Publications by authors named "Deeptee Jain"

32 Publications

The Impact of Global Spinal Alignment on Standing Spinopelvic Alignment Change After Total Hip Arthroplasty.

Global Spine J 2021 Jun 18:21925682211026633. Epub 2021 Jun 18.

Division of Spine Surgery, Department of Orthopaedic Surgery, New York University, NY, USA.

Study Design: Retrospective cohort study.

Objectives: The interactions between hip osteoarthritis (OA) and spinal malalignment are poorly understood. The purpose of this study was to assess the influence of total hip arthroplasty (THA) on standing spinopelvic alignment.

Methods: In this retrospective cohort study, patients undergoing THA for OA with pre-and postoperative full-body radiographs were included. Standing spinopelvic parameters were measured. Contralateral hip was graded on the Kellgren-Lawrence scale. Pre-and postoperative alignment parameters were compared by paired t-test. The severity of preoperative thoracolumbar deformity was measured using TPA. Linear regression was performed to assess the impact of preoperative TPA and changes in spinal alignment. Patients were separated into low and high TPA (<20 or >/=20 deg) and change in parameters were compared between groups by t-test. Similarly, the influence of K-L grade, age, and PI were also tested.

Results: 95 patients were included (mean age 58.6 yrs, BMI 28.7 kg/m2, 48.2% F). Follow-up radiographs were performed at mean 220 days. Overall, the following significant changes were found from pre-to postoperative: SPT (14.2 vs. 16.1, = 0.021), CL (-8.9 vs. -5.3, = .001), TS-CL (18.2 vs. 20.5, = .037) and SVA (42.6 vs. 32.1, = .004). Preoperative TPA was significantly associated with the change in PI-LL, SVA, and TPA. High TPA patients significantly decreased SVA more than low TPA patients. There was no significant impact of contralateral hip OA, PI, or age on change in alignment parameters.

Conclusion: Spinopelvic alignment changes after THA, evident by a reduction in SVA. Preoperative spinal sagittal deformity impacts this change. Level of evidence: III.
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http://dx.doi.org/10.1177/21925682211026633DOI Listing
June 2021

Frailty Severity Impacts Development of Hospital-acquired Conditions in Patients Undergoing Corrective Surgery for Adult Spinal Deformity.

Clin Spine Surg 2021 Jun 14. Epub 2021 Jun 14.

Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute Department of Orthopaedic Surgery, SUNY Downstate Medical Center Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY.

Study Design: This was a retrospective cohort study of a national dataset.

Purpose: The purpose of this study was to consider the influence of frailty on the development of hospital-acquired conditions (HACs) in adult spinal deformity (ASD).

Summary Of Background Data: HACs frequently include reasonably preventable complications. Eleven events are identified as HACs by the Affordable Care Act. In the surgical ASD population, factors leading to HACs are important to identify to optimize health care.

Methods: Patients 18 years and older undergoing corrective surgery for ASD identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). The relationship between HACs and frailty as defined by the NSQIP modified 5-factor frailty index (mFI-5) were assessed using χ2 and independent sample t tests. The mFI-5 is assessed on a scale 0-1 [not frail (NF): <0.3, mildly frail (MF): 0.3-0.5, and severely frail (SF): > 0.5]. Binary logistic regression measured the relationship between frailty throughout HACs.

Results: A total of 9143 ASD patients (59.1 y, 56% female, 29.3 kg/m2) were identified. Overall, 37.6% of procedures involved decompression and 100% fusion. Overall, 6.5% developed at least 1 HAC, the most common was urinary tract infection (2.62%), followed by venous thromboembolism (2.10%) and surgical site infection (1.88%). According to categorical mFI-5 frailty, 82.1% of patients were NF, 16% MF, and 1.9% SF. Invasiveness increased with mFI-5 severity groups but was not significant (NF: 3.98, MF: 4.14, SF: 4.45, P>0.05). Regression analysis of established factors including sex [odds ratio (OR): 1.22; 1.02-146; P=0.030], diabetes mellitus (OR: 0.70; 0.52-0.95; P=0.020), total operative time (OR: 1.01; 1.00-1.01; P<0.001), body mass index (OR: 1.02; 1.01-1.03; P=0.008), and frailty (OR: 8.44; 4.13-17.26; P<0.001), as significant predictors of HACs. Overall, increased categorical frailty severity individually predicted increased total length of stay (OR: 1.023; 1.015-1.030; P<0.001) and number of complications (OR: 1.201; 1.047-1.379; P=0.009).

Conclusions: For patients undergoing correction surgery for ASD, the incidence of HACs increased with worsening frailty score. Such findings suggest the importance of medical optimization before surgery for ASD.
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http://dx.doi.org/10.1097/BSD.0000000000001219DOI Listing
June 2021

Decompression of Lumbar Central Spinal Canal Stenosis Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

Clin Spine Surg 2021 May 12. Epub 2021 May 12.

Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO Department of Neurological Surgery, Henry Ford Health System, Detroit, MI Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Study Design: This was a retrospective clinical series.

Objective: The objective of this study was to evaluate radiologic changes in central spinal canal dimensions following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with placement of a static or an expandable interbody device.

Summary Of Background Data: MIS-TLIF is used to treat lumbar degenerative diseases and low-grade spondylolisthesis. MIS-TLIF enables direct and indirect decompression of lumbar spinal stenosis, with patients experiencing relief from radiculopathy and neurogenic claudication. However, the effects of MIS-TLIF on the central spinal canal are not well-characterized.

Materials And Methods: We identified patients who underwent MIS-TLIF for degenerative lumbar spondylolisthesis and concurrent moderate to severe spinal stenosis. We selected patients who had both preoperative and postoperative magnetic resonance imaging (MRI) and upright lateral radiographs of the lumbar spine. Measurements on axial T2-weighted MRI scans include anteroposterior and transverse dimensions of the dural sac and osseous spinal canal. Measurements on radiographs include disk height, neural foraminal height, segmental lordosis, and spondylolisthesis. We made pairwise comparisons between each of the central canal dimensions and lumbar sagittal segmental radiologic outcome measures relative to their corresponding preoperative values. Correlation coefficients were used to quantify the association between changes in lumbar sagittal segmental parameters relative to changes in radiologic outcomes of central canal dimensions. Statistical analysis was performed for "all patients" and further stratified by interbody device subgroups (static and expandable).

Results: Fifty-one patients (age 60.4 y, 68.6% female) who underwent MIS-TLIF at 55 levels (65.5% at L4-L5) were included in the analysis. Expandable interbody devices were used in 45/55 (81.8%) levels. Mean duration from surgery to postoperative MRI scan was 16.5 months (SD 11.9). MIS-TLIF was associated with significant improvements in dural sac dimensions (anteroposterior +0.31 cm, transverse +0.38 cm) and osseous spinal canal dimensions (anteroposterior +0.16 cm, transverse +0.32 cm). Sagittal lumbar segmental parameters of disk height (+0.56 cm), neural foraminal height (+0.35 cm), segmental lordosis (+4.26 degrees), and spondylolisthesis (-7.5%) were also improved following MIS-TLIF. We did not find meaningful associations between the changes in central canal dimensions relative to the corresponding changes in any of the sagittal lumbar segmental parameters. Stratified analysis by interbody device type (static and expandable) revealed similar within-group changes as in the overall cohort and minimal between-group differences.

Conclusions: MIS-TLIF is associated with radiologic decompression of neural foraminal and central spinal canal stenosis. The mechanism for neural foraminal and central canal decompression is likely driven by a combination of direct and indirect corrective techniques.
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http://dx.doi.org/10.1097/BSD.0000000000001192DOI Listing
May 2021

The Impact of Global Alignment and Proportion Score and Bracing on Proximal Junctional Kyphosis in Adult Spinal Deformity.

Global Spine J 2021 May 12:21925682211001812. Epub 2021 May 12.

12297NYU Langone Medical Center's Hospital for Joint Diseases, NY, USA.

Study Design: Retrospective chart review.

Objective: The goal of this study is to examine the relationship between global alignment and proportion (GAP) score and postoperative orthoses with likelihood of developing proximal junctional kyphosis (PJK).

Methods: Patients who underwent thoracic or lumbar fusions of ≥4 levels for adult spinal deformity (ASD) with 1-year post-operative alignment x-rays were included. Chart review was conducted to determine spinopelvic alignment parameters, PJK, and reoperation.

Results: A total of 81 patients were included; baseline and 1-year postoperative alignment did not differ between patients with and without PJK. There was no PJK in 53.1%, 29.6% had PJK from 10-20°, and 17.3% had severe PJK over 20° (sPJK). At baseline, 80% of patients had severely disproportioned GAP, 13.75% moderate, 6.25% proportioned. GAP improved across the population, but improved GAP was not associated with sPJK. Greater correction of the upper instrumented vertebra to pelvic angle (UIV-PA) was associated with a larger PJK angle (PJKA) change (R = -0.28) as was the 1 year T1-upper instrumented vertebra (T1-UIV) angle (R = 0.30), both < .05. GAP change was not correlated with PJKA change. Postoperative orthoses were used in 46% of patients and did not impact sPJK.

Conclusions: There was no correlation between PJK and GAP or change in GAP. Greater correction of UIV-PA and larger postop T1-UIV was associated with greater PJKA change; suggesting that the greater alignment correction led to greater likelihood of failure. Postoperative orthoses had no impact on PJK.
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http://dx.doi.org/10.1177/21925682211001812DOI Listing
May 2021

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

Int J Spine Surg 2020 Dec;14(6):1023-1030

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York University, New York, NY.

Background: As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients.

Methods: A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters.

Results: The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time ( = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings ( = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain ( = .164), how often staff talk about pain treatment ( = .595), or whether patients recommended the hospital ( = .096). There were also no differences between quarters for responses in all other patient satisfaction questions ( value range, .359-.988).

Conclusions: Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates.

Level Of Evidence: 4.

Clinical Relevance: The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.
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http://dx.doi.org/10.14444/7153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872404PMC
December 2020

The Impact of Obesity on Risk Factors for Adverse Outcomes in Patients Undergoing Elective Posterior Lumbar Spine Fusion.

Spine (Phila Pa 1976) 2021 Apr;46(7):457-463

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Study Design: Retrospective case-control study.

Objective: The aim of this study was to determine the influence of obesity on risk factors for adverse outcome after lumbar spine fusion (LSF).

Summary Of Background Data: Obesity is risk factor for complications after LSF and poses unique challenges regarding optimization of care. Nonetheless, this patient population is not well-studied.

Methods: Adult patients undergoing LSF were identified the State Inpatient Database. Patients were identified as obese or nonobese using ICD-9 codes. Outcome variables were 90-day readmission, major medical complication, infection, and revision rates. Data were queried for demographics, comorbidities, surgery characteristics, and outcome variables. Logistic multivariate regression was utilized, serially testing interactions between obesity and other independent variables in separate models for each outcome. The Benjamini-Hochberg procedure was used to adjust statistical significance for multiple comparisons.

Results: A total of 262,153 patients were included: 31,062 obese and 231, 091 nonobese. For major complications, obese patients had lower odds ratios (ORs) versus nonobese patients for cerebrovascular accident, diabetes with chronic complications, age ≥65, congestive heart failure, history of myocardial infarction, renal disease, chronic pulmonary disease, Medicare/Medicaid payor, more than two levels fused, transforaminal/posterior lumbar interbody fusion, and female sex, and higher OR for non-White race. For readmission, obese patients had lower OR for age ≥65, history of MI, renal disease, and mental health disease, and higher OR for female sex. For revision, obese patients had higher OR for female sex and TLIF/PLIF. For infection, obese patients had lower OR for diabetes with and without chronic complications, and higher OR for female sex.

Conclusion: Many medical comorbidities have less impact in obese patients than nonobese patients in predicting adverse outcomes despite increased rates of adverse outcomes in obese patients. These findings reflect the impact of obesity as an independent risk factor and have important implications for preoperative optimization.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003812DOI Listing
April 2021

Are Weightbearing Restrictions Required After Microfracture for Isolated Chondral Lesions of the Knee? A Review of the Basic Science and Clinical Literature.

Sports Health 2021 Mar 28;13(2):111-115. Epub 2020 Jul 28.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Context: A strict rehabilitation protocol is traditionally followed after microfracture, including weightbearing restrictions for 2 to 6 weeks. However, such restrictions pose significant disability, especially in a patient population that is younger and more active.

Evidence Acquisition: An extensive literature review was performed through PubMed and Google Scholar of all studies through December 2018 related to microfracture, including biomechanical, basic science, and clinical studies. For inclusion, clinical studies had to report weightbearing status and outcomes with a minimum 12-month follow-up.

Study Design: Clinical review.

Level Of Evidence: Level 3.

Results: Review of biomechanical and biology studies suggest new forming repair tissue is protected from shear forces of knee joint loading by the cartilaginous margins of the defect. This margin acts as a shoulder to maintain axial height and allow for tissue remodeling up to at least 12 months after surgery, well beyond current weight bearing restriction trends. A retrospective case-control study showed that weightbearing status postoperatively had no effect on clinical outcomes in patients who underwent microfracture for small chondral (<2 mm) defects. In fact, 1 survey showed that many orthopaedic surgeons currently do not restrict weightbearing after microfracture.

Conclusion: This clinical literature review suggests that weightbearing restrictions may not be required after microfracture for isolated tibiofemoral chondral lesions of the knee.

Strength Of Recommendation Taxonomy: C.
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http://dx.doi.org/10.1177/1941738120938662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167347PMC
March 2021

Machine Learning for Predictive Modeling of 90-day Readmission, Major Medical Complication, and Discharge to a Facility in Patients Undergoing Long Segment Posterior Lumbar Spine Fusion.

Spine (Phila Pa 1976) 2020 Aug;45(16):1151-1160

Department of Orthopaedic Surgery, University of California, San Francisco, CA.

Study Design: Retrospective case control study.

Objective: To develop predictive models for postoperative outcomes after long segment lumbar posterior spine fusion (LSLPSF).

Summary Of Background Data: Surgery for adult spinal deformity is effective for treating spine-related disability; however, it has high complication and readmission rates.

Methods: Patients who underwent LSLPSF (three or more levels) were identified in State Inpatient Database. Data was queried for discharge-to-facility (DTF), 90-day readmission, and 90-day major medical complications, and demographic, comorbid, and surgical data. Data was partitioned into training and testing sets. Multivariate logistic regression, random forest, and elastic net regression were performed on the training set. Models were applied to the testing set to generate AUCs. AUCs between models were compared using the method by DeLong et al. RESULTS.: 37,852 patients were analyzed. The DTF, 90-day readmission, and 90-day major medical complication rates were 35.4%, 19.0%, and 13.0% respectively. For DTF, the logistic regression AUC was 0.77 versus 0.75 for random forest and 0.76 for elastic net (P < 0.05 for all comparisons). For 90-day readmission, the logistic regression AUC was 0.65, versus 0.63 for both random forest and elastic net (P < 0.05 for all comparisons). For 90-day major medical complications, the logistic regression AUC was 0.70, versus 0.69 for random forest and 0.68 for elastic net (P < 0.05 for all comparisons).

Conclusion: This study created comprehensive models to predict discharge to facility, 90-day readmissions, and 90-day major medical complications after LSLPSF. This information can be used to guide decision making between the surgeon and patient, as well as inform value-based payment models.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003475DOI Listing
August 2020

Advances in Techniques and Technology in Minimally Invasive Lumbar Interbody Spinal Fusion.

JBJS Rev 2020 04;8(4):e0171

Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania.

Minimally invasive lumbar interbody fusion has had a surge in popularity in the last decade. Minimally invasive surgery (MIS) techniques reduce muscle dissection and soft-tissue disruption, offering faster recovery, reduced blood loss, and shorter hospital stays compared with open techniques. There is, however, a substantial learning curve associated with MIS techniques. MIS approaches to the lumbar spine involve anterior, posterior, and combined options. This article reviews patient selection, techniques, outcomes, and complications of the common MIS approaches, including the MIS posterior approach (a transforaminal lumbar interbody fusion) and 3 MIS anterior approaches (a mini-open anterior lumbar interbody fusion, a lateral lumbar interbody fusion, and an oblique lumbar interbody fusion).
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http://dx.doi.org/10.2106/JBJS.RVW.19.00171DOI Listing
April 2020

Management of Adult Lumbar Spine Problems for General Orthopaedic Surgeons: A Practical Guide.

Instr Course Lect 2020 ;69:597-606

Low back pain is one of the most common reasons for physician visits, leading to high heath care costs and disability. Patients may present to primary care physicians, pain management physicians, chiropractors, physical therapists, or surgeons with these complaints. A thorough history and physical examination coupled with judicious use of advanced imaging studies will aid in determining the etiology of the pain. As most cases of low back pain are self-limited and will not develop into chronic pain, nonsurgical treatment is the mainstay. First-line treatment includes exercise, superficial heat, massage, acupuncture, or spinal manipulation. Pharmacologic treatment should be reserved for patients unresponsive to nonpharmacologic treatment and may include NSAIDs or muscle relaxants. Surgery is reserved for patients with pain nonresponsive to a full trial of nonsurgical interventions and with imaging studies which are concordant with physical examination findings.
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February 2020

Initial Single-Institution Experience With a Novel Robotic-Navigation System for Thoracolumbar Pedicle Screw and Pelvic Screw Placement With 643 Screws.

Int J Spine Surg 2019 Oct 31;13(5):459-463. Epub 2019 Oct 31.

Division of Spine Surgery, Department of Orthopaedic Surgery, New York University, New York, New York.

Background: Robotic-guided navigation systems for pedicle screw placement has gained recent interest to ensure accuracy and safety and diminish radiation exposure. There have been no published studies using a new combined robotics and navigation system (Globus ExcelsiusGPS system). The purpose of this study was to demonstrate safety with this system.

Methods: This is a case series of consecutive patients at a single institution from February 1, 2018, to August 31, 2018. All patients who had planned placement of thoracic and lumbar pedicle screws using the combined robotics-navigation system were included. Chart review was performed for operative details. A subgroup analysis was performed on patients with postoperative computed tomography (CT) scans to assess screw placement accuracy using the Gertzbein and Robbins system. Acceptable pedicle screw position was defined as grade A or B.

Results: One hundred six patients were included, with 636 pedicle screws, 6 iliac screws, and 1 S2AI screw. Five cases were aborted for technical issues. In the remaining 101 patients, 88 patients had screws placed using preoperative CT planning and 13 patients using intraoperative fluoroscopy planning. All screws except for 5 pedicle screws in 2 patients were placed successfully using the robot (99%). These 5 pedicle screws were placed by converting to a fluoro-guided technique without robotic assistance. Eighty-six patients had screws placed using a percutaneous technique, and 15 patients had screws placed using an open technique. Ninety-eight patients underwent interbody placement: 28 anterior lumbar interbody fusions (ALIFs), 12 lateral lumbar interbody fusions (LLIFs), and 58 transforaminal lumbar interbody fusions (TLIFs). All ALIFs and LLIFs were performed prior to placement of the screws. Four LIF patients had screws placed in the lateral position. No patients had screw-related complications intraoperatively or postoperatively, and no patients returned to the operating room for screw revision. Thirteen patients underwent postoperative CT for various reasons. Of the 66 pedicle screws that were examined with postoperative CT, all screws (100%) had acceptable position.

Conclusion: This study demonstrates that the combined robotics and navigation system is a novel technology that can be utilized to place pedicle screws and pelvic screws safely and has the potential to reduce screw-related complications.

Level Of Evidence: 4 (case series).
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http://dx.doi.org/10.14444/6060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833964PMC
October 2019

The Impact of Adult Thoracolumbar Spinal Deformities on Standing to Sitting Regional and Segmental Reciprocal Alignment.

Int J Spine Surg 2019 Aug 31;13(4):308-316. Epub 2019 Aug 31.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York, New York.

Background: Regional and segmental changes of the lumbar spine have previously been described as patients transition from standing to sitting; however, alignment changes in the cervical and thoracic spine have yet to be investigated. So, the aim of this study was to assess cervical and thoracic regional and segmental changes in patients with thoracolumbar deformity versus a nondeformed thoracolumbar spine population.

Methods: This study was a retrospective cohort study of a single center's database of full-body stereoradiographic imaging and clinical data. Patients were ≥ 18 years old with nondeformed spines (nondegenerative, nondeformity spinal pathologies) or thoracolumbar deformity (ASD: PI-LL > 10°). Patients were propensity-score matched for age and maximum hip osteoarthritis grade and were stratified by Scoliosis Research Society (SRS)-Schwab classification by PI-LL, SVA, and PT. Patients with lumbar transitional anatomy or fusions were excluded. Outcome measures included changes between standing and sitting in global alignment parameters: sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), pelivc tilt (PT), thoracic kyphosis, cervical alignment, cervical SVA, C2-C7 lordosis (CL), T1 slop minus CL (TS-CL), and segmental alignment from C2 to T12. Another analysis was performed using patients with cervical and thoracic segmental measurements.

Results: A total of 338 patients were included (202 nondeformity, 136 ASD). After propensity-score matching, 162 patients were included (81 nondeformity, 81 ASD). When categorized by SRS-Schwab classification, all nondeformity patients were nonpathologically grouped for PI-LL, SVA, and PT, whereas ASD patients had mix of moderately and markedly deformed modifiers. There were significant differences in pelvic and global spinal alignment changes from standing to sitting between nondeformity and ASD patients, particularly for SVA (nondeformed: 49.5 mm versus ASD: 27.4 mm; &thinsp< .001) and PI-LL (20.12° versus 13.01°,  < .001). With application of the Schwab classification system upon the cohort, PI-LL ( = .040) and SVA ( = .007) for severely classified deformity patients had significantly less positional alignment change. In an additional analysis of patients with segmental measurements from C2 to T12, nondeformity patients showed significant mobility of T2-T3 (-0.99° to -0.54°,  = .023), T6-T7 (-3.39° to -2.89°,  = .032), T7-T8 (-2.68° to -2.23°,  = .048), and T10-T11 (0.31° to 0.097°,  = .006) segments from standing to sitting. ASD patients showed mobility of the C6-C7 (1.76° to 3.45°,  < .001) and T11-T12 (0.98° to 0.54°,  = 0.014) from standing to sitting. The degree of mobility between nondeformity and ASD patients was significantly different in C6-C7 (-0.18° versus 1.69°,  = .003), T2-T3 (0.45° versus -0.27°,  = .034), and T10-T11 (0.45° versus -0.30°,  = .001) segments. With application of the Schwab modifier system upon the cohort, mobility was significant in the C6-C7 (nondeformed: 0.18° versus moderately deformed: 2.12° versus markedly deformed: 0.92°,  = .039), T2-T3 (0.45° versus -0.08° versus -0.63°,  = .020), T6-T7 (0.48° versus 0.36° versus -1.85°,  = .007), and T10-T11 (0.45° versus -0.21° versus -0.23°,  = .009) segments.

Conclusions: Nondeformity patients and ASD patients have significant differences in mobility of global spinopelvic parameters as well as segmental regions in the cervical and thoracic spine between sitting and standing. This study aids in our understanding of flexibility and compensatory mechanisms in deformity patients, as well as the possible impact on unfused segments when considering deformity corrective surgery.
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http://dx.doi.org/10.14444/6042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724758PMC
August 2019

Preoperative Expectations Associated With Postoperative Dissatisfaction After Total Knee Arthroplasty: A Cohort Study.

J Am Acad Orthop Surg 2020 Feb;28(4):e145-e150

From the Departments of Surgery and Pediatrics, Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL (Dr. Ghomrawi), the Healthcare Research Institute, (Ms. Lee, and Dr. Lyman), the Department of Orthopedic Mechanics and Biomaterials (Dr. Wright), and the Department of Orthopedics (Dr. Padgett), Hospital for Special Surgery, New York, NY, the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Nwachukwu), the Department of Orthopedics, New York University, New York, NY (Dr. Jain), and the Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX (Dr. Bozic).

Introduction: Unfulfilled expectations, assessed postoperatively, have been consistently associated with dissatisfaction after total knee arthroplasty (TKA). However, identifying these expectations preoperatively has been a challenge. We aimed at identifying specific expectations that are most likely to affect postoperative dissatisfaction.

Methods: We included all patients in our institutional registry with a body mass index of <40 kg/m who underwent primary unilateral TKA and had a minimum 2-year follow-up. Preoperatively, patients completed the 19-item Hospital for Special Surgery Expectations Survey, Short Form-12, Knee Injury and Osteoarthritis Outcomes Score and EuroQol 5-D. Two years postoperatively, patients reported their dissatisfaction on five domains. We estimated logistic regression models to identify the expectation items associated with each domain.

Results: A total of 2,279 TKA patients (mean age: 65.3 ± 9.2 years; mean body mass index: 30.2 ± 5.9 kg/m) met our inclusion/exclusion criteria. The association between expectations and dissatisfaction was domain specific, that is, subsets of 4 to 5 items were markedly associated with each dissatisfaction domain, and these expectations differed depending on the dissatisfaction domain examined. Of those, expectations predicting dissatisfaction on multiple domains included kneeling ability and leg straightening and participation in recreation and sports.

Discussion: We identified a subset of expectations most likely to affect dissatisfaction after TKA. Our findings should inform preoperative patient education approaches on those expectations to realistically orient patient expectations and increase satisfaction.

Level Of Evidence: Level II.
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http://dx.doi.org/10.5435/JAAOS-D-18-00785DOI Listing
February 2020

The Relationship Between Endplate Pathology and Patient-reported Symptoms for Chronic Low Back Pain Depends on Lumbar Paraspinal Muscle Quality.

Spine (Phila Pa 1976) 2019 Jul;44(14):1010-1017

Department of Orthopaedic Surgery, University of California, San Francisco, CA.

Study Design: Cross-sectional cohort study of chronic low back pain (CLBP) patients and matched controls.

Objective: To explore the interplay between vertebral endplate damage and adjacent paraspinal muscle (PSM) quality, and to test their association in a cohort of patients with CLBP and matched controls.

Summary Of Background Data: Nonspecific CLBP is challenging to diagnose, in part, due to uncertainty regarding the source of pain. Delineating interactions among potential CLBP mechanisms may enhance diagnosis and treatment customization.

Methods: We collected advanced MRI imaging on 52 adult subjects, including 38 CLBP patients and 14 age- and sex-matched asymptomatic control subjects. Mean multifidus and erector spinae fat fraction (FF) was measured throughout the spine using an IDEAL MRI sequence. Presence of cartilage endplate (CEP) defects was determined at each disc level using UTE MRI. Logistic regression was used to test association of PSM FF, CEP defects, modic changes (MC), disc degeneration, and their interplay.

Results: We observed that CEP defects were the strongest predictor of nonspecific CLBP (OR: 14.1, P < 0.01) even after adjusting for MC and disc degeneration (OR: 26.1, P = 0.04). PSM quality did not independently distinguish patient and control groups, except for patients with high self-reported disability.At specifically L4L5, CEP damage was most prevalent and CEP damage was significantly associated with CLBP (OR: 3.7, 95% CI: 1.2-21.5, P = 0.03). CEP damage at L4L5 was predictive of CLBP when adjacent to PSMs with greater FF (MF, OR 14.7, P = 0.04; ES, OR: 17.3, P = 0.03), but not when PSM FF was lower and comparable to values in control, asymptomatic subjects.

Conclusion: These results demonstrate the clinically important reciprocity between passive and dynamic spinal stabilizers, and support the notion that therapies targeting the PSMs may provide clinical benefit even in the presence of other spinal pathologies.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597281PMC
July 2019

A validated preoperative score for predicting 30-day readmission after 1-2 level elective posterior lumbar fusion.

Eur Spine J 2019 Jul 9;28(7):1690-1696. Epub 2019 Mar 9.

Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU West 321, Box 0728, San Francisco, CA, 94143, USA.

Purpose: To develop a model to predict 30-day readmission rates in elective 1-2 level posterior lumbar spine fusion (PSF) patients.

Methods: In this retrospective case control study, patients were identified in the State Inpatient Database using ICD-9 codes. Data were queried for 30-day readmission, as well as demographic and surgical data. Patients were randomly assigned to either the derivation or the validation cohort. Stepwise multivariate analysis was conducted on the derivation cohort to predict 30-day readmission. Readmission after posterior spinal fusion (RAPSF) score was created by including variables with odds ratio (OR) > 1.1 and p < 0.01; value assigned to each variable was based on the OR and calibrated to 100. Linear regression was performed between readmission rate and RAPSF score to test correlation in both cohorts.

Results: There were 92,262 and 90,257 patients in the derivation and validation cohorts. Thirty-day readmission rates were 10.9% and 11.1%, respectively. Variables in RAPSF included: age, female gender, race, insurance, anterior approach, cerebrovascular disease, chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, rheumatic disease, drug abuse, electrolyte disorder, osteoporosis, depression, obesity, and morbid obesity. Linear regression between readmission rate and RAPSF fits the derivation cohort and validation cohort with an adjusted r of 0.92 and 0.94, respectively, and a coefficient of 0.011 (p < 0.001) in both cohorts.

Conclusion: The RAPSF can accurately predict readmission rates in PSF patients and may be used to guide an evidence-based approach to preoperative optimization and risk adjustment within alternative payment models for elective spine surgery.

Level Of Evidence: 3. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-05937-yDOI Listing
July 2019

Effect of Obesity on the Development, Management, and Outcomes of Spinal Disorders.

J Am Acad Orthop Surg 2019 Jun;27(11):e499-e506

From the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Obesity is a major public health issue in the United States, and rates of obesity continue to increase across the population. The association of obesity with degenerative spinal pathology underlies the observation that a substantial number of patients undergoing spine surgery are either overweight or obese. Obesity is a notable independent risk factor for both surgical and medical complications in the perioperative period and an important consideration in preoperative planning, intraoperative strategies, and postoperative management. Despite these increased risks, surgery in obese patients for a variety of degenerative conditions results in improvement in outcomes. Although obese patients may undergo gains that are absolutely lower than their nonobese counterparts, they still experience a positive treatment effect with surgery appropriate for their condition. An evidence-based approach to both preoperative and perioperative management of patients with obesity is not well established. The purpose of this article is to review the effect of obesity on the development, management, and outcomes of patients with spinal disorders and to provide data that may guide an evidence-based approach to care in this expanding patient population.
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http://dx.doi.org/10.5435/JAAOS-D-17-00837DOI Listing
June 2019

Comparison of Stand-Alone, Transpsoas Lateral Interbody Fusion at L3-4 and Cranial vs Transforaminal Interbody Fusion at L3-4 and L4-5 for the Treatment of Lumbar Adjacent Segment Disease.

Int J Spine Surg 2018 Aug 31;12(4):469-474. Epub 2018 Aug 31.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.

Study Design: Retrospective cohort study.

Objective: To compare outcomes and complications of stand-alone minimally invasive lateral interbody fusion (LIF) vs revision posterior surgery for the treatment of lumbar adjacent segment disease.

Methods: Adults who underwent LIF or transforaminal lumbar interbody fusion (TLIF) for adjacent segment disease were compared. Exclusion criteria: >grade 1 spondylolisthesis, posterior approach after LIF, and L5/S1 surgery. Patient demographics, estimated blood loss, hospital length of stay, complications, reoperations, health-related quality of life measures, and radiographs were examined. Data were analyzed with the χ, Wilcoxon signed rank, and Mann-Whitney tests.

Results: A total of 17 LIF and 16 TLIF patients were included. Demographics were similar. Follow up was similar (LIF: 22.9 ± 11.8 months vs TLIF: 22.0 ± 4.6 months;  = .86). The LIF patients had significantly less blood loss (LIF: 36 ± 16 mL vs TLIF: 700 ± 767 mL;  < .001) and shorter length of stay (LIF: 2.6 ± 2.9 days vs TLIF: 3.3 ± 0.9 days;  = .001). There were no intraoperative complications. Revision rate was 4 of 17 in LIF and 3 of 16 in TLIF ( = .73). Baseline health-related quality of life and radiographic measurements were similar. In both groups, back and leg pain scores significantly improved, and in LIF, the Owestry Disability Index, and EuroQol-5D significantly improved. The LIF had a significant increase in intervertebral height (LIF: 4.8 ± 2.9 mm,  < .001, TLIF: 1.3 ± 3.4 mm,  = .37), which was significantly greater for LIF than TLIF ( = .002). Similarly, LIF had a significant increase in segmental lordosis (LIF: 5.6° ± 4.9°,  < .001, TLIF: 3.6° ± 8.6°,  = .16), which was not significantly different between groups.

Conclusions: Patients with adjacent segment disease may receive significant benefit from stand-alone LIF or TLIF. The LIF offers advantages of less blood loss and a shorter hospital stay.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/5056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159729PMC
August 2018

Gendered Innovations in Orthopaedic Science: On Fashion and Orthopaedic Surgery.

Authors:
Deeptee Jain

Clin Orthop Relat Res 2019 02;477(2):288-289

D. Jain, Orthopaedic Surgeon and Spine Surgery Fellow, New York University, New York, NY.

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http://dx.doi.org/10.1097/CORR.0000000000000472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370090PMC
February 2019

Bariatric surgery before elective posterior lumbar fusion is associated with reduced medical complications and infection.

Spine J 2018 09 23;18(9):1526-1532. Epub 2018 Feb 23.

Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave, MU West 321, Box 0728, San Francisco, CA 94143, USA.

Background Context: Severely obese patients with operative spinal pathology present a challenge to the spine surgeon, given the increased complication risk.

Purpose: We aimed to determine the impact of bariatric surgery (BS) on perioperative complications of posterior lumbar fusion.

Study Design: This is a retrospective cohort study.

Patient Sample: Patients undergoing posterior lumbar fusion surgery in the State Inpatient Databases of New York, Florida, North Carolina, Nebraska, Utah, and California comprised the patient sample.

Outcomes: Thirty-day medical complications, surgical complications (nerve injury, infection, revision), death, readmission, and hospital length of stay (LOS) were the study's outcomes.

Methods: We analyzed 156,517 patients using International Classification of Diseases, Ninth Revision codes. Patients were categorized into three groups: Group 1: history of BS and obesity, Group 2: severe obesity, body mass index (BMI)>40 (severely obese), and Group 3: normal weight, BMI<25 (non-obese). Logistic and linear multivariate regressions were performed to compare complications and LOS, respectively, between BS and severely obese groups and BS and non-obese groups while controlling for confounders. There were no sources of funding for this study.

Results: There were 590 patients with BS, 5,791 severely obese, and 150,136 non-obese. Comparing BS with severely obese, BS had significantly lower rates of respiratory failure (odds ratio [OR] 0.59, p=.019), urinary tract infection (OR 0.64, p=.031), acute renal failure (OR 0.39, p=.007), overall medical complications (OR 0.59, p<.001), and infection (OR 0.65, p=.025). Bariatric surgery also had significantly lower hospital LOS (B=-0.46, p=.01). Comparing BS with non-obese, there were no significant differences in medical complications; however, BS had significantly higher rates of infection (OR 2.70, p<.001), reoperation (OR 2.05, p=.045), and readmission (OR 1.89, p<.001).

Conclusion: Bariatric surgery before elective posterior lumbar fusion mitigates risk of medical complications and infection. However, these patients still have increased risk of infection, revision surgery, and readmission compared with patients with normal BMI. Surgeons might consider referral for BS for the severely obese patient before undergoing spine surgery.
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http://dx.doi.org/10.1016/j.spinee.2018.01.023DOI Listing
September 2018

Tidemark Avulsions are a Predominant Form of Endplate Irregularity.

Spine (Phila Pa 1976) 2018 08;43(16):1095-1101

University of California, San Francisco, CA.

Study Design: Descriptive histologic and magnetic resonance imaging study of human cadaveric spines.

Objective: To identify and characterize common endplate pathologies to form a histologic foundation for an etiology-based classification system.

Summary Of Background Data: Irregularities at the spinal disc-vertebra interface are associated with back pain and intervertebral disc herniation injuries. However, there is currently a lack of consensus regarding terminology for classification. This limits the potential for advancing understanding of back pain mechanisms, and prohibits meaningful comparisons for identifying priorities for prevention and treatment. Prior classification systems largely rely on observations from clinical imaging, which may miss subtle pathologic features.

Methods: Fifteen cadaveric spines with moderate to severe disc degeneration were obtained and scanned with MRI in the sagittal plane using two-dimensional T1-weighted and T2-weighted fast spin-echo sequences. Eighty-nine lumbar and lower thoracic bone-disc-bone motion segments were extracted, fixed, sectioned, and stained for histologic evaluation. Focal endplate irregularities were identified and categorized based on features that inferred causation. The presence, type, and anatomic location were recorded. A classification system with three major categories of focal endplate irregularities was created.

Results: Disc-vertebra avulsion and vertebral rim degeneration were more common than subchondral nodes: 50% of irregularities were classified as rim degeneration (75/150), 35% were classified as avulsions (52/150), and 15% were classified as nodes (23/150). Ninety percent of avulsions were subclassified as "tidemark avulsions," a highly prevalent form of endplate irregularity in which the outer annulus separates from the vertebra at the tidemark. These tidemark avulsions have not been previously described, yet are visible on T2-weighted MRI as high-intensity regions.

Conclusion: This study provides histologic basis for a system to classify focal endplate irregularities. Included is a previously unidentified but prevalent finding of tidemark avulsions, which are visible with both histology and magnetic resonance imaging. These observations will help clinicians better organize patients into meaningful groups to facilitate diagnosis, treatment, and clinical research.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035893PMC
August 2018

Body mass index predicts risk of complications in lumbar spine surgery based on surgical invasiveness.

Spine J 2018 07 16;18(7):1204-1210. Epub 2017 Nov 16.

Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, 301 E. 17th St, New York, NY 10003, USA. Electronic address:

Background Context: Obesity as a comorbidity in spine pathology may increase the risk of complications following surgical treatment. The body mass index (BMI) threshold at which obesity becomes clinically relevant, and the exact nature of that effect, remains poorly understood.

Purpose: Identify the BMI that independently predicts risk of postoperative complications following lumbar spine surgery.

Study Design/setting: Retrospective review of the National Surgery Quality Improvement Program (NSQIP) years 2011-2013.

Patient Sample: A total of 31,763 patients were undergoing arthrodesis, discectomy, laminectomy, laminoplasty, corpectomy, or osteotomy of the lumbar spine.

Outcome Measures: Complication rates.

Methods: The patient sample was categorized preoperatively by BMI according to the World Health Organization stratification: underweight (BMI <18.5), normal overweight (BMI 20.0-29.9), obesity class 1 (BMI 30.0-34.9), 2 (BMI 35.0-39.9), and 3 (BMI≥40). Patients were dichotomized based on their position above or below the 75th surgical invasiveness index (SII) percentile cutoff into low-SII and high-SII. Differences in complication rates in BMI groups were analyzed by Bonferroni analysis of variance (ANOVA) method. Multivariate binary logistic regression evaluated relationship between BMI and complication categories in all patients and in high-SII and low-SII surgeries.

Results: Controlling for baseline difference in SII, Charlson Comorbidity Index (CCI) score, diabetes, hypertension, and smoking, complications significantly increased at a BMI of 35 kg/m. The odds ratios for any complication (odds ratio [OR] [95% confidence interval {CI}]; obesity 2: 1.218 [1.020-1.455]; obesity 3: 1.742 [1.439-2.110]), infection (obesity 2: 1.335 [1.110-1.605]; obesity 3: 1.685 [1.372-2.069]), and surgical complication (obesity 2: 1.622 [1.250-2.104]; obesity 3: 2.798 [2.154-3.634]) were significantly higher in obesity classes 2 and 3 relative to the normal-overweight cohort (all p<.05).

Conclusion: There is a significant increase in complications, specifically infection and surgical complications, in patients with BMI≥35 following lumbar spine surgery, with that rate further increasing with BMI≥40.
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http://dx.doi.org/10.1016/j.spinee.2017.11.015DOI Listing
July 2018

On gender roles in spine surgery.

Authors:
Deeptee Jain

Spine J 2017 11 16;17(11):1768-1769. Epub 2017 Aug 16.

Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave, MU West 321, Box 0728, San Francisco, CA. Electronic address:

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http://dx.doi.org/10.1016/j.spinee.2017.08.226DOI Listing
November 2017

Do Patient Expectations Influence Patient-Reported Outcomes and Satisfaction in Total Hip Arthroplasty? A Prospective, Multicenter Study.

J Arthroplasty 2017 11 16;32(11):3322-3327. Epub 2017 Jun 16.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California; Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas.

Background: The relationship between patient expectations and patient-reported outcomes (PROs) in total hip arthroplasty (THA) patients is controversial. The purpose of this study was to examine the impact of preoperative patient expectations on postoperative PROs and patient satisfaction.

Methods: This was a prospective multicenter observational cohort study of primary THA patients. Preoperatively, patients completed Hospital for Special Surgery (HSS) Hip Replacement Expectations Survey (expectations), 12 item Short Form Survey (SF-12), University of California, Los Angeles (UCLA) activity score, and Hip Disability and Osteoarthritis Score (HOOS). Postoperatively at 6 months and 1 year, patients completed the Hospital for Special Surgery Hip Replacement Fulfillment of Expectations Survey (fulfillment of expectations), a satisfaction survey, and the same PROs as preoperatively. Stepwise multivariate regression models were created.

Results: A total of 207 patients were enrolled. Follow-up rate was 91% at 6 months and 92% at 1 year. Being employed and lower baseline HOOS predicted higher expectations (employment status: B = -7.5, P = .002; HOOS: B = -0.27, P = .002). Higher preoperative expectations predicted greater improvements in UCLA activity, SF-12 physical component score, and HOOS at 6 months (UCLA activity: B = 0.03, P = .001; SF-12 physical component score: B = 0.15, P = .001; HOOS: B = 0.20; P = .008) and UCLA activity at 1 year (B = 0.02, P = .004). Furthermore, higher expectations predicted higher postoperative satisfaction and fulfillment of expectations at 6 months (satisfaction: B = 0.21, P < .001; fulfillment of expectations: B = 0.30, P < .001) and higher fulfillment of expectations at 1 year (B = 0.17, P = .006).

Conclusion: In patients undergoing THA, being employed and worse preoperative hip function predict of higher preoperative expectations of surgery. Higher expectations predict greater improvement in PROs, greater patient satisfaction, and the fulfillment of expectations. These findings can be used to guide patient counseling and shared decision making preoperatively.
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http://dx.doi.org/10.1016/j.arth.2017.06.017DOI Listing
November 2017

Gender trends in authorship of spine-related academic literature-a 39-year perspective.

Spine J 2017 11 1;17(11):1749-1754. Epub 2017 Jul 1.

Department of Internal Medicine, Stanford University, 300 Pasteur Dr, Stanford, CA 94305, USA.

Background Context: Despite recent advances in gender equity in medicine, the representation of women in orthopedic and neurosurgery remains particularly low. Furthermore, compared with their male colleagues, female faculty members are less likely to publish research, limiting opportunities in the academic promotion process. Understanding disparities in research productivity provides insight into the "gender gap" in the spine surgeon workforce.

Purpose: This study aims to determine the representation and longevity of female physician-investigators among the authors of five spine-related research journals from 1978 to 2016.

Study Design: This is a retrospective bibliometric review.

Methods: The authors of original research articles from five prominent spine-related journals (European Spine Journal, The Spine Journal, Spine, Journal of Spinal Disorders and Techniques, and Journal of Neurosurgery: Spine) were extracted from PubMed. For authors with a complete first name listed, gender was determined by matching first name using an online database containing 216,286 distinct names across 79 countries and 89 languages. The proportion of female first and senior authors was determined during the time periods 1978 to 1994, 1995 to 1999, 2000 to 2004, 2005 to 2009, and 2010 to 2016. The authors who had their first paper published between 2000 and 2009 were included in additional analyses for publication count and longevity (whether additional articles were published 5 years after first publication). Student t test, chi-square analysis, and Cochran-Armitage trend test were used to determine significance between groups.

Results: From 1978 to 2016, 28,882 original research articles were published in the five spine-related journals. A total of 24,334 abstracts (90.9%) had first names listed, identifying 120,723 authors, in total of which 100,286 were successfully matched to a gender. A total of 33,480 unique authors were identified (female authors: 31.8%). Female representation increased for first and senior authors from 6.5% and 4.7% (1978-1994) to 18.5% and 13.6% (2010-2016, p<.001). Growth in female senior author representation declined after 2000 (12.3% vs. 12.9% vs. 13.5% between 2000-2004, 2005-2009, and 2010-2016). Compared with male authors, on average, female authors published fewer articles (mean: 2.1 vs. 3.3, p<.001). Of 15,304 authors who first published during 2000 to 2009, 3,478 authors (22.7%) continued to publish 5 years after their first publication. Female authors were less likely to continue publishing after their first article (15.3% of female authors vs. 24.8%, p<.001).

Conclusions: Female representation in academic spine research has doubled over the past 4 decades, although the growth of female representation as senior author has plateaued. Female physician-investigators are half as likely to continue participating in spine-related research longer than 5 years and on average publish half as many articles as senior author. In addition to recruiting more women into research, efforts should be made to identify and address barriers in research advancement and promotion for female physician-investigators.
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http://dx.doi.org/10.1016/j.spinee.2017.06.041DOI Listing
November 2017

Team Approach: Degenerative Spinal Deformity.

JBJS Rev 2017 04;5(4):e1

1University of California, San Francisco, California.

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http://dx.doi.org/10.2106/JBJS.RVW.16.00058DOI Listing
April 2017

Higher Patient Expectations Predict Higher Patient-Reported Outcomes, But Not Satisfaction, in Total Knee Arthroplasty Patients: A Prospective Multicenter Study.

J Arthroplasty 2017 09 18;32(9S):S166-S170. Epub 2017 Jan 18.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas.

Background: The relationship between patient expectations, patient-reported outcomes (PROs), and satisfaction in total knee arthroplasty (TKA) patients is not well understood.

Methods: We prospectively evaluated patients who underwent primary TKA at 4 institutions. Demographics were collected. Preoperatively, patients completed the Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), SF-12, UCLA activity, and Knee Disability and Osteoarthritis Score. At 6 months and 1 year postoperatively, patients completed the Hospital for Special Surgery Knee Replacement Fulfillment of Expectations Survey (HSS-KRFES), a satisfaction survey, and PROs. Step-wise multivariate regression models were created.

Results: Eighty-three patients were enrolled. At 6 months and 1 year postoperatively, the follow-up rate was 84.3% and 92.7%, respectively. No demographics or preoperative PROs were predictive of HSS-KRES. Preoperative HSS-KRES did not predict postoperative satisfaction, but higher HSS-KRES predicted higher HSS-KRFES at 1 year, greater improvement in UCLA activity at 6 months and 1 year, and SF-12 Physical Composite Scale and Knee Disability and Osteoarthritis Score at 6 months. Higher HSS-KRFES predicted higher satisfaction at 6 months and 1 year.

Conclusion: In TKA patients, preoperative expectations are not influenced by patient demographics or preoperative function. Higher preoperative expectations predict greater postoperative improvement in PROs and fulfillment of expectations. These findings highlight the importance of preoperative patient expectations on postoperative outcome.
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http://dx.doi.org/10.1016/j.arth.2017.01.008DOI Listing
September 2017

Circumferential fusion for degenerative lumbar spondylolisthesis complicated by distal junctional grade 4 spondylolisthesis in the sub-acute post-operative setting.

Eur Spine J 2017 12 15;26(12):3075-3081. Epub 2017 Feb 15.

Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Avenue, MU West 3rd Floor, San Francisco, CA, 94143, USA.

Introduction: Surgical management for lumbar stenosis is generally safe and provides significant improvements in pain, disability, and function. Successful lumbar decompression hinges on removing an appropriate amount of lamina and other compressive pathology in the lateral recess. Too little bony decompression can result in persistent pain and disability, while over resection of the pars and/or facets may jeopardize spinal stability.

Case Report: In this unique report, we present for the first time an acute iatrogenic grade 4 L5-S1 spondylolisthesis distal to a L3-5 laminectomy and circumferential instrumented fusion due to bilateral iatrogenic L5 pars fractures and its management and clinical outcomes after revision operation. The patient presented with worsening pain, neurologic compromise, and severe sagittal imbalance. The iatrogenic, high-grade spondylolisthesis was urgently addressed with a L5-S1 anterior lumbar interbody fusion and extension of posterior instrumentation to the pelvis, which resulted in considerable pain relief, resolution of neurologic deficits, and reconstitution of acceptable sagittal imbalance.

Conclusion: All attempts during a lumbar decompression should be made to prevent iatrogenic pars fractures, as they may result in severe sagittal imbalance, neurologic compromise, and persistent disability. Iatrogenic, high-grade L5-S1 spondylolisthesis can be successfully treated with reduction using circumferential fusion of the lumbosacral junction.
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December 2017

Commentary on development and assessment of a digital X-ray software tool to determine vertebral rotation in adolescent idiopathic scoliosis.

Spine J 2017 02;17(2):266-268

Department of Orthopaedic Surgery, UC San Francisco, 500 Parnassus Ave - MU320W, San Francisco, CA 94143-0728, USA. Electronic address:

Commentary On: Eijgenraam SM, Boselie TF, Sieben JM, Bastiaenen CH, Willems PC, Arts JJ, Lataster A. Spine J 2015;September 26. pii: S1529-9430(15)01449-7.
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http://dx.doi.org/10.1016/j.spinee.2016.08.027DOI Listing
February 2017

Dietary fatty acid content regulates wound repair and the pathogenesis of osteoarthritis following joint injury.

Ann Rheum Dis 2015 Nov 10;74(11):2076-83. Epub 2014 Jul 10.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA Department of Biomedical Engineering, Duke University Medical Center, Durham, North Carolina, USA Department of Cell Biology, Duke University Medical Center, Durham, North Carolina, USA.

Objective: The mechanisms linking obesity and osteoarthritis (OA) are not fully understood and have been generally attributed to increased weight, rather than metabolic or inflammatory factors. Here, we examined the influence of fatty acids, adipokines, and body weight on OA following joint injury in an obese mouse model.

Methods: Mice were fed high-fat diets rich in various fatty acids (FA) including saturated FAs (SFAs), ω-6 polyunsaturated FAs (PUFAs), and ω-3 PUFAs. OA was induced by destabilising the medial meniscus. Wound healing was evaluated using an ear punch. OA, synovitis and wound healing were determined histologically, while bone changes were measured using microCT. Activity levels and serum cytokines were measured at various time-points. Multivariate models were performed to elucidate the associations of dietary, metabolic and mechanical factors with OA and wound healing.

Results: Using weight-matched mice and multivariate models, we found that OA was significantly associated with dietary fatty acid content and serum adipokine levels, but not with body weight. Furthermore, spontaneous activity of the mice was independent of OA development. Small amounts of ω-3 PUFAs (8% by kcal) in a high-fat diet were sufficient to mitigate injury-induced OA, decreasing leptin and resistin levels. ω-3 PUFAs significantly enhanced wound repair, SFAs or ω-6 PUFAs independently increased OA severity, heterotopic ossification and scar tissue formation.

Conclusions: Our results indicate that with obesity, dietary FA content regulates wound healing and OA severity following joint injury, independent of body weight, supporting the need for further studies of dietary FA supplements as a potential therapeutic approach for OA.
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http://dx.doi.org/10.1136/annrheumdis-2014-205601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363043PMC
November 2015

Impact of subsidence on clinical outcomes and radiographic fusion rates in anterior cervical discectomy and fusion: a systematic review.

J Spinal Disord Tech 2014 Feb;27(1):1-10

Division of Neurosurgery, Duke University Medical Center, Durham, NC.

Study Design: Systematic review.

Objective: To provide a systematic review of published literature on the impact of subsidence on clinical outcomes and radiographic fusion rates after anterior cervical discectomy and fusion with plates or without plates.

Background: Subsidence of interbody implants is common after anterior cervical spine fusions. The impact of subsidence on fusion rates and clinical outcomes is unknown.

Methods: Systematic literature review on published articles on anterior cervical discectomy and fusion, which objectively measured graft subsidence, radiographic fusion rates, and clinical outcomes between April 1966 and December 2010.

Results: A total of 35 articles that measured subsidence and provided fusion rates and/or clinical outcomes were selected for inclusion. The mean subsidence rate ranged from 19.3% to 42.5%. The rate of subsidence based on the type of implant ranged from 22.8% to 35.9%. The incidence of subsidence was not impacted by the type of implant (P=0.98). The overall fusion rate of the combined studies was 92.8% and was not impacted by subsidence irrespective of subsidence definition or the measurement technique used (P=0.19). Clinical outcomes were evaluated in 27 of 35 studies with all studies reporting an improvement in patient outcomes postoperatively.

Conclusions: Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes.
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February 2014
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