United States

Background: Primary spine tumors are aggressive in nature and en bloc resection and reconstruction can be essential for preventing recurrence and improving survival. Although stereotactic navigation is becoming an indispensable tool for the placement of instrumentation in complex spine surgery, the evidence for its application in primary spine tumors is limited. 

Questions/purposes: The purpose of this systematic review was to describe: (1) the advances in technology and their application in primary spine tumor resection and reconstruction, (2) the efficacy in adequately achieving negative margins, and (3) the perioperative outcomes of these techniques.

Methods: A systematic review was registered with PROSPERO and performed according to PRISMA guidelines using the PubMed, Embase, and Ovid MEDLINE databases. All level I-IV clinical studies published in the English language investigating the application of stereotactic navigation for primary spinal tumors were included. 

Results: A total of 13 articles with 169 patients (94 males, 75 females) were included in the analysis. One study was level III evidence and 12 studies were level IV. Intraoperative computer tomography (CT) scan alone for stereotactic navigation was performed in 10 articles with 136 patients. Preoperative magnetic resonance imaging (MRI) was merged with intraoperative computer tomography (CT) in three studies with 33 patients. Nine studies with 131 patients reported intraoperative margins, of which, 103 patients had negative margins, 28 patients had positive margins. Eleven studies with 164 patients reported perioperative outcomes, of which 46 patients experienced one or more perioperative complications. 

Conclusion: 
There is moderate evidence to suggest that frameless stereotactic navigation is a safe and effective tool for obtaining negative margins during en bloc resections of primary spinal column tumors. Further cohort studies are necessary to critically evaluate if these initial trends persist across larger cohorts.


2023 AMA Research Challenge

Advances in Stereotactic Navigation for Primary Spinal and Pelvic Tumor Resection and Reconstruction: A Systematic Review

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Chat Generative Pre-Trained Transformer, or ChatGPT, is a large language model that has gained increased popularity among the general public, which can lead to unwarranted use of the model to make clinical recommendations for the treatment of anterior cruciate ligament (ACL) injuries. This study will evaluate and compare ChatGPT's two models, GPT-3.5 and GPT-4.0, in their ability to predict appropriate clinical recommendation ratings for 10 ACL treatment options based on 56 patient scenarios, as set by the AAOS Appropriate Use Criteria for ACL Treatment. In doing so, we hope to inform orthopedic surgeons and patients alike to remain cautious of ChatGPT's response in this field.

Can ChatGPT Models Appropriately Predict Treatment Options for Anterior Cruciate Ligament Injuries?

Background: Efforts have been made to promote awareness of female athlete differences from their male counterparts as well as minimize discrepancies in their wages and publicity. However, a critical component has been overlooked: establishing evidence-based recommendations specific to female athletes. Smith et al. notes that “female-targeted research related to sports science/sports medicine has failed to mirror the increase in participation and popularity of women’s sport.”(Smith et al., 2022) Achilles tendon rupture is one of the most common musculoskeletal injuries, occurring in 15 – 55 per 100,000 people annually.(Huttunen et al., 2014) Differences in injury rate and complications could be due hormonal effects, as estrogen receptors have been identified in lower limb tendons along with decreased Achilles tendon strain based on oral contraceptive use.(Bridgeman et al., 2010; Bryant et al., 2008; Liu et al., 1996) The primary purpose of this study is to audit the representation of female athletes in the literature regarding Achilles tendon repair.

Methods: An electronic search was performed using PubMed to identify articles related to Achilles repair using the standardized protocol by Smith et al. to assess female representation in research. (Smith et al., 2022) Studies were assessed by population, size, athletic caliber, study impact, research theme, and menstrual status.

Results: Female representation across all studies was 1783/10673 subjects (16.71%). Composition of included studies was predominantly mixed sex cohorts with 131/169 (77.51%) included studies. Within mixed sex cohort studies, the total representation of female athletes was 1651/8741 participants (18.89%). 32 studies were male only cohorts constituting 1540 participants while 3 studies were female only cohort studies comprised of 86 athletes. Importantly, the disparity between male and female representation worsened as the athletic caliber of the study population increased with 4.96% female representation in studies with professional athletes. No study collected data related to menstrual status and its potential relationship to Achilles rupture or post operative outcomes.

Conclusion: To our knowledge, this is the first review auditing the representation of female athletes in research related to Achilles rupture and repair. Mixed sex cohort studies underrepresented female athletes and male only cohort studies were more common than female only studies. These findings indicate a need for increased representation of female athletes in research related to Achilles repair. Future studies should focus on equal representation of female athletes and data collection related to sex specific hormones and menstrual status to improve recommendations and treatment of Achilles tendon ruptures for female athletes.


Auditing the Representation of Female Athletes in Sports Medicine Research: Achilles Repair

Periprosthetic joint infections are relatively rare complications of total joint replacements that are becoming increasingly common. The standard of care involves the placement of a temporary spacer made out of polymethyl methacrylate (PMMA) bone cement combined with antibiotics. The rate of major complication can be as high as 12 % for PMMA spacers. Therefore, the purpose of this study was to develop a method to produce a biocompatible material that could be 3D printed, provide mechanical support needed for ambulation, and deliver a therapeutic dose of antibiotics. Printed structures were successfully fabricated out of Biomed Clear (BMC) doped with up to 16% Gentamicin or 10 % Vancomycin. PMMA and BMC composites were characterized with differential scanning calorimetry, dynamic mechanical analysis, wear testing, compression testing, and a 30-day drug elution study. The thermoset properties of the BMC allowed for the compressive properties to remain unchanged as antibiotics were added to the polymer, but limited the amount of drug that eluted out of the composite. In contrast, the thermoplastic properties of PMMA led to the compressive properties to decrease with the addition of antibiotics, but PMMA was able to elute significantly more antibiotics. This study described a novel method to 3D print load bearing structures that can release antibiotics over 30 days. BMC composites have some advantages and disadvantages compared to PMMA that need to be considered when developing new treatments for orthopaedic infections. 


A 3D printed, High Strength and Drug Eluting Composite for the Treatment of Periprosthetic Joint Infections


INTRODUCTION: Obesity is the most common modifiable risk factor necessitating medical optimization prior to total joint arthroplasty surgery. At our institution, patients with a BMI >40 are referred to an interdisciplinary medical weight management program. The purpose of this study is to examine whether sustained treatment in the program leads to increased weight loss, continued orthopedic follow-up, and an increased likelihood of undergoing total joint arthroplasty surgery.

METHODS: A retrospective review of the medical record identified 136 patients with hip or knee arthritis and a BMI >40 who were referred to our medical weight management clinic over a two-year period. These patients were divided into three groups: those that failed to participate, those with a single visit, and those who underwent sustained treatment. Records were reviewed for demographic data, treatment interventions, and weight-loss and follow-up outcome measures. Continuous variables were assessed with t-test, and Fisher’s exact test was performed for categorical variables.

RESULTS: Patients with sustained treatment lost an average of 14 pounds versus 1.3 in those who attended a single appointment (p=0.01). 61.1% of patients with sustained treatment continued to follow-up in the orthopedic clinic, compared to 27% of patients who did not participate (p<0.01). 22.2% of patients with sustained treatment eventually underwent total joint arthroplasty surgery compared with 6.3% of patients who did not participate (p=0.02). 88.9% of patients with sustained treatment were treated with novel weight loss medications, with semaglutide the most popular choice.

CONCLUSION: Morbidly obese patients that engage in sustained treatment in an interdisciplinary medical weight management program experience greater weight loss, improved orthopedic follow-up rates, and a higher rate of total joint arthroplasty surgery when compared to those with minimal or no participation. The use of novel weight loss medications in achieving optimal outcomes in this cohort remains promising.

Sustained Medical Weight Management Program Leads to Increased Weight Loss and Arthroplasty Surgery

Background
Bone autograft is a mainstay in the surgical treatment of fracture nonunion. A traditional donor site for autologous bone graft harvest is the anterior or posterior iliac crest. A bone grafting technique that has gained favor over the past decade has been the Reamer/Irrigator/Aspirator (RIA) system (Synthes,Inc, West Chester, PA). Both techniques come with complications including donor site pain and iatrogenic fracture. The purpose of this study is to compare complications between autogenous bone graft harvest using the RIA system with subsequent prophylactic retrograde intramedullary nailing (rIMN) and the more common posterior iliac crest bone graft (PICBG) technique, as reported in the literature.

Methods
A single center retrospective cohort study was conducted to evaluate all patients who underwent prophylactic retrograde intramedullary nailing after bone graft harvest of the femur using the RIA device between January 2017 and September 2022 by a single surgeon. All patients were over the age of 18 and treated at the institution. All operations performed during January 2017 and September 2022 were manually reviewed from the surgeon daily schedule to identify pertinent procedures. Data collection was performed using the digitized medical records from the institution’s EMR (EPIC). 

Results
Thirty-six patients who underwent retrograde Reamer-Irrigator-Aspirator (RIA) with prophylactic intramedullary nailing were evaluated in this study. Of the 36 patients, two reported harvest site pain (5%). Three patients (8%) had an osteoporosis diagnosis, eleven (30.5%) had an osteomyelitis diagnosis, and four (11%) received prophylactic nailing for cancer. No subjects demonstrated a femoral neck fracture following prophylactic retrograde intramedullary nailing.

Conclusion
RIA with Prophylactic Intramedullary Nailing is a favorable option for bone graft harvest and prophylactic fixation. It has a lower harvest site morbidity, measured by harvest site pain, as compared to anterior or posterior iliac crest bone graft technique.

Retrograde Reamer-Irrigator-Aspirator (RIA) with Prophylactic Intramedullary Nailing vs Posterior Iliac Crest for Bone Grafting

1. Background
Approximately 1.2 million spine surgeries are performed each year in the US. Of those, an estimated 60-80% are successful, while 20-40% require revision due to a wide range of causes. Additionally, recovery from spine surgery often requires significant rehabilitation and care plan adherence, which can be impacted by biopsychosocial factors. As follows, substance use and other psychiatric comorbidities can worsen spine surgery patient outcomes.
Per the US Department of Health and Human Services, 61.2 million Americans over 12 years old use an illicit substance, and 9.2 million misuse opioids. Furthermore, 46.3 million meet criteria for substance use disorder (SUD), but 94% receive no treatment, and the vast majority are unaware of their SUD. With both SUD and spine surgery numbers increasing, and the likelihood that the former negatively impacts the latter, more research is needed to better understand the effects of perioperative substance use, both illicit and prescription, on the outcomes of spine surgeries to elucidate the significance of this emerging public health threat.
2. Methods
The PubMed database was searched in June 2023 using spine disease, spine surgery, and substance use search terms. Opinion articles, studies on extraspinal surgeries, and ongoing studies were excluded, but review articles were eligible for inclusion. Included studies tracked perioperative substance use and related spine surgery outcomes.
3. Results
Thirteen of nineteen included studies investigated perioperative opioid use and collectively found deleterious postoperative effects of acute, subacute, and chronic opioid use in spine surgery patients. Impacts were consistent across prescription and illicit drugs, even in opioid naïve patients and those receiving low-dose
regimens, though SUD exacerbated effects.
One study investigated opioids and muscle relaxants and showed elevated reoperation risk with both compared to controls (40% and 19%, respectively). A case report series of patients with SUDs also found increased complications and inadequate follow-ups. Postoperative effects of these substances included increased pain, surgical site infection rates, reoperations, healthcare costs, and medical complication rates.
Data on cannabis use remains contradictory. One study demonstrated reduced complications; another, decreased length of hospital stays; others, no effect or increased complications.
4. Conclusion
Substance use diminishes spine surgery success rates and increases medical complications, reoperations, and healthcare costs, whether use is acute or continuous with chronic SUD. As such, enhanced preoperative screening and careful prescribing should be a high priority in these patients, and perioperative patient education may also mitigate risks resulting from postoperative pain management regimens.

Perioperative Prescription and Illicit Substance Use Profoundly Impacts Spine Surgery Outcomes

Childhood bone sarcomas are treated with chemotherapy and surgical resection, with limb salvage favored. Noninvasive expandable endoprostheses use magnet driven lengthening to minimize limb-length inequality in growing children. However, these endoprostheses can have complications sometimes requiring revision surgery. The aim of this study is to investigate the frequency and indications for revision surgery in patients with noninvasive expandable endoprostheses.

Revision Surgery of Non-invasive Expandable Endoprosthetic Reconstruction in Pediatric Patients

Background
Around the world more than 1 million total hip arthroplasties (THA) are performed annually. With such a high case volume and projected increase in future demand, it is advantageous to optimize cost and care around THAs. This study will investigate two approaches to THA, the direct anterior (DA) and posterior approach. Neither approach has an advantage regarding long term outcomes, however there is uncertainty whether one yields improved early outcomes. Some studies have favored the DA approach citing better early outcomes while others have described no difference between the two approaches. This study compares early outcomes in a rural patient population undergoing DA and posterior THA.

Methods
We retrospectively compared 66 DA and 48 posterior THA cases performed by a single surgeon at a healthcare system that serves 4 rural counties with total populations less than 50,000. Electronic medical record data between the years of 2017-2021 was used to gather information that included demographics, perioperative information, clinical follow up notes, and billing information. Demographic data including age, body mass index (BMI), sex, and American Society of Anesthesiology (ASA) classification was used to determine whether confounding variables existed between groups. The early outcomes consisted of length of stay (LOS), procedure time, dislocations, intraoperative fractures, discharge disposition, length of pain (number of postoperative days until patient no longer had pain with flexion, internal/external rotation of the hip joint), and length of physical therapy. Lastly a cost comparison was done between the two approaches. 

Results
There were no significant differences in the demographics data, procedure time, number of dislocations, number of intraoperative fractures, and length of physical therapy. The mean LOS (1.5 vs. 2.4 days, p = 0.000) and mean length of pain (21.7 vs. 49.1 days, p = 0.0000) were shorter in the DA group. Fifty-seven (86%) patients and thirty (62%) patients were discharged home in the DA and posterior groups respectively (p = 0.0001). The mean cost ($81,606 vs. $71,020, p = 0.0000) was higher in the DA group.

Conclusions
Overall, the patients who received the DA approach had a shorter LOS, shorter length of pain, and higher rate of discharge to home as compared to patients who received the posterior approach. There was no significant increase in procedure time, number of intraoperative fractures, or number of dislocations between groups. This suggests that there is an advantage to the DA approach for THA that results in superior early outcomes with no increased risk for adverse events. However, the cost associated with the DA approach is on average $10,586 higher when compared to the posterior approach. While there are limitations to this study, it examines a rural community-based hospital patient population that is not a common demographic in the literature when comparing approaches to THA.

Comparison of Early Outcomes Between Direct Anterior and Posterior Total Hip Arthroplasty in a Rural Community Hospital

Background
Wound complications are well documented following spine tumor surgery due to risk factors including prior radiation therapy, poor nutritional status, and immunocompromise. Increasing evidence has shown that a multidisciplinary approach to complex oncological spine reconstruction surgery can decrease wound complication rates. The goal of this study is to assess whether plastic surgery wound closure in the setting of spine tumor surgery can lead to a decreased rate of wound complications.

Methods
A retrospective analysis of 157 consecutive patients who underwent spine tumor surgery between October 2012 and October 2022 at a Level 1 Trauma Center was performed. Clinical data regarding pre- and post-operative oncological treatment, surgical management, intra- and post-operative complications, and quality of life surveys were collected. Patients were stratified based on plastic surgery involvement in soft-tissue reconstruction and wound closure. Post-operative complications and outcomes were analyzed between groups. Statistical significance was set at p < 0.05.

Results
130 (82.8%) oncological spine surgeries underwent closure by spine surgeons (SS) and 27 (17.2%) underwent closure by plastic surgeons (PS). The PS group was 33% (N=9) female compared to 38% (N=50) female for the SS group. The PS group was younger compared to SS group (55.3 ± 18.3 vs. 62.5 ± 16.1 years; p=0.035). The PS group had a greater number of levels fused (3.3 ± 4.5 vs. 2.3 ± 2.1; p= 0.049) but a lower number of levels decompressed (1.48 ± 1.5 vs. 2.4 ± 1.2; p<0.001) compared to the SS group.

Patients in the PS group had a longer operative time (362.6 ± 278.3 vs. 225 ± 84.5 minutes; p<0.001), greater blood loss (631.8 ± 576.3 vs. 480.6 ± 454.9 mL; p=0.048), and greater length of stay (57 ± 132 vs. 10 ± 15 days; p<0.001) compared to SS group, which could be attributed to increased complexity of the PS cases. Pre-operative and post-operative Day 3 Albumin (p=0.82), Hematocrit (p=0.095), Glucose (p=0.367) and HA1c (p=0.417) had no effect on wound healing in both surgical groups. The most common coverage performed in the PS group were local paraspinal advancement flaps. The PS group had 0% post-op wound complications, wound infections, or wound-related reoperations, while the SS group had 4% (N=5) wound-related reoperations.


Conclusion
Spine tumor patients are at increased risk for impaired wound healing and post-operative wound complications. A multidisciplinary approach to oncological spine surgery, involving both spine surgeons and plastic surgeons, can improve surgical outcomes and wound healing.

Outcomes and Spine Oncology Surgery With and Without Plastic Surgery Reconstruction

Background
Acute hip fractures are a public health problem that affect primarily older adults. Given the subtleties in different patient indications and classifications such as fracture type, preoperative mobility/functional status, and presence or absence of preexisting/symptomatic arthritis, Chat Generative Pre-trained Transformer (ChatGPT) may be a helpful clinical decision-making tool in the treatment plan to optimize patient outcomes. The purpose of this study was to evaluate the accuracy of ChatGPT-4.0 by comparing its appropriateness scores for acute hip fractures with the American Academy of Orthopedic Surgeons (AAOS) Appropriate Use Criteria (AUC) given various patient scenarios. 

Methods
Using the AUC as the gold standard, a numerical scale was utilized to quantify the appropriateness of 6 different treatments. Quantitative scores ranging from 1-9 were assigned as follows: 7-9 signifies “Appropriate,” 4-6 signifies “May Be Appropriate,” and 1-3 signifies “Rarely Appropriate.” ChatGPT-4.0 was prompted separately and asked to assign an appropriate score for each treatment. To measure any notable errors, AAOS AUC scores were subtracted from the ChatGPT-4.0 scores, and the mean error, mean absolute error, and mean squared error were calculated. Spearman’s rank correlation coefficients and paired t-tests were used to determine statistical significance.

Results
30 patient scenarios were evaluated among 6 different treatment options for a total of 180 paired scores. Spearman’s rank correlation testing found that there was a very strong positive correlation between AAOS and ChatGPT-4.0 scores for Multiple Cannulated Screw Fixation, a strong positive correlation between scores for THA and for Hemiarthroplasty, and a moderate positive correlation for Long Cephalomedullary Nails. There was a non-significant weak positive correlation between scores for Short Cephalomedullary Nails and for Sliding Hip Screw ± Anti-Rotation Screw. Using a paired t-test, there were significant differences between scores for Long Cephalomedullary Nails.

Conclusion
The AAOS AUC is designed to optimize treatment outcomes for acute hip fractures in adults by improving the quality of care, and minimizing short- and long-term mortality. The appropriateness scores for THA, Hemiarthroplasty, Long Cephalomedullary Nails, and Multiple Cannulated Screw Fixation determined by ChatGPT-4.0 were positively correlated with the AUC scores. ChatGPT-4.0 overestimated the appropriateness of THA, Hemiarthroplasty, and Long Cephalomedullary Nails. The scores to treat with Long Cephalomedullary Nails were non-equivalent. Although it demonstrated some utility in recommending the appropriateness of treatment options for acute hip fractures in older adults, clinicians should refrain from fully relying on ChatGPT-4.0. The AI model needs improvement to assist physicians and must be further evaluated.

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Advances in Stereotactic Navigation for Primary Spinal and Pelvic Tumor Resection and Reconstruction: A Systematic Review

Next from 2023 AMA Research Challenge

Can ChatGPT Models Appropriately Predict Treatment Options for Anterior Cruciate Ligament Injuries?