Background: Prone trans-psoas (PTP) interbody fusion is a minimally invasive technique for sagittal correction in adult spinal deformity. Advantages include enhanced lordosis due to prone positioning and avoidance of patient repositioning. The same approach allows for anterior longitudinal ligament release, which may improve lordotic correction. However, limited data exist on the combined technique, prompting this investigation into postoperative complications and radiographic outcomes of PTP interbody fusion versus combined PTP with anterior longitudinal ligament (ALL) release (PTP-ALL). Methods: A retrospective cohort study was conducted at a tertiary academic center from November 2020 to October 2023. Patients were grouped into two cohorts: PTP and PTP-ALL. Radiographic outcomes included changes in segmental lordosis, lumbar lordosis, L4-S1 lordosis, pelvic incidence-lumbar lordosis (PI-LL) mismatch, T1-pelvic angle, and sagittal vertical axis. Complications assessed were wound infections, venous thromboses, transfusions, and mortalities. Welch’s modified two-sample t-tests and chi-squared tests were used for analysis. Results: Twenty-two patients underwent PTP and six underwent PTP-ALL. There were no significant differences in operative time ( P =0.443), length of stay ( P =0.169), or estimated blood loss ( P =0.795). No complications occurred in the PTP-ALL group. Compared to PTP, PTP-ALL achieved greater improvements in segmental lordosis (9.3° vs. 1.6°, P =0.134), lumbar lordosis (30.6° vs. 8.5°, P =0.003), L4-S1 lordosis (10.2° vs. 6°, P =0.25), and PI-LL mismatch correction (25.8° vs. 8.9°, P =0.036). Conclusions: PTP with ALL release may be a safe and effective option to enhance sagittal correction in adult spinal deformity without increasing perioperative complications. However, the small sample size limits the generalizability of these findings and underscores the need for further study. Level of Evidence: III

Study Design: This is a systematic review and meta-analysis of comparative studies that investigates the efficacy of ultrasonic bone scalpel (UBS) as a tool for decompressive spine surgery. Purpose: The study aims to compare the outcomes of UBS with conventional methods of decompression, such as high-speed drill (HSD) and osteotome. Overview of Literature: We discuss the traditional methods of removing bone during decompressive spine surgery using instruments such as osteotome, rongeurs, and drills. We highlight the advantages of UBS, which selectively cuts bony tissues and spares the adjacent soft tissues, thereby avoiding their inadvertent injury. Methods: A systematic literature search was conducted in electronic databases, including PubMed, Embase, Scopus, and Google Scholar, to identify potentially eligible comparative studies. Data from eligible studies were extracted into spreadsheets, and a meta-analysis was performed using appropriate computer software. Results: The final analysis included seven studies, involving a total of 1024 patients. The results indicate that the UBS group had significantly shorter mean operating time and significantly reduced incidence of complications when compared to osteotome. However, there was no significant difference in the safety profile of UBS and HSD. Conclusions: UBS is a novel technology that shows promising results in terms of efficiency and complication rates in decompressive spine surgery. It has a comparable, if not better, safety profile than conventional methods such as osteotome and HSD and leads to quicker surgeries.

Background: Current Procedural Terminology (CPT) codes are critical for billing and documentation in orthopaedic surgery, yet coding can be complex and costly. Large language models (LLMs) have shown promise in automating CPT coding. Methods: Ten orthopaedic procedures were selected from each of the subspecialties of sports, foot and ankle, and hand. Procedure names were generated by the authors to reflect practice at our institution, and CPT codes for each procedure were secondarily validated for ground truth analysis using the American Association of Professional Coders “Codify” tool. An institutional Health Insurance Portability and Accountability Act (HIPAA)-compliant, ChatGPT-4 Omni (ChatGPT4o)-based LLM was prompted to generate CPT codes based on a procedure name. Three independent trials were performed per procedure. Responses were categorized as “correct”, “partially correct”, or “incorrect” and assigned a score (+1, +0.5, or +0, respectively). Model performance was assessed as a percentage of the maximum possible score. For incorrect responses, the model was prompted to try again. Results: The LLM generated the correct response in 86.7% of trials, with an overall performance of 88.9% of the maximum possible score. Performance varied by subspecialty (P=0.018), with lower scores in hand compared to sports (P=0.019). After re-prompting, LLM performance improved to 93.9% of the maximum possible score. The LLM had the most difficulty distinguishing between closely related codes for hand procedures. Conclusions: This study demonstrates promising potential for rapid, accurate, and cost-effective LLM-driven orthopedic coding, suggesting practical applications in reducing administrative workload, improving coding consistency, and potentially lowering costs in orthopaedic clinical practices.

Background: With the rise of hip and knee arthroplasties in outpatient settings, optimizing outcomes is crucial. Periprosthetic joint infection is a rare but serious complication following joint arthroplasty. There is limited evidence comparing single-dose versus multiple-dose antibiotic prophylaxis for infection prevention after joint arthroplasties in ambulatory surgery centers, where an increasing number of these surgeries are performed. Methods: We retrospectively reviewed 374 patients from an ambulatory surgery center and 313 patients from a hospital setting undergoing total hip arthroplasty, total knee arthroplasty, and partial knee arthroplasty between 2017 and 2021. The primary outcome was the rate of infection within 90 days post-surgery. Secondary outcome was the rate of infection within 1 year postoperatively. Demographic and clinical variables such as age, body mass index, and comorbidities were collected and adjusted for in multivariate analysis. Results: Ninety-day infection rates were 0.5% in the ambulatory surgery center cohort and 0.6% in the hospital cohort, with no statistically significant difference (P=1.00). Multivariate logistic regression showed that ambulatory surgery patients had a higher but non-significant odds ratio for infection (2.04, 95% CI: 0.184-22.574) compared to patients from the hospital setting. Both groups also showed no significant differences in 1-year infection rates. Conclusion: Single-dose antibiotic prophylaxis in ambulatory surgery centers is associated with low postoperative infection rates in outpatient joint arthroplasties and is non-inferior to multiple-dose regimens used in hospital settings. These findings support the use of single-dose prophylaxis in outpatient care, aligning with the trend toward outpatient surgery and highlighting its effectiveness for infection prevention. Level of Evidence: III.

Background: A clinical trial to assess short term functional outcomes after arthroscopic meniscal repair of radial tears in adult patients. Methods: We recruited fifteen adult patients with radial knee meniscal tears. We did meniscal repair with two horizontal sutures with either all-inside or out-side in techniques. Post-operatively, We assessed pain, range of motion (ROM), International Knee Documentation Committee (IKDC) 2000 score, Lysholm, score. Results: Our series included fifteen patients with mean age of 31.36 yrs with radial meniscal tears who underwent arthroscopic repair either with outside in or all-inside technique. The mean time from injury to surgery was two months. The mean follow up period was 19.5 mos. The cohort included 9 patients with medial meniscus injury and 6 patients with lateral meniscus injury. Eight patients with posterior horn injuries and seven patients with body of the meniscus injuries. All patients had injuries reaching the red-red zone. All patients had full range of motion (ROM) preoperatively except two patients. We augmented the repair with fibrin clots in three patients. We assessed IKDC and Lysholm score six months and eighteen months following surgery. We found statistically significant improvement in fourteen patients in both IKDC and lysholm score and the mean difference of both scores measured 41.8 and 36.1 respectively. Our subgroup analysis revealed no statistically significant difference in clinical outcomes between neither the medial and lateral meniscal injuries nor the isolated injuries and concomitant ACL injuries. Conclusions: Patients who underwent arthroscopic repair of radial meniscal tears showed improved functional knee outcomes.

Background: This study aimed to determine if the disparity in pay described between male and female orthopedic surgeons extends to a payment per service model. Methods: Public data from the Centers for Medicare & Medicaid Services was accessed for orthopedic surgeons from 2019-2020. Credentials were documented from public websites. The number of services provided and payment amounts were compared across states, and between genders of provider. Multivariable linear regression models were used to determine predictors of total payments. Results: Women make up 5.88% orthopedic surgeons through CMS. Male providers had a higher average number of HCPCS codes, Medicare patients, total submitted charges, and total payment amounts. The total Medicare payment and total drug Medicare payment were significantly higher for male providers. However, when adjusted for payment per service, there was no significant difference between genders. Additional graduate degrees, and the state, and RUCA code of the provider’s practice were significant predictors of amount paid per service; having a Doctor of Medicine versus any other medical degree was not. There was no significant difference in payment per service between male and female orthopedic surgeons. Nevertheless, major gender disparities exist for women in orthopedic surgery impacting their income when compared to their male counterparts. Conclusion: The problem of the gendered wage gap in orthopedics does not lie with payment per-service compensation protocols themselves, but in other factors that affect female orthopedic surgeons’ ability to provide services. These findings support a call for pay transparency and objective criteria to inform and modify salaries.

Introduction: Female orthopaedic surgeons report delaying pregnancy secondary to their career and also have higher risks for infertility and pregnancy complications. The purpose of this study was to determine if a relationship exists between orthopaedic subspecialty and fertility, pregnancy complications, and paid parental leave. Methods: An anonymous, 168-item online survey was distributed to the Ruth Jackson Orthopaedic Society and the Women in Orthopaedics Facebook group. Respondents were queried regarding subspecialty, family planning, fertility, age and training stage at each pregnancy, pregnancy complications and paid parental leave. One way ANOVA and multiple regression were used for statistical analysis. Results: Subspecialty was reported by 586 (of 801) respondents. Respondents with children (n=324) were surveyed about their first three pregnancies. Subspecialty was not associated with age at first delivery, number of miscarriages, method of conception, assistance with conception, secondary infertility, or complications. There was a significant relationship between subspecialty and weeks of paid leave. Adult reconstruction surgeons were offered the shortest paid leave time (average 2.5 wk), while oncology offered the longest (average 9.9 wk). Surgeons who were offered less paid leave took less leave overall (P=0.023). The cost of leave was significantly associated with weeks offered and weeks taken (P<0.001). Discussion: Subspecialty choice was not found to have a relationship with fertility and pregnancy outcomes. However, subspecialty was related to the amount of paid leave offered, which influenced the amount of leave taken and associated costs. These findings demonstrate the need for the development of parental leave policies that provide equal opportunities across subspecialties.

Introduction: By stratifying perceptions of importance of diversity, equity and inclusion from orthopedic staff, this research aims to guide effective initiatives centered around DEI. Materials & Methods: A prospective survey study was distributed to a metropolitan university-based Orthopedic Surgery Department. Chi square analysis was used to compare perception of personal and professional experiences, health, gender and sexual identity between age, gender, ethnicity, level of education, socioeconomic status in childhood, and household income of respondents. Results: Of 111 respondents, 79.4% aged ≤35 saw apt diverse representation of their own professional experience versus 93.0% in the >35 age group (P value 0.020). 89.9% of females and 71.9% of males agreed on DEI’s importance, while 9.4% of males disagreed (P value 0.011). Level of education showed no significance. There was a significance between household income levels less than and greater than $70,000 in perceived importance of every category of DEI, including importance of diverse representation of personal/background experiences (race/ethnicity, religion, marital status, parental status, and SES as a child, P value 0.001), professional experiences (P value 0.013), personal health (P value 0.024), gender/sexual identity (P value 0.024), and importance of DEI in health care (P value 0.026). 56.7% respondents agreed to participate in DEI initiatives through the department. Discussion and Conclusion: Distinct variations related to perception of DEI were observed across demographics, particularly age, gender, and household income. Specific areas were identified, including gender and income differences, that require focused interventions. These findings provide insights for designing comprehensive and tailored DEI initiatives.

Introduction: Among the fastest growing age demographics are individuals in their ninth decade of life. As the population in the United States ages and life expectancy increases, more elderly individuals are pursuing elective orthopaedic procedures, including total knee arthroplasty (TKA). Methods: The American College of Surgeons NSQIP database was used to identify patients undergoing elective TKA between January 1st, 2007 and December 31st, 2017. Exact propensity score matching was used to match patients aged 90 years and older to patients between 65-89 years-old based on demographic factors and comorbidities. 30-day outcome measures and complications were compared between the two age groups. Binary logistic regression was used to identify risk factors for adverse events in the matched nonagenarian patients. Results: 150,326 patients were included in the final cohort (65-89 year-olds: 149,721; 90+ year-olds: 605). 585 patients aged 65-89 years-old were then propensity matched to 585 patients aged 90+ years-old. Statistically similar rates of reoperation (P=0.207), mortality (P>0.999), and overall medical complications (P=0.055) were noted between the two groups; however, nonagenarians and centenarians were more likely to have an unplanned hospital readmission (P=0.049) and non-home discharge (P<0.001). 90+ year-olds were less likely to experience bleeding requiring transfusion (P<0.001). Hypertension, ASA class IV, and a history of bleeding disorder were independent risk factors for adverse outcomes. Conclusion: TKA can be a safe and viable treatment option for nonagenarians and centenarians and recommend that comorbidity profiles, rather than age, principally guide shared clinical decision making.

Background: Elevated blood pressure (BP) measurements seen in patients having total hip arthroplasty (THA), pose a significant issue for surgeons. The study objective was to investigate the effectiveness of preoperative anxiolytic medications in the maintenance of blood pressure and reduction of total blood loss in patients undergoing THA surgeries. Methods: A retrospective case-control cohort study in a tertiary care university hospital included patients who had THA and had either primary managed hypertension or were non-hypertensive. 190 patients who underwent primary THR; 103 controls and 87 treatment group (Oral 3 mg Bromazepam). Pearson’s chi-square, independent sample t-test, paired samples t-test, and a two- way repeated measures analysis of variance (ANOVA) was utilized in the analysis. Results: Bromazepam group had a significantly lowered ratio of systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP) in the morning of the surgery (P<0.05). Bromazepam also reduced the ratio of SBP and MAP in theaters before anesthesia (P<0.05). A repeated measures ANOVA showed significant treatment effects for SBP and MAP but not DBP (P<0.001 for both). SBP, DBP, and MAP showed a significant time-treatment effect (P<0.001, 0.019, and<0.001, respectively). Conclusions: Oral bromazepam (anxiolytic) aids in the regulation of blood pressure in individuals with well-managed hypertension and in healthy patients having total hip arthroplasty without apparent adverse effects related to the medication. This could potentially reduce the number of uncontrolled hypertension-related surgery delays and patients on the surgical waiting list.