Surgical Decision-making Process Research Articles

Navigating the Pandemic: Shifts in Breast Reconstruction Trends and Surgical Decision-Making in the United States.

Background: This study aimed to investigate the impact of the COVID-19 pandemic on breast reconstruction trends in the United States, focusing on implant-based and autologous techniques, as well as the timing of reconstruction (immediate vs. delayed). Methods: A retrospective analysis of data from 2015 to 2022 from the American Society of Plastic Surgeons' National Plastic Surgery Statistics was conducted. Annual trends in breast reconstruction procedures were analyzed, comparing the pre-pandemic (2015-2019) and pandemic (2020-2022) periods. A sensitivity analysis was performed to assess the impact of missing data from 2019 and 2021. Results: The total number of breast reconstructions increased from 106,338 in 2015 to 151,641 in 2022. The proportion of implant-based reconstructions decreased from 81.41% pre-pandemic to 76.51% during the pandemic (p < 0.001), with a notable rise in direct-to-implant procedures from 10.37% to 19.12% (p < 0.001). Autologous reconstructions increased from 18.59% to 23.49% (p < 0.001). Among autologous techniques, DIEP flaps remained the most popular. Immediate reconstruction rates increased from 72.61% pre-pandemic to 75.57% during the pandemic, while delayed reconstruction rates decreased from 27.39% to 24.43% (p < 0.001). The sensitivity analysis confirmed the robustness of these trends. Conclusions: During the COVID-19 pandemic, there was a significant shift towards autologous breast reconstruction techniques, particularly DIEP flaps, and an increase in immediate reconstructions in the United States. Within implant-based reconstructions, the proportion of DTI procedures increased while the proportion of tissue expander procedures decreased. These changes likely reflect adaptations in surgical practice and decision-making processes in response to the unique challenges posed by the pandemic, rather than alterations in surgical techniques themselves. The insights gained from this study can help guide plastic surgeons and healthcare providers in preparing for future pandemics or similar disruptions.

Differences of sex development and surgical decisions: focus group interviews with health care professionals in Norway

ABSTRACT Background: Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals’ (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process. Methods: Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis. Results: Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child’s and caregivers’ needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals. Conclusion: HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents’ wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures

BackgroundDistal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention. MethodsThe Nationwide Inpatient Sample (NIS) was queried for years 2003–2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05. ResultsA weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type. ConclusionIn the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Spine surgeons facing second opinions: a qualitative study

BACKGROUND CONTEXTThe social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. PURPOSEThe solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. STUDY DESIGN/SETTINGThis qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. PATIENT SAMPLEWe interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). OUTCOME MEASURESThemes and subthemes were analyzed using semistructured interviews until saturation was reached. METHODSData were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). RESULTSIndex surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). CONCLUSIONSThe second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

Effect of Varus-Producing Distal Femoral Osteotomy and High Tibial Osteotomy on Compartment Pressures and Contact Area at Varying Degrees of Knee Flexion.

In patients with valgus alignment and degenerative changes in the lateral compartment, both distal femoral osteotomy (DFO) and high tibial osteotomy (HTO) can be used to unload the lateral compartment. Prior studies have shown that in valgus knees, the tibial wear is posterior and DFO exerts the greatest effect in extension; however, its effect is decreased as flexion angle rises. Medial closing-wedge (MCW) HTO would significantly decrease contact area, mean contact pressure (MCP), and peak contact pressure (PCP) in the lateral knee compartment through knee flexion to a greater extent compared with lateral opening-wedge (LOW) DFO. Controlled laboratory study. MCWHTO and LOWDFO were performed, correcting a mean of 8° of valgus alignment, in 10 cadaveric knees using plate fixation. Tibiofemoral contact pressure of the medial and lateral compartments was measured in 0°, 30°, 60°, and 90° of knee flexion before and after osteotomy using thin electronic sensors and load applied through an Instron device. PCP, MCP, and contact area were measured for each condition. The lateral MCP was significantly decreased in the HTO state compared with the native state in 30° (P = .015), 60° (P = .0199), and 90° (P < .0001) of flexion. The lateral MCP was also significantly decreased in the HTO state when compared with the DFO state in 60° (P = .0093) and 90° of flexion (P < .0001). After DFO, the lateral MCP returned to that of the native state in 60° (P > .999) and 90° (P > .999) of flexion. The lateral PCP decreased for all test states in all degrees of flexion; the HTO state was significantly decreased when compared with the native state in 60° (P < .0001) and 90° (P < .0001). With varus corrections of 8°, MCWHTO was more effective at unloading the lateral compartment than LOWDFO. This effect was significant as the knee flexion angle increased. This study should be considered as one aspect of the surgical decision-making process. In patients with mild to moderate valgus deformity without hypoplastic lateral femoral condyle and without significant joint line obliquity, MCWHTO may improve offloading of the lateral compartment in flexion.

The Role of Ultrasonography in Diagnosing and Managing Sialolithiasis: A Case Report and Literature Review

Abstract Sialolith-induced obstructive sialadenitis is a commonly encountered clinical scenario, yet the variations in the size and location of the stone can complicate immediate clinical assessment. Utilizing dynamic ultrasound imaging along with specific structural markers can provide valuable, immediate objective evidence in diagnosing submandibular sialolithiasis. This initial ultrasound evaluation streamlines the decision-making process by facilitating the timely scheduling of confirmatory computed tomography scans and guiding subsequent surgical interventions. This case report illustrates how in-office ultrasonography expedited the diagnosis and subsequent surgical decision-making process for submandibular sialolithiasis within a span of just 1 week.

Predicting central cervical lymph node metastasis in papillary thyroid carcinoma with Hashimoto's thyroiditis: a practical nomogram based on retrospective study.

In papillary thyroid carcinoma (PTC) patients with Hashimoto's thyroiditis (HT), preoperative ultrasonography frequently reveals the presence of enlarged lymph nodes in the central neck region. These nodes pose a diagnostic challenge due to their potential resemblance to metastatic lymph nodes, thereby impacting the surgical decision-making process for clinicians in terms of determining the appropriate surgical extent. Logistic regression analysis was conducted to identify independent risk factors associated with central lymph node metastasis (CLNM) in PTC patients with HT. Then a prediction model was developed and visualized using a nomogram. The stability of the model was assessed using ten-fold cross-validation. The performance of the model was further evaluated through the use of ROC curve, calibration curve, and decision curve analysis. A total of 376 HT PTC patients were included in this study, comprising 162 patients with CLNM and 214 patients without CLNM. The results of the multivariate logistic regression analysis revealed that age, Tg-Ab level, tumor size, punctate echogenic foci, and blood flow grade were identified as independent risk factors associated with the development of CLNM in HT PTC. The area under the curve (AUC) of this model was 0.76 (95% CI [0.71-0.80]). The sensitivity, specificity, accuracy, and positive predictive value of the model were determined to be 88%, 51%, 67%, and 57%, respectively. The proposed clinic-ultrasound-based nomogram in this study demonstrated a favorable performance in predicting CLNM in HT PTCs. This predictive tool has the potential to assist clinicians in making well-informed decisions regarding the appropriate extent of surgical intervention for patients.

Cortical resting motor threshold difference in asleep-awake craniotomy for motor eloquent gliomas: WHO grading influences motor pathway excitability.

Developing neurophysiological tools to predict WHO tumor grade can empower the treating teams for a better surgical decision-making process. A total of 38 patients with supratentorial diffuse gliomas underwent an asleep-awake-sedated craniotomies for tumor removal with intraoperative neuromonitoring. The resting motor threshold was calculated for different train stimulation paradigms during awake and asleep phases. Receiver operating characteristic analysis and Bayesian regression models were performed to analyze the prediction of tumor grading based on the resting motor threshold differences. Significant positive spearman correlations were observed between resting motor threshold excitability difference and WHO tumor grade for train stimulation paradigms of 5 (R = 0.54, P = 0.00063), 4 (R = 0.49, P = 0.002), 3 (R = 0.51, P = 0.001), and 2 pulses (R = 0.54, P = 0.0007). Kruskal-Wallis analysis of the median revealed a positive significant difference between the median of excitability difference and WHO tumor grade in all paradigms. Receiver operating characteristic analysis showed 3mA difference as the best predictor of high-grade glioma across different patterns of motor pathway stimulation. Bayesian regression found that an excitability difference above 3mA would indicate a 75.8% probability of a glioma being high grade. Our results suggest that cortical motor excitability difference between the asleep and awake phases in glioma surgery could correlate with tumor grade.

Parental experience and understanding of parent-provider discussions of treatment for infants with ureteropelvic junction obstruction.

The purpose of the current study was to understand what families identify as necessary information to guide decision-making in the treatment of their child with UPJO. We conducted semi-structured interviews with parents of children with UPJO using phenomenological methodology. Data were systematically analyzed according to principles of thematic analysis, using a team-based inductive approach. 32 parents were interviewed. Findings are organized by three major themes including barriers to meaningful participation in decision making, logistical aspects of the decision, and psychosocial aspects of the decision. These findings suggest the need to increase parent education and understanding around medical and surgical decision-making, and the need to enhance psychosocial support for more meaningful parental engagement in the surgical decision-making process. The findings from the interviews highlight the importance of caregivers needing clear and accurate information in order to engage in meaningful discussions related to surgical decision-making for decisions around surgery for UPJO treatment.

Mini Percutaneous Nephrolithotomy vs Standard Percutaneous Nephrolithotomy: A Perioperative Decision Support System for Surgical Success Comparison.

This study aimed to rank the features that are important in terms of safety and effectiveness in choosing the surgical method and providing appropriate care to the patient by using the variables examined before and after the surgery to evaluate the success of mini percutaneous nephrolithotomy and standard percutaneous nephrolithotomy surgeries. The features evaluated before and after surgery were ranked according to their importance in the features considered, using Multivariate Adaptive Regression Splines (MARS), LASSO, Ridge, Elastic_net, and Random Forest algorithms as variable selection techniques. There are 278 samples in the relevant data set. Type of surgery (100%), intercostal access (97.75%), kidney opening procedure (94.25%), postoperative creatinine (59.22%), hydronephrosis (52.23%), the number of entries (41.61%), and pre- and post-operative hemoglobin difference (45.13%) were determined as the most critical variables. The MARS algorithm showed the most successful performance, with the lowest mean absolute error (MAE) value of 0.3622, the lowest root mean square error (RMSE) value of 0.3960, and the highest R2 value of 0.3405. Clinical decision support systems can be helpful in eliminating errors and reducing costs. It can also improve the quality of healthcare and aid in the early diagnosis of diseases. Computer-aided decision-making systems can be developed using the results of such products. These systems can provide doctors with better information about their patient's treatment options and improve decision-making. It can contribute to patients being better informed about the surgery results and taking an active role. In conclusion, this study provides essential information that should be included in the surgical decision-making process for patients using medications and with a history of percutaneous nephrolithotomy.

Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review.

To identify how pre-surgical conservative care is characterized and reported in randomized controlled trials of adults undergoing elective lumbar fusion, including duration and type of treatment. The study design is a scoping review. Data sources include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials published in English between January 1, 2005, and February 15, 2022, assessing lumbar fusion as the intervention were included in this review. Of 166 studies, 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative carereceived. None of the trials provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, recency/timing, or dosage of conservative interventions. Although roughly two-thirds of trials reported thatpatients failed conservative care prior to receiving a lumbar fusion, few studies named the conservative intervention provided and no studies provided any details regarding dosing or recency of care. This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.

Biomechanical Comparison of Open vs Percutaneous Techniques for Primary Mid-Substance Achilles Tendon Repair: A Systematic Review and Meta-Analysis

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m). Results: Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (p = 0.109; Figure 4) between the PARS and Achillon tendon repair systems. Conclusion: The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.

The lifetime revision risk of primary anatomic and reverse total shoulder arthroplasty.

Implant survival in total shoulder arthroplasty (TSA) is currently defined with reference to a set time period (eg, 5-year implant survival). This is a difficult concept for patients to understand, especially for younger patients who have more years of life remaining. Our study aims to calculate a patient's lifetime revision risk after primary anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty-a more meaningful projection of revision risk over a patient's remaining lifetime. The New Zealand Joint Registry (NZJR) and national death data was used to calculate the incidence of revision and mortality in all patients who underwent primary aTSA and rTSA in New Zealand between 1999 and 2021. Lifetime revision risk was calculated using previously described methods, and this risk was stratified by age (46-90 years, 5-year bins), sex, and procedure type (aTSA and rTSA). In total, there were 4346 patients in the aTSA cohort and 7384 patients in the rTSA cohort. Lifetime revision risk was highest in the youngest age group (46-50 years) at 35.8% (95% CI 34.5%-37.0%) for aTSA and 30.9% (95% CI 29.9%-32.0%) for rTSA, with risk decreasing with increasing age. Across all age groups, the lifetime revision risk was higher for aTSA compared to rTSA. By sex, females reported higher lifetime revision risk for each age group in the aTSA cohort whereas males reported higher lifetime revision risk for each group in the rTSA cohort. Our study demonstrates that younger patients have higher lifetime revision risk after total shoulder arthroplasty. Our results highlight the long-term revision risks associated with the trend of offering shoulder arthroplasty to younger patients. The data may be used among various health care stakeholders to inform the surgical decision-making process and plan for future health care resource use.

Modified classifications and surgical decision-making process for chronic anterior talofibular ligament injuries based on the correlation of imaging studies and arthroscopic findings.

Surgical treatment of chronic ankle instability (CAI) typically includes ligament repair or reconstruction. Using preoperative ultrasonography or magnetic resonance imaging (MRI) to choose an appropriate arthroscopic procedure is still difficult. The aim of this study was to evaluate the correlation of imaging studies with arthroscopic findings and support the arthroscopic surgical decision-making process. One hundred twelve patients with chronic anterior talofibular ligament (ATFL) injuries were treated using the arthroscopic surgical decision-making process from November 2018 to August 2020. Preoperative imaging assessments using dynamic ultrasonography, MRI, and combined methods were applied to categorize the ATFL remnants into three quality grades ("good," "fair," and "poor"). Arthroscopic findings were classified into 6 major types (7 subtypes) and used to select an appropriate surgical procedure. Correlations between imaging studies, arthroscopic findings, and surgical methods were evaluated. Diagnostic parameters, clinical outcomes, and complications were also assessed. There was a significant interobserver agreement in the evaluation of dynamic ultrasonography (0.954, P < 0.001), MRI (0.958, P < 0.001), and arthroscopy diagnosis (0.978, P < 0.001). There was a significant correlation between the modified imaging classifications, arthroscopic diagnostic types, and surgical procedures. The mean follow-up period was 33.58 ± 8.85 months. Significant improvements were documented in postoperative ankle functions when assessed with Karlson-Peterson scores and Cumberland Ankle Instability Tool scores. The risk of complications is also very low. The modified classifications and surgical decision-making process based on dynamic ultrasonography, MRI, and arthroscopic findings, as proposed in this study, might help in selecting an appropriate arthroscopic surgical procedure for chronic ATFL injuries.

Shared Decision Making for Elective Surgical Procedures in Older Adults with and without Cognitive Insufficiencies.

Older adults are prone to cognitive impairment, which may affect their ability to engage in aspects of shared decision making (SDM) and their ability to complete surveys about the SDM process. This study examined the surgical decision-making processes of older adults with and without cognitive insufficiencies and evaluated the psychometric properties of the SDM Process scale. Eligible patients were 65 y or older and scheduled for a preoperative appointment before elective surgery (e.g., arthroplasty). One week before the visit, staff contacted patients via phone to administer the baseline survey, including the SDM Process scale (range 0-4), SURE scale (top scored), and the Montreal Cognitive Assessment Test version 8.1 BLIND English (MoCA-blind; score range 0-22; scores < 19 indicate cognitive insufficiency). Patients completed a follow-up survey 3 mo after their visit to assess decision regret (top scored) and retest reliability for the SDM Process scale. Twenty-six percent (127/488) of eligible patients completed the survey; 121 were included in the analytic data set, and 85 provided sufficient follow-up data. Forty percent of patients (n = 49/121) had MoCA-blind scores indicating cognitive insufficiencies. Overall SDM Process scores did not differ by cognitive status (intact cognition = 2.5, s = 1.0 v. cognitive insufficiencies = 2.5, s = 1.0; P = 0.80). SURE top scores were similar across groups (83% intact cognition v. 90% cognitive insufficiencies; P = 0.43). While patients with intact cognition had less regret, the difference was not statistically significant (92% intact cognition v. 79% cognitive insufficiencies; P = 0.10). SDM Process scores had low missing data and good retest reliability (intraclass correlation coefficient = 0.7). Reported SDM, decisional conflict, and decision regret did not differ significantly for patients with and without cognitive insufficiencies. The SDM Process scale was an acceptable, reliable, and valid measure of SDM in patients with and without cognitive insufficiencies. Forty percent of patients 65 y or older who were scheduled for elective surgery had scores indicative of cognitive insufficiencies.Patient-reported shared decision making, decisional conflict, and decision regret did not differ significantly for patients with and without cognitive insufficiencies.The Shared Decision Making Process scale was an acceptable, reliable, and valid measure of shared decision making in patients with and without cognitive insufficiencies.

Distance between the C2 vertical line and the femoral heads: a quasi-invariant global sagittal alignment parameter in both standing and sitting positions for asymptomatic adults.

This study aimed to investigate whether the distance between the C2 vertical line and the femoral heads (C2-FH) is quasi-invariant for the sitting position. A cross-sectional, prospective study was conducted. A cohort of 59 asymptomatic volunteers was prospectively recruited between February 1, 2020, and February 31, 2020, at Nanjing Drum Tower Hospital of Nanjing University Medical School. The following radiographical parameters were evaluated: T4-T12 thoracic kyphosis (TK), cervical lordosis (CL), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), T1-pelvic angle (TPA), and the C2-FH. The inclusion criteria were as follows: age between 18 and 35 years and no symptoms related to neck or back pain. The exclusion criteria were as follows: a history of any prior lower extremity or spine surgery; and a history of inflammatory arthritis, neuromuscular disorders, or congenital anomalies. Individuals were divided into the following 3 groups according to the percentile of ΔPT (PT difference between standing position and sitting position): group A (1-25% ΔPT, n=14), group B (25-75% ΔPT, n=30), and group C (75-100% ΔPT, n=15). Summary statistics calculated using analysis of variance (ANOVA) were used to provide 95% confidence intervals for measurement errors. The significance level of all statistical analyses was set as P < 0.05. There was no significant difference in any of the parameters among the 3 groups in the standing position. In the sitting position, for different degrees of pelvic retroversion, there were significant differences between the 3 groups in the other parameters except for C2-FH (P=0.80; 95% CI: -20.486 to -3.893), CL (P=0.47; 95% CI: -5.645 to 4.964), TK (P=0.54; 95% CI: 17.058-25.1), and PI (P=0.44; 95% CI: 40.747-49.087). Surprisingly, C2-FH changed slightly among the 3 groups in both the standing (P=0.87) and sitting (P=0.80) positions. As ΔPT gradually increased, ΔSS, ΔLL, ΔSVA, ΔL1-L4, ΔL4-S1, ΔTPA, ΔPT/PI, and ΔPI-LL showed corresponding gradual changes (all P values <0.05). However, there was no significant difference in PI (P=0.39), CL (P=0.46), C2-FH (P=0.51), or TK (P=0.51). C2-FH is a quasi-invariant parameter in both the standing and sitting positions for asymptomatic adults. The mean value of C2-FH was -11.95 mm in the standing position and -1.01 mm in the sitting position. Stable C2-FH could serve as a reference during the surgical decision-making process in adult patients with spinal deformity and sagittal malalignment.

Poster 354: Biomechanical Comparison of Open versus Percutaneous Techniques for Primary Mid- Substance Achilles Tendon Repair: A Systematic Review and Meta-Analysis

Objectives: Primary repair of mid-substance Achilles tendon rupture may be performed using an open or a percutaneous technique. Previous meta-analyses of clinical data comparing the two techniques have demonstrated mostly equivalent functional outcomes and re-rupture rates. Individual cadaveric studies have also compared the biomechanical properties of the two approaches. However, the results of these studies have been heterogeneous, and there is currently no consensus as to whether one technique may be biomechanically superior. The purpose of this meta-analysis was to evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair. Methods: A systematic review of original research articles was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. To qualify for study inclusion, articles were required to be published in English, utilized a cadaveric laboratory design, and had to directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique versus percutaneous repair using either the PARS (Arthrex) or Achillon (Integra) tendon repair systems. Evaluated outcomes included displacement (mm), load to failure (N), and stiffness (N/m). Results: Nine studies met inclusion criteria, including 190 cadaveric specimens (open: 83, PARS: 56; Achillon: 51) that underwent primary mid-substance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (p = 0.418; Figure 1), load to failure (p = 0.923; Figure 2), or stiffness (p = 0.195; Figure 3) between the open and percutaneous techniques. Conclusions: The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process for primary mid-substance Achilles tendon repair.

Hinge abduction hip dysplasia in (morquio a syndrome) treated by proximal femoral valgization osteotomy: a rare case report.

A 10-year-old girl suffering from MPS IVA with many signs of orthopedic manifestations. When concentrating on the hip joint, she had acetabulofemoral dysplasia and hinge abduction hip with the aid of plain radiographs and arthrography with dynamic testing. A valgization osteotomy of the proximal femur in combination with a shelf acetabuloplasty was performed bilaterally. There is no documented case of valgus osteotomy of the proximal femur in MPS IVA patients. Furthermore, preoperative arthrographies are not described as a routine diagnostic tool, because the routine surgical procedure was to do varus osteotomy with a high rate of failure. In our opinion, understanding of the dynamic function of the hip is essential for the surgical decision-making process. Our successful case with an 8-year follow-up illustrates that the well-known and widely performed valgus osteotomy in cases of hinge abduction in MPS IVA is an alternative, which should be considered preoperatively.

Prediction of clinically relevant postoperative pancreatic fistula using radiomic features and preoperative data

Clinically relevant postoperative pancreatic fistula (CR-POPF) can significantly affect the treatment course and outcome in pancreatic cancer patients. Preoperative prediction of CR-POPF can aid the surgical decision-making process and lead to better perioperative management of patients. In this retrospective study of 108 pancreatic head resection patients, we present risk models for the prediction of CR-POPF that use combinations of preoperative computed tomography (CT)-based radiomic features, mesh-based volumes of annotated intra- and peripancreatic structures and preoperative clinical data. The risk signatures were evaluated and analysed in detail by visualising feature expression maps and by comparing significant features to the established CR-POPF risk measures. Out of the risk models that were developed in this study, the combined radiomic and clinical signature performed best with an average area under receiver operating characteristic curve (AUC) of 0.86 and a balanced accuracy score of 0.76 on validation data. The following pre-operative features showed significant correlation with outcome in this signature (p < 0.05) - texture and morphology of the healthy pancreatic segment, intensity volume histogram-based feature of the pancreatic duct segment, morphology of the combined segment, and BMI. The predictions of this pre-operative signature showed strong correlation (Spearman correlation co-efficient, rho = 0.7) with the intraoperative updated alternative fistula risk score (ua-FRS), which is the clinical gold standard for intraoperative CR-POPF risk stratification. These results indicate that the proposed combined radiomic and clinical signature developed solely based on preoperatively available clinical and routine imaging data can perform on par with the current state-of-the-art intraoperative models for CR-POPF risk stratification.

Prospective application of the risk analysis index to measure preoperative frailty in spinal tumor surgery: A single center outcomes analysis

IntroductionSurgeons are frequently faced with challenging clinical dilemmas evaluating whether the benefits of surgery outweigh the substantial risks routinely encountered with spinal tumor surgery. The Clinical Risk Analysis Index (RAI-C) is a robust frailty tool administered via a patient-friendly questionnaire that strives to augment preoperative risk stratification. The objective of the study was to prospectively measure frailty with RAI-C and track postoperative outcomes after spinal tumor surgery. MethodsPatients surgically treated for spinal tumors were followed prospectively from 7/2020–7/2022 at a single tertiary center. RAI-C was ascertained during preoperative visits and verified by the provider. The RAI-C scores were assessed in relation to postoperative functional status (measured by modified Rankin Scale score [mRS]) at the last follow-up visit. ResultsOf 39 patients, 47% were robust (RAI 0–20), 26% normal (21–30), 16% frail (31–40), and 11% severely frail (RAI 41+).). Pathology included primary (59%) and metastatic (41%) tumors with corresponding mRS>2 rates of 17% and 38%, respectively. Tumors were classified as extradural (49%), intradural extramedullary (46%), or intradural intramedullary (5.4%) with mRS>2 rates of 28%, 24%, and 50%, respectively. RAI-C had a positive association with mRS>2 ​at follow-up: 16% for robust, 20% for normal, 43% for frail, and 67% for severely frail. The two deaths in the series had the highest RAI-C scores (45 and 46) and were patients with metastatic cancer. The RAI-C was a robust and diagnostically accurate predictor of mRS>2 in receiver operating characteristic curve analysis (C-statistic: 0.70, 95 CI: 0.49–0.90). ConclusionsThe findings exemplify the clinical utility of RAI-C frailty scoring for prediction of outcomes after spinal tumor surgery and it has potential to help in the surgical decision-making process as well as surgical consent. As a preliminary case series, the authors intend to provide additional data with a larger sample size and longer follow-up duration in a future study.