The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF)

Background

Anterior cervical discectomy and fusion (ACDF) is a reliable procedure commonly performed in older patients with degenerative diseases of the cervical spine. Over 130,000 procedures are performed every year with an annual increase of 5%, and overall morbidity rates can reach as high as 19.3%, indicating a need for surgeons to gauge their patients' risk for adverse outcomes. Frailty is an age-associated decline in functioning of multiple organ systems and has been shown to predict adverse outcomes following various spine procedures. There have been several proposed frailty indices of various factors including the 11-factor modified frailty index (mFI-11), which has been shown to be an effective tool for predicting complications in patients undergoing ACDF. However, there is a paucity of literature assessing the utility of the 5-factor modified frailty index (mFI-5) as a risk stratification tool for patients undergoing ACDF. The purpose of this study was to analyze the predictive capability of the mFI-5 score for 30-day postoperative adverse events following elective ACDF.

Methods

A retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2019. Patients older than 50 years of age who underwent elective ACDF were identified using Current Procedural Terminology ([CPT] codes 22554, 22551, 22552, and 63075). Exclusion criteria removed patients under the age of 51, as well as those with fractures, sepsis, disseminated cancer, a prior operation in the last 30 days, ascites, wound infection, or an emergency surgery. Patients were grouped using mFI scores of 1, 2, and 3+. Univariate analysis, using chi-squared and one-way analysis of variance (ANOVA) tests, was conducted to compare demographics, comorbidities, and postoperative complications across the varying cohorts based on mFI-5 scores. Multivariate logistic regression, including patient demographics and preoperative comorbidities as covariates, was performed to evaluate if mFI-5 scores were independent predictors of 30-day postoperative adverse events. Covariates including race, BMI, sex, ASA, and comorbidities were included in regression models.

Results

The 45,991 patients were identified and allocated in cohorts based on mFI-5 score. Rates for superficial surgical site infection (SSI), organ/deep space SSI, pneumonia, progressive renal insufficiency, acute renal failure (ARF), urinary tract infection (UTI), stroke/cardiovascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, bleeding requiring transfusions, deep vein thrombosis/thrombophlebitis, sepsis, septic shock, readmissions, reoperation, and mortality incrementally increased with mFI-5 scores from 0 to 3+. Multivariate regression analysis revealed that mFI-5 scores 1 to 3+ increased the odds, in a stepwise manner, of total complications, cardiac arrest requiring CPR, pneumonia and mortality. MFI-5 scores of 2 and 3+ were independent predictors of readmission (2: OR=1.5, p<.001; 3+: OR=2.0, p<.001) and myocardial infarction (2: OR=3.4, p=.001; 3+: OR=6.9, p<.001). A score of 3+ increased the odds of ARF (OR=9.7, p=.022), septic shock (OR=3.6, p=.036), UTI (OR=2.1, p=.007), bleeding requiring transfusions (OR=2.1, p=.016), and reoperations (OR=1.7, p=.004).

Conclusion

mFI-5 score is a quick and viable option for surgeons to use as an assessment tool to stratify high risk patients undergoing elective ACDF, as increasing mFI-5 scores showed significantly higher rates of all adverse outcomes accounted for in this study, except for deep incisional SSI, wound disruption, and PE. Additionally, moderate to severe mFI-5 scores of 2 or 3+ were independent predictors for 30-day postoperative ARF, UTI, MI, bleeding requiring transfusions, septic shock, reoperation, and readmissions following elective ACDF surgery in adults over 50 years old.

Comparing outcomes between anterior cervical disc replacement (ACDR) and minimally invasive posterior cervical foraminotomy (MI-PCF) in the treatment of cervical radiculopathy

BACKGROUND CONTEXT

Anterior cervical disc replacement (ACDR) and minimally invasive posterior cervical foraminotomy (MI-PCF) have emerged as two increasingly popular alternatives to anterior cervical discectomy and fusion (ACDF) for the management of cervical radiculopathy. Both techniques provide advantages of segmental motion preservation and lower rates of adjacent segment degeneration (ASD) compared to ACDF.

PURPOSE

The purpose of this study was to analyze the clinical and functional outcomes of patients undergoing ACDR or MI-PCF for the treatment of unilateral cervical radiculopathy.

STUDY DESIGN/SETTING

Retrospective Cohort Review.

PATIENT SAMPLE

A total of 152 patients were included (86 ACDR and 66 MI-PCF).

OUTCOME MEASURES

(1) Patient demographics; (2) perioperative data; (3) rates of complications and revisions; (5) visual analogue scale (VAS) and Neck Disability Index (NDI) scores.

METHODS

A retrospective cohort review was performed to identify all patients at a single institution between 2012-2020 who underwent 1- or 2- level ACDR or MI-PCF from C3-C7 with a minimum follow-up of 24 months. Patient demographics, perioperative data, postoperative complications, and revisions were analyzed. Patient reported outcome measures including VAS and NDI scores were compared.

RESULTS

The ACDR group had a significantly greater mean operative time (99.8 minutes vs 79.2 minutes, p<.001), but comparable estimated blood loss and length of stay following surgical intervention (p=.899). The overall complication rate was significantly greater in the ACDR group than the MI-PCF group (24.4% vs 6.2%; p=.003) but was largely driven by approach-related dysphagia in 20.9% of ACDR patients. The MI-PCF group had significantly greater revision rates (13.6% vs 1.2%; p=.002) with an average time to revision of 20.7 months in the MI-PCF group compared to 40.3 months in the ACDR group. The ACDR cohort had significantly greater improvements in NDI scores at the final follow-up (25.0 vs 21.3, p<.001).

CONCLUSION

Our results suggest that ACDR offer clinically relevant advantages over MI-PCF in terms of long-term revision rates despite an increased approach-related risk of transient postoperative dysphagia. Additionally, patients in the ACDR cohort achieved greater mean improvements in NDI scores but these results may have limited clinical significance due to inability to reach minimally clinically important difference (MCID) thresholds.

Safety and Efficacy of Outpatient Anterior Cervical Disk Replacement (ACDR) in an Ambulatory Surgery Center Versus Hospital Setting: A 2-year Retrospective Analysis

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To compare clinical outcomes of outpatient anterior cervical disk replacements (ACDR) performed in free-standing private ambulatory surgery centers versus tertiary hospital centers.

SUMMARY OF BACKGROUND DATA

ACDR is an increasingly popular technique for treating various degenerative pathologies of the cervical spine. There has been an increase in the utilization of ambulatory surgery centers (ASCs) for outpatient cervical procedures due to economic and convenience benefits; however, a paucity of literature exists in evaluating long-term safety and efficacy of ACDRs performed in ASCs versus outpatient hospital centers.

METHODS

A retrospective cohort review of all patients undergoing 1- or 2-level ACDRs at 2 outpatient ASCs and 4 tertiary care medical centers from 2012 to 2020, with a minimum follow-up of 24 months, was performed. Approval by each patient's insurance and patient preference determined distribution into an ASC or non-ASC. Demographics, perioperative data, length of follow-up, complications, and revision rates were analyzed. Functional outcomes were assessed using VAS and NDI at follow-up visits.

RESULTS

One hundred seventeen patients were included (65 non-ASC and 52 ASC). There were no significant differences in demographics or length of follow-up between the cohorts. ASC patients had significantly lower operative times (ASC: 89.5 minutes vs. non-ASC: 110.5 minutes, P<0.001) and mean blood loss (ASC: 17.5 mL vs. non-ASC: 25.3 mL, P<0.001). No significant differences were observed in rates of dysphagia (ASC: 21.2% vs. non-ASC: 15.6%, P<0.001), infection (ASC: 0.0% vs. non-ASC: 1.6%, P=0.202), ASD (ASC: 1.9% vs. non-ASC: 1.6%, P=0.202), or revision (ASC: 1.9% vs. non-ASC: 0.0%, P=0.262). Both groups demonstrated significant improvements in VAS and NDI scores (P<0.001), but no significant differences in the degree of improvement were observed.

CONCLUSIONS

Our 2-year results demonstrate that ACDRs performed in ASCs may offer the advantages of reduced operative time and blood loss without an increased risk of postoperative complications.

Are Patients With Segmental Cervical Kyphosis Appropriate Candidates for Cervical Disc Arthroplasty (CDA)? A Clinical and Radiographic Analysis Compared to Anterior Cervical Discectomy and Fusion (ACDF)

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare the clinical and radiographic outcomes of Anterior Cervical Discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in patients with preoperative segmental kyphosis.

METHODS

Patients with segmental cervical kyphosis at the operative levels undergoing 1- or 2-level ACDF or CDA from 2017 to 2020 with 2 years of follow were identified. Patient demographics, perioperative data, complication rates, radiographic findings and reported outcomes were analyzed.

RESULTS

A total of 48 patients met inclusion criteria and were included in our study (ACDF: n = 24, CDA: n = 24). Patient demographic data between the 2 cohorts was similar expect for proportion of males (ACDF: 62.5% vs CDA: 33.3%, P = .043). There was no statistical significance in the change of segmental lordosis (ACDF: +8.09° vs CDA: +5.88°, P = .075) between the preoperative and final postoperative period. Additionally, the change in cervical lordosis was similar between groups (ACDF:+ 9.86° vs CDA: +7.60°, P = .226). VAS scores were similar between the 2 groups at every follow-up interval. NDI scores were significantly different at the 6-month, 12 month and the final follow-up. Mean improvements between preoperative and final postoperative periods were statistically superior in the CDA cohort compared to the ACDF cohort (ACDF: 22.8 vs CDA: 24.1, P = .0375).

CONCLUSION

CDA was superior to ACDF in regards to NDI scores following index procedure in patients with preoperative segmental cervical kyphosis. Those in the CDA cohort had similar complication rates, revision rates and radiographic outcomes as those who underwent ACDF.

Should patient eligibility criteria for cervical disc arthroplasty (CDA) be expanded? A retrospective cohort analysis of relatively contraindicated patients undergoing CDA

BACKGROUND CONTEXT

Cervical disc arthroplasty (CDA) is a safe and effective alternative to anterior cervical discectomy and fusion (ACDF) in the treatment of various degenerative pathologies with advantages of motion preservation and lower rates of adjacent segment degeneration (ASD). Absolute contraindications for CDA have been well outlined in order to prevent adverse outcomes in patients. However, in cases of patients with relative contraindications (kyphotic deformity, prior cervical surgery, etc.), there remains controversy. There is minimal literature evaluating long-term outcomes in this patient population.

PURPOSE

To compare long-term clinical and functional outcomes of CDA in typical patients versus those with relative contraindications.

DESIGN

Retrospective cohort review.

PATIENT SAMPLE

Eighty-nine patients were included in the study: 55 (no contraindications) in Group 1 and 34 (relatively contraindicated) in Group 2 and 26 (preoperative segmental kyphosis) in Group 3.

OUTCOME MEASURES

(1) Patient demographics; (2) perioperative data; (3) rates of complications and revisions; (5) visual analogue scale (VAS), and neck disability index (NDI) scores.

METHODS

Patients were placed in the relatively contraindicated cohort if they possessed at least one of the following: (1) segmental kyphosis of 5° to 10°, (2) significant loss of disc height (between 50% and 75% of initial measurements or 1.5-3mm), (3) bridging osteophytes, and (4) prior cervical spine surgery based on preoperative cervical radiographs. The other cohort included patients without any relative contraindication who underwent CDA over the same time frame. Additionally, a subgroup analysis was used to compare those without any contraindications to those with only preoperative segmental kyphosis. Patients were included in this study if they met the following criteria: over 18 years of age, minimum follow-up of 24 months, and availability of complete medical records. Patient demographics, levels operated on, and perioperative outcomes were assessed between the two groups. Revision and complication rates were recorded. Functional outcomes scores were compared using VAS and NDI scores at 6-months, 12-months and final follow-up.

RESULTS

Mean follow-up was 40.8 months in Group 1 and 38.3 months in Group 2 (p=.569). Complication rates were 21.8% in Group 1 and 26.4% in Group 2 (p=.615). Complication rates in a comparison between Groups 1 and 3 were statistically insignificant (p=.383). The most common complication was transient approach-related postoperative dysphagia (Group 1: 20% vs Group 2: 23.5%, p=.693). No significant differences were observed in the rates of transient dysphonia (Group 1: 0.0% vs Group 2: 2.9%, p=.201), adjacent segment degeneration (ASD) (Group 1: 1.8% vs Group 2: 0.0%, p=.429), infection (Group 1: 1.8% vs Group 2: 2.9%, p=.712), heterotopic ossification (Group 1: 49.1% vs Group 2: 50.0%, p=.934) or spontaneous fusion (Group 1: 1.8% vs Group 2: 2.9%, p=.728). No revision surgeries were observed in either cohort. All three groups demonstrated significant improvements in their VAS and NDI scores compared with preoperative measurements (p<.001), but no significant differences were found in the degree of improvement between groups at any point in time.

CONCLUSIONS

Our study found no significant differences in clinical and functional outcomes between patients undergoing 1- and 2-level CDA with relative contraindications versus typical patients. These findings suggest that patient eligibility criteria for CDA may warrant expansion. However, future prospective studies over a longer period of follow-up are necessary to corroborate our results.

Intercostal Nerve Transfer for Biceps Reinnervation in Obstetrical Brachial Plexus Palsy: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data Systematic Review using Individualized Fusion and Comparison to Supraclavicular Exploration and Nerve Grafting

Introduction

The objective of this study was to search existing literature on nerve reconstruction surgery in patients with obstetric brachial plexus palsy to determine whether treatment with supraclavicular exploration and nerve grafting produced better elbow flexion outcomes compared to intercostal nerve transfer.

Methods

This study was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data guidelines. A systematic search was conducted using multiple databases. An ordinal regression model was used to analyze the effect of using supraclavicular exploration and nerve grafting or intercostal nerve on elbow flexion with the two scores measured: elbow flexion Medical Research Council scores and Toronto active movements scale scores for elbow flexion.

Results

A final patient database from 6 published articles consisted of 83 supraclavicular exploration and nerve grafting patients (73 patients with Medical Research Council and 10 patients with Toronto score) and 7 published articles which consisted of 131 intercostal nerve patients (84 patients with Medical Research Council and 47 patients with Toronto scores). Patients who underwent supraclavicular exploration and nerve grafting presented with an average Medical Research Council score of 3.9 ± 0.72 and an average Toronto score of 6.2 ± 2.2. Patients who underwent intercostal nerve transfer presented with an average Medical Research Council score of 3.9 ± 0.71 and an average Toronto score of 6.4 ± 1.2. There was no statistical difference between supraclavicular exploration and nerve grafting and intercostal nerve transfer when utilizing Medical Research Council elbow flexion scores (ordinal regression: 0.3821, standard error: 0.4590, p = 0.2551) or Toronto Active Movement Scale score for elbow flexion (ordinal regression: 0.7154, standard error: 0.8487, p = 0.2188).

Conclusion

Regardless of surgical intervention utilized (supraclavicular exploration and nerve grafting or intercostal nerve transfers), patients had excellent outcomes for elbow flexion following obstetric brachial plexus palsy when utilizing Medical Research Council or Toronto scores for elbow flexion. The difference between these scores was not statistically significant.

Type of study/Level of evidence

Therapeutic Study: Investigating the Result of Treatment/level III.

Readability assessment of patient educational materials for pediatric spinal conditions from top academic orthopedic institutions

Background

The Internet has become a popular source of health information for patients and their families. Healthcare experts recommend that the readability of online education materials be at or below a sixth grade reading level. This translates to a standardized Flesch Reading Ease Score between 81 and 90, which is equivalent to conversational English. However, previous studies have demonstrated that the readability of online education materials of various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal conditions has not been analyzed. The objective of this study was to assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal conditions.

Methods

Online patient education materials from the top 25 pediatric orthopedic institutions, as ranked by the U.S. News and World Report hospitals for pediatric orthopedics, were assessed utilizing multiple readability assessment metrics including Flesch-Kincaid, Flesch Reading Ease, Gunning Fog Index, and others. Correlations between academic institutional ranking, geographic location, and the use of concomitant multimedia modalities with Flesch-Kincaid scores were evaluated using a Spearman regression.

Results

Only 32% (8 of 25) of top pediatric orthopedic hospitals provided online health information at or below a sixth grade reading level. The mean Flesch-Kincaid score was 9.3 ± 2.5, Flesch Reading Ease 48.3 ± 16.2, Gunning Fog Score 10.7 ± 3.0, Coleman-Liau Index 12.1 ± 2.8, Simple Measure of the Gobbledygook Index 11.7 ± 2.1, Automated Readability Index 9.0 ± 2.7, FORCAST 11.3 ± 1.2, and Dale-Chall Readability Index 6.7 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of video material with Flesch-Kincaid scores (p = 0.1042, p = 0.7776, p = 0.3275, respectively).

Conclusion

Online educational material for pediatric spinal conditions from top pediatric orthopedic institutional websites is associated with excessively complex language which may limit comprehension for the majority of the US population.

Type of study/Level of evidence

Economic and Decision Analysis/level III.

Septic Tenosynovitis of the Lower Extremity: A Case Report

Category:

Other

Introduction/Purpose:

Tibialis anterior rupture is an exceptionally rare complication of septic tenosynovitis. One case of septic tenosynovitis of TA has been previously documented by Lowell et al. 2020 It is worth noting in this case, that TA was unruptured. In this abstract, we present a case of TA rupture secondary to septic tenosynovitis.

Methods:

A 46-year-old female with a past medical history of depression, HIV, HCV, Diabetes Mellitus, medication noncompliance and current heroin abuse presented with 2 days of right ankle pain. She also reported fever, chills, diaphoresis, nausea and vomiting. She was diagnosed with right foot cellulitis based on clinical findings of erythema, induration and tenderness. She underwent computed tomography (CT) with contrast of her right lower extremity which showed a peripherally enhancing fluid collection surrounding the tibialis anterior tendon consistent with tenosynovitis. There appeared to be medial extension beyond the tendon sheath (Figure 1). A sagittal view is provided in Figure 2, which further demonstrates the fluid collection.

Results:

She had an I&D of the fluid collection and started on IV vancomycin. After admission to the medical floor, blood cultures were drawn. The patient failed to improve after 2 days of vancomycin therapy. The blood cultures were negative. She subsequently had MRI of her right lower extremity that showed a persistent peripherally enhancing fluid collection anterior to the tibialis anterior tendon and high-grade partial tear of the tibialis anterior tendon (Figure 3). She was then taken to the operating room for a repeat incision and drainage where the tendon sheath of the tibialis anterior was incised and the tendon was exposed with washout. Wound cultures were drawn, and afterward, her antibiotic regimen was broadened with Piperacillin-Tazobactam. She was taken back to the operating room a third time for primary closure of the wound. Wound cultures grew methicillin- sensitive Staphylococcus Aureus resistant to clindamycin and she was discharged on Bactrim.

Conclusion:

Septic or suppurative tenosynovitis is the infection and inflammation of the closed synovial sheath of a tendon. These infections typically involve the tendons and tendon sheaths of the flexor muscles in the hand. The potential spaces of tendon sheaths create a walled-off environment ideal for pathogens to grow in isolation from host defenses. he pathogenesis of septic tenosynovitis typically involves trauma from a laceration, puncture or bite but other cases of disseminated hematogenous spread have been reported (Newman et al., 1989). Both medical and surgical management is recommended for the best possible outcome.

Trends of Age and Geographical Location in Microsurgical Treatment of Obstetric Brachial Plexus Palsy

BACKGROUND

Debate over the optimal age at time of surgery for treatment of brachial plexus birth injury (BPBI) remains controversial, and there exists geographical varia- tion in surgical preference for age at time of surgery. The objective of this review was to analyze trends in age and geography in brachial plexus microsurgery for treatment of brachial plexus birth injury (BPBI) over time.

METHODS

Review of the literature in this study was con- ducted according to the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched.

RESULTS

Pediatric patients undergoing brachial plexus microsurgery described in published reports before 2011 had a mean of 7.15 ± 6.56 months of age, while pediatric patients undergoing brachial plexus microsurgery surgery described in published reports after 2011 had a mean of 11.23 ± 9.76 months of age (p < 0.05). The mean age at surgery was lower in publications from Asian countries (6.29 months) than in publications from North America (11.34 months; p < 0.05).

CONCLUSIONS

Age at time of microsurgery for treatment of BPBI is increasing, with mean age at surgeries occurring in and after 2011 being 4 months higher than thos occuring before 2011. The mean age at surgery was about 5 months higher in North American publications than in Asian pub- lications.

Upper cervical spine instability systematic review: a bibliometric analysis of the 100 most influential publications

BACKGROUND

Instability in the upper cervical spine, although rare, can be devastating. This spectrum of conditions includes occipitocervical instability, atlantoaxial instability and atlantoaxial rotatory displacement. Knowledge of the literature can provide better understanding of disease processes and management, and aid in clinical decision making. The objective of this study was to perform a bibliometric analysis to formulate a comprehensive review of the most cited publications.

METHODS

A systematic search of the literature was conducted using the Clarivate Web of Science database. The search query was '"Atlanto-occipital dislocation" OR "atlanto-occipital dissociation" OR "atlantoaxial rotatory displacement" OR "atlantoaxial instability"'. The top 100 articles based on frequency of citation were included in our study. Data extracted from articles included frequency of citation, year of publication, country of origin, journal of publication, level of evidence and article type.

RESULTS

Our initial search yielded 257 results that met the criteria. Articles not pertaining to atlanto-occipital instability were removed. Citation frequency ranged from 15 to 195. The most cited article was "Traumatic Anterior Atlanto-Occipital Dislocation" published by Powers et al. in 1979. The most productive decade was 2000-2009 with 45 publications. All decades showed a progressive increase in the number of papers published except for 2010-2019. Overall, 19 countries contributed and the most productive was the United States (n=61). The articles found in our search were cited a total of 4,095 times (3,463 without self-citations) averaging 40.95 citations per publication.

DISCUSSION

The goal of a bibliometric study is to assess trends in a specific field of study, provide evidence for the impact of an individual or field of study's research, and highlight potential areas for future research. While the number of citations does not necessarily reflect publication quality, it reflects overall influence based on recognition by peers in the field. Publications from the last 20 years have emphasized the use of newer technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) to aid in diagnosis. Our study highlights the lack of high-level evidence articles and underscores that our understanding of these conditions in both pediatric and adult patients is maturing.

Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review

Background

Neonatal brachial plexus palsy (NBPP) is a serious complication of high‐risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes.

Methods

A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA‐IPD guidelines was conducted in January 2020 to include full‐text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two‐tailed t‐tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores.

Results

Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS‐I assessment tool. Mallet subscore for hand‐to‐mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = −0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand‐to‐mouth (3.43 ± 0.83). T‐tests revealed a significant decrease in Mallet hand‐to‐mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation.

Conclusion

The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand‐to‐mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.

Readability assessment of patient educational materials for pediatric spinal deformity from top academic orthopedic institutions

STUDY DESIGN

Cross-sectional analysis of patient educational materials from top pediatric orthopedic hospital websites.

OBJECTIVE

To assess the readability of online educational materials of top pediatric orthopedic hospital websites for pediatric spinal deformity. The internet has become an increasingly popular source of health information for patients and their families. Healthcare experts recommend that the readability of online education materials be at or below a 6^th-grade reading level. However, previous studies have demonstrated that the readability of online education materials on various orthopedic topics is too advanced for the average patient. To date, the readability of online education materials for pediatric spinal deformity has not been analyzed.

METHODS

Online patient education materials from the top 25 pediatric orthopedic institutions, as ranked by the U.S. News and World Report hospitals for pediatric orthopedics, were accessed utilizing the following readability assessments: Flesch-Kincaid (FK), Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index (SMOG), Automated Readability Index, FORCAST, and the New Dale and Chall Readability. Correlations between academic institutional ranking, geographic location, and the use of concomitant multi-media modalities with FK scores were evaluated using a Spearman regression.

RESULTS

Only 48% (12 of 25) of top pediatric orthopedic hospitals provided online information regarding pediatric spinal deformity at or below a 6^th-grade reading level. The mean FK score was 9.0 ± 2.7, Flesch Reading Ease 50.8 ± 15.6, Gunning Fog Score 10.6 ± 3.1, Coleman-Liau Index 11.6 ± 2.6, SMOG index 11.7 ± 2.0, Automated Readability Index 8.6 ± 2.8, and Dale-Chall Readability Score 6.4 ± 1.4. There was no significant correlation between institutional ranking, geographic location, or use of multimedia with FK scores.

CONCLUSION

Online educational material for pediatric spinal deformity from top pediatric orthopedic institutional websites are associated with poor readability.