Comparison of the volume of scoliosis surgery between spine and pediatric orthopaedic fellowship-trained surgeons in New York and California

Advancing spinal fellowship training: an international multi-centre educational perspective

PURPOSE

The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery.

METHODS

Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training.

RESULTS

Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training.

CONCLUSIONS

Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.

Epidemiology of Medial Ulnar Collateral Ligament Reconstruction: A 10-Year Study in New York State

BACKGROUND

Despite an increase in the prevalence of medial ulnar collateral ligament (UCL) reconstruction of the elbow in professional baseball and popularity within the media, there are no population-based studies examining the incidence of UCL reconstruction.

PURPOSE

To examine the epidemiological trends of UCL reconstruction on a statewide level over a 10-year period. The primary endpoint was the yearly rate of UCL reconstruction over time; secondary endpoints included patient demographics, institution volumes, and concomitant procedures on the ulnar nerve.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database contains records for each ambulatory discharge in New York State. This database was used to identify all UCL reconstructions in New York State from 2002 to 2011 using the outpatient CPT-4 (Current Procedural Terminology, 4th Revision) code. Assessed were patient age, sex, ethnicity, insurance status, and associated procedures, as well as hospital volume.

RESULTS

There was a significant yearly increase in the number of UCL reconstructions (P < .001) performed in New York State from 2002 to 2011. The volume of UCL reconstructions increased by 193%, and the rate per 100,000 population tripled from 0.15 to 0.45. The mean ± SD age was 21.6 ± 8.89 years, and there was a significant trend for an increased frequency in UCL reconstruction in patients aged 17 to 18 and 19 to 20 years (P < .001). Male patients were 11.8 times more likely to have a UCL reconstruction than female patients (P < .001), and individuals with private insurance were 25 times more likely to have a UCL reconstruction than those with Medicaid (P = .0014). There was a 400% increase in concomitant ulnar nerve release/transposition performed over time in the study period, representing a significant increase in the frequency of ulnar nerve procedures at the time of UCL reconstruction (P < .001).

CONCLUSION

The frequency of UCL reconstruction is steadily rising in New York State and becoming more common in adolescent athletes. Emphasis on public education on the risks of overuse throwing injuries and the importance of adhering to preventative guidelines is essential in youth baseball today.

Shoulder arthroplasty in New York State, 1991 to 2010: changing patterns of utilization

BACKGROUND

Shoulder arthroplasty is now used to treat an expanding variety of glenohumeral disorders.

METHODS

This study assessed the demographic patterns and utilization rates of shoulder hemiarthroplasty (HA) and anatomic or reverse total shoulder arthroplasty (TSA) within New York State (NYS) from 1991 to 2010. Using the New York Statewide Planning and Research Cooperative System database, all shoulder arthroplasty procedures that occurred within NYS during the study period were retrospectively identified and analyzed.

RESULTS

During the 20-year period, 24,040 shoulder arthroplasty procedures were performed. During the second decade (2001-2010), there was a 393% increase in utilization of TSA with a 98% increase in HA. This disproportionate increase is likely due to the introduction and expanding indications of reverse TSA as an effective procedure in place of HA for the treatment of proximal humerus fractures and rotator cuff arthropathy, as rotator cuff arthropathy as a primary indication for HA was significantly less prevalent in period 2. Also notable was an identifiable disparity in race; whites represented approximately 80% of the shoulder arthroplasty procedures in both decades, whereas African Americans made up <5%. This is significantly different from the general racial demographics of NYS during both periods analyzed.

DISCUSSION

It is clear that the volume of shoulder arthroplasty procedures performed in NYS is increasing, mirroring the national experience. This trend reflects the expanding indications, the general success of these procedures, the aging demographic of our population, and a greater desire and willingness of patients to consider operative management to maintain or to improve quality of life.

The association between insurance status and complications, length of stay, and costs for pediatric idiopathic scoliosis

STUDY DESIGN

Observational cross-sectional population study using national sample of pediatric hospital discharges from 2000 to 2009.

OBJECTIVE

To determine whether there is an association between insurance status and in-hospital surgical outcome for pediatric patients with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Association between health insurance status and in-hospital surgical outcome after spinal fusion for pediatric idiopathic scoliosis is unknown.

METHODS

An analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database 2000, 2003, 2006, and 2009 was performed. Patients aged 0 to younger than 18 years with idiopathic scoliosis and no underlying neurological disorders who underwent fusion were included. National trends, patient, hospital and surgical characteristics, postoperative in-hospital complications, and associated factors were studied. Univariate analysis and multivariable logistic regressions were used.

RESULTS

An estimated 19,439 surgical procedures (Medicaid 4766 vs. private 14,673) were performed for pediatric idiopathic scoliosis from 2000 to 2009 in the United States. Spinal fusions for pediatric idiopathic scoliosis steadily increased from 2000 to 2009 by 18.0%. Patients with private insurance were more likely to undergo surgery than patients with Medicaid insurance (7.7 vs. 5.9 per 100,000 capita; P = 0.003). Patients with private insurance were slightly older than patients with Medicaid insurance at the time of surgery (mean age = 13.9 yr vs. 13.4 yr; P < 0.001). Patients with Medicaid insurance had a higher prevalence of asthma (10.8% vs. 7.4%; P < 0.001), hypertension (1.4% vs. 0.4%; P < 0.001), hyperlipidemia (0.3% vs. 0.1%; P = 0.01), diabetes (0.8% vs. 0.3%; P < 0.001), and obesity (2.6% vs. 1.5%; P < 0.001). Patients with Medicaid insurance underwent more fusions involving 9 or more vertebrae than private patients (43.0% vs. 33.9%; P < 0.001). Postoperative in-hospital complications, including neurological (Medicaid 1.8% vs. private 1.7%; P = 0.64) and infectious (Medicaid 0.3% vs. private 0.2%; P = 0.44), were similar. Length of stay was longer (6.1 d vs. 5.6 d; P < 0.001) and hospital costs were higher ($45,443 vs. $41,635; P < 0.001) for patients with Medicaid insurance. Surgery performed in the South and Midwest regions, older age, and female sex were associated with lower rates of in-hospital neurological complications, whereas the presence of cardiac disease, obesity, and refusion were associated with higher rates of in-hospital neurological complications.

CONCLUSION

Patients with Medicaid insurance were younger, underwent longer fusions, and had more medical comorbidities than patients with private insurance. However, insurance status was not associated with an increased rate of postoperative in-hospital complications.

LEVEL OF EVIDENCE

4.

The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older

BACKGROUND

Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures.

METHODS

We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA).

RESULTS

The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010.

DISCUSSION

The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.

Experience of a fellowship in spinal surgery: a quantitative analysis

OBJECTIVES

The objective of our paper was to ascertain the self-reported competency level of surgeons who had completed a 1-year spine fellowship versus those who had not. Our secondary objective was to determine whether there was any difference between orthopaedic and neurosurgeons.

METHODS

A 60 question online questionnaire was provided to AOSpine Europe members for completion online.

RESULTS

289 members provided a response, of which 64% were orthopaedic surgeons and 31% neurosurgeons (5% did not specify). Eighty (28%) had completed a 1-year fellowship. Theoretical and practical knowledge of the management of spinal deformity was the greatest difference seen upon completing a fellowship. Multiple elective and emergent conditions were demonstrated to have a significant difference upon completion of a fellowship. There was no difference between orthopaedic surgeons and neurosurgeons.

CONCLUSIONS

In order to provide an efficient and safe service covering the broad spectrum of spinal pathology, a formal spine fellowship, ideally with a formal curriculum, should be considered.

Do authors report surgical expertise in open spine surgery related randomized controlled trials? A systematic review on quality of reporting

STUDY DESIGN

A systematic review of published trials in orthopedic spine literature.

OBJECTIVE

To determine the quality of reporting in open spine surgery randomized controlled trials (RCTs) between 2005 and 2010 with special focus on the reporting of surgical skill or expertise.

SUMMARY OF BACKGROUND DATA

In technically demanding procedures such as spine surgery, a surgeon's skill and expertise is expected to play an important role in the outcome of the procedure. To appraise the reported treatment effect of spine surgery related RCTs adequately, any potential skill or experience bias must be reported.

METHODS

MEDLINE, the Cochrane Library, and EMBASE were systematically searched for open spine surgery RCTs published between January 1, 2005, and December 31, 2010. Percutaneous techniques were excluded. The quality of reporting of all eligible studies was determined using the checklist to evaluate a report of a nonpharmacological trial. The reporting of surgeons' skill and experience was scored additionally. Subsequently, all authors were surveyed to determine if any information on methodological safeguards was omitted from their reports. All data were analyzed in 2-year time frames.

RESULTS

Ninety-nine RCTs were included. Ten studies (10%) described surgical skill or experience, mostly as a description of the learning curve. The majority of publications were unclear about "concealment of treatment allocation" (77%), "blinding of participants" (68%), "blinding of outcome assessors" (77%), and "adhering to the intention-to-treat principle" (67%). Of the 99 surveys, we received 22 (22%) completed questionnaires. In these questionnaires, information about essential methodological safeguards was often available, although not reported in the primary publication.

CONCLUSION

This study shows that in open spine surgery RCTs information on skill and experience is scarcely reported. Authors often fail to report essential methodological safeguards. These studies may therefore be prone to expertise bias.