.1; p=.008). Similarly, the far-lateral disc herniation patients also presented with significantly lower VR-12 mental (47.2±12.8 vs. 56.9±7.0; p=.024) and physical scores (25.8±8.7 vs.39.38±11.8; p=.005). However, postoperatively, all patients have similar SF-12 and CR-12 survey scores. The improvement in ODI score was significantly lower in the patients presenting with a far lateral disc herniation (7.8±15.1 vs. 28.3±21.5; p=.002). No significant difference in re-operation rates was found (p=.236). CONCLUSIONS Patients presenting with far lateral disc herniations present with significantly lower SF-12 mental and physical scores as well as lower VR-12 mental and physical scores. However, at approximately 2 years following a lumbar microdecompression surgery, both groups of patients express similar successful outcomes, including SF-12 and VR-12 survey scores. Re-operation rates are similar between the two groups. Despite compression at the site of the dorsal root ganglion and the reported greater difficulty in addressing far lateral disc herniations, patients presenting with these far lateral disc herniations can expect similar outcomes to those patients present with herniations in the central or paracentral region.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P75. Does the concomitant presence of scoliosis or spondylolisthesis affect outcomes following stability-preserving lumbar decompression for spinal stenosis?

BACKGROUND CONTEXT Lumbar stenosis can be accompanied by degenerative scoliosis and spondylolisthesis, which complicates neural compression and makes deciding on a surgical treatment more complex. Once conservative measures fail, procedures can include: decompression alone, decompression with limited spinal fusion (or fusion at just the spondylolisthesis level), or long spinal fusion to regain acceptable alignment. The concern of an open decompression-only surgery in patients with lumbar stenosis and concurrent scoliosis and/or spondylolisthesis has been described in literature, given the risk of destabilizing the spine and precipitate deformity progression. PURPOSE The purpose of this study was to compare the patient outcomes between lumbar decompression alone for patients with lumbar stenosis alone and those with stenosis and a concomitant scoliosis and/or spondylolisthesis. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery), were under 18years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into three groups: those diagnosed with lumbar stenosis alone (without concomitant scoliosis or spondylolisthesis), those with a concomitant scoliosis (>10° of coronal angulation), and those with stenosis and a concomitant spondylolisthesis at the level of decompression). OUTCOME MEASURES Lumbar plain radiographs were evaluated to assess for concomitant scoliosis and spondylolisthesis diagnoses. Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. All patients with a spondylolisthesis were found to be Meyerding Grade 1 and stable on flexion or extension lumbar plain radiographs. The patients in the scoliosis group were found to have significantly more patients with an American Society of Anesthesiologists (ASA) grade of 3 or greater (48.8% vs. 32.2%; p=.001) compared to the stenosis-only patients. A herniated disc was present more often in the stenosis-only and stenosis group compared to the patients presenting with spondylolisthesis (p CONCLUSIONS At approximately two years after lumbar decompression alone, the presence of concomitant scoliosis or stable spondylolisthesis in lumbar spinal stenosis patients do not appear to impact clinical outcomes. Overall re-operation rates are low and similar between the three groups. Patients who present with scoliosis or a stable spondylolisthesis can expect similar improvement of symptoms, following a stability-preserving lumbar decompression, as those who present with stenosis-alone.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P130. Obese patients may experience worse back pain and less improvement in back pain compared to nonobese patients following lumbar decompression-only surgery

BACKGROUND CONTEXT Obesity is a significant comorbidity that can increase the risk, technical difficulty and outcomes following spine surgery. Recent studies have examined the impact of obesity on outcomes following lumbar degenerative stenosis up to one year after surgery. However, the impact of obesity on longer-term outcomes following lumbar decompression is unclear. PURPOSE The goal of this study was to compare obese and nonobese patients in terms of patient reported outcomes preoperatively and at final follow-up between. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy, discectomy or a combination of the two between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery, were under 18years of age at the time of surgery or had postoperative follow up less than 3. Patients were considered obese if their BMI was 30 or greater. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 325 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 200 patients with a BMI less than 30 and 125 patients with a BMI of 30 or greater (obese group). The obese group contained significantly more patients with a diabetes diagnosis (62.6% vs. 30.7%; p CONCLUSIONS At approximately 2years following lumbardecompression-only surgery, obese patients may expect worse postoperative back pain and less improvement in back pain compared to their nonobese counterparts. Otherwise, other patient reported outcomes appear to reveal similar clinical improvement in mental and physical health following surgery. Reoperation rates are similar between the two groups of patients. Both groups report being satisfied with their outcome with their expectations being met or exceeded. These concerns and the effect of obesity on overall health continue to emphasize the importance of weight discussions and expectations prior to surgery.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P131. The duration of lumbar radicular symptoms does not impact clinical outcomes following lumbar decompression surgery

BACKGROUND CONTEXT The success of surgical interventions for lumbar spinal stenosis can vary significantly depending on various factors, one of which is the duration of symptoms. Literature does not provide a clear indication of when lumbar decompression surgery become less effective in the setting of acute versus chronic symptoms from nerve root compression. PURPOSE The main objective of this study was to assess whether the duration of symptoms has an effect on clinical outcomes, especially resolution of radicular symptoms due to pathology compressing the lumbar nerve roots in patients undergoing lumbar decompression-only procedures. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy, discectomy or a combination of the two between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery were under 18years of age at the time of surgery or had postoperative follow-up less than 3 months. Patients were divided into two groups: those with lumbar radicular symptoms for less than one year prior to surgery, and those who experienced symptoms for one year or greater before undergoing surgery. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 210 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 108 patients that experienced radicular symptoms for less than one year, while 102 patients experienced radicular symptoms for one year or more. Patients who experienced radicular symptoms for less than one year had a significantly higher rate of a herniated nucleus pulposus present (75.9% vs. 49.0%; p 1 year 7.9%; p=.904). Patients presented with high levels of satisfaction (pain 1 year 82.4%; OR1.06, p=.904) and expressed that the surgery met or exceeded their expectations (pain 1 year 96.1%; OR1.06, p=.904). CONCLUSIONS Overall, patients present with similar clinical outcome scores, despite the differences in the duration of their lumbar radicular symptoms prior to surgery. At approximately 2years following lumbar decompression-only surgery, all patients, despite their symptom chronicity, appear to show similar improvement in their clinical outcome scores. Re-operation rates were low and similar between the two groups of patients. Most patients report being satisfied with their outcome and with their expectations being met or exceeded to similar degrees. Given the various options available for nonoperative management of lumbar spinal stenosis and/or a lumbar herniated nucleus pulposus, the extended effort of these conservative treatments or delay of operative intervention do not appear to negatively impact the eventual outcome of surgery. Patients report significant improvement in their symptoms, based on clinical outcome surveys, regardless of their symptom chronicity.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Understanding Lumbar Stenosis/Spondylolisthesis: 14. Stability-preserving multilevel versus single-level decompression-only surgery for lumbar spinal stenosis: demographic patterns and outcomes

BACKGROUND CONTEXT There has been debate on the stability, and thus clinical outcomes, of multilevel lumbar decompression-only surgeries compared to those undergoing a single-level procedure. In patients with single-level stenosis, laminectomy has long been considered the standard of surgical care, with generally favorable outcomes. However, there has been considerable debate regarding the optimal surgical approach for patients with multi-level spinal stenosis. While the addition of a posterior lumbar fusion has been supported for a number of patient populations (degenerative spondylolisthesis, degenerative scoliosis, pars defects with disc disease, symptomatic baseline instability), the merits of fusion in patients with only multi-level stenosis is still debated. PURPOSE The goal of this study was to compare patient outcomes following a multi-level versus a single-level stability-preserving decompression-only surgery for lumbar spinal stenosis. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by one of two senior orthopedic spine surgeons for lumbar spinal stenosis. Patients were excluded from analysis if they had any previous lumbar surgery, an unstable spondylolisthesis, were under 18 years of age at the time of surgery, or had postoperative follow-up less than 3 months. Patients were divided into three groups based on the number of decompression levels: single-level, two-level, or three or more levels. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3-78 months). There were 106 patients who underwent a single-level, 74 patients underwent a two-level, and 32 patients underwent a three- or more level laminectomy. The multi-level decompression patients were significantly older (3+ levels 67.9±8.7 years, 2-level 56.4±14.7 years, single-level 48.7±16.4 years; p CONCLUSIONS Patients undergoing decompression of three or more levels present with similar postoperative outcomes to those who undergo a single-level decompression for lumbar spinal stenosis. Despite concerns for instability following a multi-level decompression, re-operation rates are low and not significantly different when comparing the number of levels that underwent a stability-preserving lumbar decompression. Under specific clinical and radiographic criteria, a multi-level decompression of three or more levels appears to be a safe and effective procedure with acceptable outcomes at 2 years after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P132. Preexisting lumbar spinal stenosis does not affect outcomes of lumbar microdiscectomy

BACKGROUND CONTEXT Despite how commonly lumbar spinal stenosis is encountered, it is unknown if preexisting degenerative or congenital lumbar spinal stenosis has implications in patients who develop lumbar herniated nucleus pulposus (HNP) requiring discectomy. PURPOSE The purpose of the present study was to compare lumbar microdiscectomy patients with and without concomitant lumbar spinal stenosis in terms of baseline characteristics and longer term clinical outcome measures. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar discectomy between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery, were under 18years of age at the time of surgery, or had postoperative follow up less than 3 months. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Microdiscectomy patients with and without concomitant lumbar spinal stenosis were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 134 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 13.3±15.5 months (range 3–61 months). There were 49 patients (36.6% of all patients) with concomitant stenosis. Patients with concomitant stenosis were older (57.4+14.2vs. 42.5+14.1, p CONCLUSIONS Patients with concomitant lumbar stenosis who underwent lumbar microdiscectomy for HNP had similar clinical outcomes compared to patients with isolated HNP. Reoperation rates are similar between the two groups of patients. Both groups report being satisfied with their outcome with their expectations being met or exceeded.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 218. Patients undergoing revision microdiscectomy for recurrent lumbar disc herniation experience worse clinical outcomes and more reoperations compared to patients undergoing a primary microdiscectomy

BACKGROUND CONTEXT When conservative measures fail, lumbar disc herniation has been shown to be successfully treated by a microdiscectomy surgery. The percentage of patients that necessitate revision surgery within 2years varies between 0.5% and 24% in literature, with recurrent herniation being the most common presentation.However, in the setting of a revision discectomy surgery for a recurrent disc herniation, outcomes can be more difficult to predict. Some studies with smaller patient populations and diverse outcome protocols have not found significant clinical outcome differences between these two patient populations. Other studies have begun to elucidate differences at 1 year after surgery. PURPOSE The goal of this study is the compare the demographics and outcomes of patients undergoing primary lumbar microdiscectomy surgery for a disc herniation and those undergoing a revision microdiscectomy surgery for a recurrent disc herniation. STUDY DESIGN/SETTING Retrospectivec cohort series. PATIENT SAMPLE We performed a retrospective analysis of patients who underwent a primary or revision lumbar microdiscectomy between 2009 and 2015 by one of two senior orthopaedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery (other than a microdiscectomy at the recurrent disc herniation level), were under 18 years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into two groups: those undergoing a primary surgery for a lumbar disc herniation (primary) and those undergoing a revision procedure for a recurrent disc herniation (recurrent). OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 296 consecutive patients who fulfilled our inclusion criteria were assessed. The patients in the recurrent group were significantly younger than those in the primary group (44.6±12.7 vs. 53.2±16.2 years; p CONCLUSIONS Patients who presented with symptoms related to a recurrent lumbar disc herniation underwent surgery significantly sooner than those patients who underwent a primary lumbar microdiscectomy for a disc herniation. At 2 years following surgery, patients that underwent a revision lumbar microdiscectomy for a recurrent disc herniation reported significantly worse patient outcomes following surgery. These patients that underwent revision surgery were also significantly less satisfied and felt as though their results did not exceed nor meet their expectations of the procedure. Revision rates were also significantly higher in patients undergoing a revision lumbar microdiscectomy. Although three-quarters or patients will not require a repeat operation following a revision microdiscectomy, preoperative educations should be clearly communicated regarding the elevated risk of a subsequent reherniation and/or worse back pain as well as expectations following this revision procedure.

Radiological follow up of volar locking plating of distal radius fracture

Introduction: Fracture of the distal end radius constitutes one of the most common skeletal injuries treated by an orthopaedic surgeon. This study was aimed to assess the clinical and radiological outcome of the intra-articular fracture distal end radius treated with variable angle mini-fragment volar plate fixation. Methodology: In the prospective study, patients presenting with distal end radius fracture and then operated with mini-fragment volar locking distal radius plating were included. All patients were evaluated by a senior orthopaedic surgeon at 3, 6 and 24 weeks post-operatively, during which patients underwent a physical examination of the wrist and forearm motion and grip strength, followed by radiological evaluation. Range of movement and complications were noted for all patients at each follow up visit.Results: 64% of the patients were below the age of 40 years. Approximately three fourths of all patients were classified as Frykmann distal radius fracture type VIII. The mean radial inclination, length and tilt were maintained throughout the follow up period. The range of dorsiflexion, palmarflexion, supination and pronation improved significantly at each follow up. 8% had superficial skin infection, 4% had serous discharge and loss of reduction each and 84% did not report any complications.Conclusions: Primary volar mini-fragment variable angle plate fixation of freshly displaced distal radius fracture provides complete union, with immediate mobilization, better functional outcomes, minimizes chances of delayed/malunion.

Using the Medial and Lateral Humeral Lines as an Adjunct to Intraoperative Elbow Arthrography to Guide Intraoperative Reduction and Fixation of Distal Humerus Physeal Separations Reduces the Incidence of Postoperative Cubitus Varus.

Distal humerus physeal separations are rare pediatric elbow fractures that are often misdiagnosed and difficult to treat. Adequate reduction is often technically challenging and up to 71% of children develop postoperative cubitus varus. We propose using the medial and lateral humeral lines as an adjunct to elbow arthrography in order to guide intraoperative fixation of distal humerus physeal separations to reduce the incidence of postoperative cubitus varus. From 2009 to 2014, all pediatric patients under the age of 3 diagnosed with a distal humerus physeal separation and treated surgically at our institution were included for analysis. Two senior pediatric orthopaedic surgeons separately reviewed the preoperative, intraoperative, and postoperative images of all patients and measured the position of the ulnar axis relative to the medial and lateral humeral lines. The medial and lateral humeral shafts were defined as parallel lines drawn along the medial and lateral humeral diaphysis. Adequate reduction was defined by reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines. Patients were assessed at latest follow-up for cubitus varus and any other surgical complications. Thirteen patients fulfilled the inclusion criteria and were on average 1.70 years old, ranging from 0.62 to 3 years old. Intraoperatively and immediately postoperatively, all 13 patients (100%) were noted to have adequate reduction of the ulnar axis within the boundaries medial and lateral humeral lines. None of the patients required intraoperative arthrography (0%). At the date of latest follow-up, 12 patients (92.3%) had no angular deformities compared with the contralateral limb and 1 patient (7.7%) had developed cubitus varus. No surgical complications were noted (0%). Intraoperative reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines is associated with a lower incidence of postoperative cubitus varus in the treatment of distal humerus physeal separations in children. Level IV.

Compatibility of Lauge-Hansen Classification Between Plain Radiographs and Magnetic Resonance Imaging in Ankle Fractures

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries.